INFORMATION STANDARDS BOARD FOR HEALTH AND SOCIAL CARE

Transcription

1 INFORMATION STANDARDS BOARD FOR HEALTH AND SOCIAL CARE Date: 23 July 2008 Document Name: Document Number: KO41a Hospital and Community Services Complaints and KO41b General Practice (including Dental Complaints) Change Operational Change Submission V0.5 July 2008 ISB HaSC08-215

2 ISB HaSC CHANGE TO AN INHERITED INFORMATION STANDARD SUBMISSION NAME OF STANDARD KO41a Hospital and Community Services Complaints and KO41B General Practice (including Dental) Complaints. DEVELOPER The developer of this change is Tamara Akroyd, Responsive & Accountable Services Workstream, within the Commissioning & System Management Directorate of the Department of Health. SPONSOR Meredith Vivian, Head of Responsive & Accountable Services Workstream, Commissioning Directorate (Patient & Public Empowerment Division). COMMERICAL There are several companies who provide software that is relevant to this change; Datix, Sentinel, Ulysses and Vantage Technologies. CUSTOMER NEED The subject of the submission is the 2007/08 reform of the current KO41 data collection, with a view to preparing for more substantive changes between now and 2009/10. We have committed to the reform of the current complaints procedures in health and social care and are currently consulting on our proposals. Complaints reform is an essential and integral element of the Department of Health's programme for improving patients' overall experience of health care. The complaints procedure for health services has undergone a series of changes in recent years, with the NHS (Complaints) Regulations 2004 (SI 2004/1768) and more recently, the NHS (Complaints) Amendment Regulations 2006 (SI 2006/2084). These have resulted in there being different processes across primary and secondary care, as well as there being different processes across ordinary NHS Trusts and Foundation Trusts. The pace of reform to date has been affected by the Shipman Inquiry and the Kerr/ Haslam, Ayling and Neale Inquiries. There is still a fundamental requirement to have access to some information about the trends in complaints each year, which feeds into ongoing policy development. Mandatory Central Returns for NHS Complaints were formally introduced in 1990 via DSCN 26/1990. Since then, DSCN 86/95/P69 revised and renamed the return as KO41(a), DSCN 03/96/P02 introduced KO41(b) and DSCN 03/2001 was issued to introduce the KO41(c), together with changes to KO41A and KO41B. This DSCN also published revised paper returns, which we incorporated in the NHS Data Dictionary & Manual to replace the previous versions. DSCN 24/2001, specified the updates to data standards necessary to support the central return changes. However, as a result of the Dictionary & Manual migrating to new software at that time, the guidance notes revisions for the central returns had to be published 2008).doc Page 2 of 20

3 separately later in DSCN 07/2002. The KO41(c) was discontinued in DH policy leads for complaints have instigated an annual revision to the KO41a and b since 2004/05, although this has not been accompanied by a DSCN. The 2004/05 collection was split into two phases; the first related to April 2004 to June 2004 and the second related to July 2004 to March This reflected the introduction of the NHS (Complaints) Regulations 2004 and marked the establishment of the Healthcare Commission, which took over stage 2 of the complaints procedure. It also coincided with the transfer of the management of the collection from the Department of Health Planning & Performance Review Team (PPRT) to the Health & Social Care Information Centre. We planned to split the next stage of reform of the collection into two phases; the first phase included changes that could be carried out with immediate effect for the 2005/06 collection in order to reduce the burden on the NHS; and the second phase would relate to the 2006/07 collection. We intended to allow time for more significant changes in the second phase, by writing to Trusts and PCTs in advance of the changes. The original plan was to expand the categories of subject of complaint in the KO41, although we were later asked by the Healthcare Commission to consider aligning the overall collection with Standards for Better Health and their associated core standards upon which the annual healthcheck is based. It became clear that a more fundamental revision of our data requirements would be required and that there should be minimal changes made during the 2006/07 exercise, allowing the Policy Team to scope future information requirements in the longer term. In light of the changes made to Local Resolution, (stage 1 of the current complaints procedure), in the NHS (Complaints) Amendment Regulations 2006, it was necessary to reflect the introduction of the extended response time. Therefore 2006/07, it was necessary to add a new worksheet to the KO41a, in order to measure the proportion of complaints that were resolved locally within 25 days, as opposed to 20 days. There are other minor changes that were required, such as renaming the KO41b General Practice (including Dental) Complaints, in order to clarify what this should cover. These are set out in greater detail in the next section. Future Direction: October 2007 & the Transitional Phase of Complaints Reform We have not yet been able to scope the review of our future information requirements, as we will not have a solution in terms of what the new process will look like until the current consultation comes to an end in mid-october. This will be followed by a transitional phase, during which any new complaints processes will be trialled by a number of early adopter organisations (comprising both commissioners and providers). We will keep the ISB informed of any progress. For the purposes of the 2007/08 data collection, we will only need to remove part 1a of the KO41a, as the timeframe for local resolution will be the same throughout the whole of the reporting year. 2008).doc Page 3 of 20

4 PURPOSE Whilst scoping our future requirements, we will need to remove part 1a of the KO41a, as the timeframe for local resolution will be the same throughout the whole of the reporting year 2007/08. Background: We have already made changes to the template for the 2006/07 collection that reflect the September 2006 changes to the complaints procedure, as agreed with ROCR. On 1 September 2006 the NHS (Complaints) Amendment Regulations 2006 came into force. One of the key elements covered by these Regulations had a significant impact on stage one of the complaints procedure and specifically affected complaints handling by front line NHS bodies. This effectively extended the time limit for responding to a complaint at the first (local) stage from 20 working days to 25 working days. This limit can be extended further only if the complainant agrees. There is no "backstop" time limit -- this differs from the social care complaints procedures, where the limit is a maximum of three months. In conjunction with this change, DH and the Healthcare Commission will continue to support local healthcare organisations to provide complainants with a full response as quickly as possible. If the complaint is not resolved after six months, patients can go direct to the Healthcare Commission. Between now and 2009, when there will be a single complaints system across NHS and social care, the Department of Health will be working with social care colleagues to align these timescales. The changes to the statutory response time at stage one of the current process came about following comments made to the Department of Health, as well as the Healthcare Commission about there being insufficient time to take appropriate action at a local level to resolve a complaint. The Department had discussed this with the Strategic Health Authority Complaints Leads, during numerous meetings attended by representatives of the Healthcare Commission, the Parliamentary & Health Service Ombudsman and Monitor. There were also in depth discussions held with the Department of Health s solicitors, in conjunction with the Healthcare Commission and Monitor. There were changes made to the relationship between the two regulators, but the KO41 remains unaffected by this. Major Changes to the KO41 in 2006/07 The major revision of the collection relates solely to the layout of part one of the KO41a (not the KO41b), reflecting the percentage of complaints that were resolved at local resolution within the 20/25 day timeframe. This required a change to the template to add a new worksheet and so divide the year into 2 periods; the first covers the April 2006 to August 2006 period, when the time limit for local resolution was 20 days and the second covers the September 2006 to March 2007 period, in order to reflect the extension of the time limit to 25 days. This is essential to reflect the changes introduced under the 2006 Complaints (Amendment) Regulations. In subsequent years, this split will be removed to reflect the new arrangements only. Minor changes to the KO41 in 2006/07 The name of the KO41b was amended, from General Practice Complaints to General Practice (including Dental) Complaints, in order to provide clarity about what this covers. Part 2 of the KO41b (subject of complaint): there was an addition made to the template last year, as part of the Phase 1 changes. There were issues with PCTs being asked to obtain a breakdown of the subject of complaint from their respective GP practices, rather than the practices supplying them with numeric 2008).doc Page 4 of 20

5 data as in the past. This was not covered by the GP regulations and therefore, it could not be mandatory. We have yet to resolve the issue with the relevant policy team and therefore, this section will be marked optional/voluntary. There were queries relating to the fact that the totals in part 4 of the KO41a and part 5 of the KO41b, (ethnicity of staff complained about), were not permitted to be more than the total number of complaints in part 1 of the KO41a/b, (total number of written complaints). This did not allow there to be complaints recorded where more than one staff member was concerned (eg. complaints about a team) and therefore, it did not produce a true reflection of the situation. The totals were set to do this to provide some sort of validation of the figures provided, but recommended removing the restriction for 2006/07 onwards. There were similar restrictions surrounding the totals in part 2 of the KO41b (subject of complaint); we recommended that these are permitted to be more than the total number of complaints in part 1. We recommended that the same restrictions surrounding the totals in part 3 of the KO41a (subject of complaint) are removed, so that they allow the totals to be more than the total number of complaints in part 1. We recommended that the guidance was revised to ensure that it was clearer and tackled specific queries raised during the 2005/06 exercise. The 2006/07 data collection was completed in July 2007; the revised guidance issued to support this is attached at Appendix A and Appendix B. SCOPE 1. Within the scope: The returns provide information on local handling of complaints by Trusts, PCTs, GPs, Dentists and independent providers (the latter is covered by PCT commissioning). The data is collated at Trust level and submitted to the Health & Social Care Information Centre in an Excel spreadsheet, by . The 2007/08 data will be requested in April 2008 and this covers all complaints received between 1 April 2007 and 31 March The data is published at organisational level (by Trust and PCT), so no individual General Practices are identified. It is publicly accessible on the Information Centre website and is used by the Department of Health, Strategic Health Authorities and the Healthcare Commission (as this is part of Core Standard C14 in Standards for Better Health, upon which the Annual Healthcheck is based). 2. Outside the scope: The KO41 is only concerned with local resolution. It does not measure the proportion of complaints that progressed to the Healthcare Commission at Stage 2 of the procedure. However, it does not exclude these complaints; it will still capture all formal complaints at local resolution. The KO41 does not record any data on Stage 2 or Stage 3 of the complaints procedure. Since July 2004, the Healthcare Commission have been responsible for independent review or stage 2 of the complaints process and they hold data on the number of requests for independent review each year. Therefore, the 2005/06 and 2006/07 returns have focused on local resolution. There is also data published by the Parliamentary and Health Service Ombudsman, (as part of their annual report), on the 2008).doc Page 5 of 20

6 number of complaints reviewed by her office each year at stage 3 of the procedure. The KO41 does not include informal complaints, which do not go on to become formal; there is no national data collection relating to informal complaints in the NHS. A formal complaint, for the purposes of the KO41, is described in the Data Dictionary as any complaint which is recorded in writing at any stage of the process. The remit of the Patient Advice and Liaison Service (PALS) varies across the country; some PALS staff do not deal with formal complaints, but this remains a grey area. The KO41 does not collect qualitative data. There is qualitative data collected locally, relating to those cases that Independent Complaints Advocacy Service (ICAS) providers are involved in; ICAS providers are bound by contract to submit regular reports on their activity, known as Outcome Registers, to local Patient and Public Involvement Forums. The KO41 does not collect data on Social Care Complaints. Care Trusts are currently only required to submit data relating to NHS complaints. 3. Scope of future information requirements: We are currently consulting on principles for new unified arrangements for handling complaints across health and social care. This follows a commitment made in the Our Health, Our Care, Our Say White Paper to develop by 2009 a comprehensive single complaints system across health and social care, that will focus on resolving complaints locally with a more personal and comprehensive approach to handling complaints. The consultation runs from 18 June to 17 October 2007 and we will then be in a stronger position to consider our future information requirements. We envisage there being a requirement to design and introduce a new data collection, which would replace the KO41 from 2009/10, once it is clear what the new process will look like. Data on complaints made to local authorities has been collected only recently by the Commission for Social Care Inspection. PERFORMANCE CHARACTERISTICS The proposed changes for 2007/08 to this Standard will not have a significant effect on current processes, since organisations already submit this mandatory central return to the Information Centre. The collection has a long history of being supplied in this format. The data, as it stands, is validated by the Health and Social Care Information Centre, but there may also be local measures in place to test that the data is compatible with other systems or returns to other organisations. The Department will be looking to redesign the data collection in the future (after the 2007/08 exercise), with a view to providing a more comprehensive picture about complaints handling across the whole of health and social care. BUSINESS JUSTIFICATION: Changes to this collection usually follow changes in the legislation governing complaints handling. The NHS (Complaints) Amendment Regulations 2006 (SI 2006/2084) resulted in there being changes made to local resolution and consequently an approach was made to ROCR to amend the KO41 template in February 2007, which was approved with the exception of Monitor. 2008).doc Page 6 of 20

7 We anticipate that new legislation will be drafted towards the end of 2007/early 2008; at which point we will be in a better position to design a new return. The regulations will not come into force until STRATEGIC FIT The Information Standard will be used by the Department of Health as part of public scrutiny of NHS services. This activity will be able to be described in terms of a structure, process and expected outcomes, ie. be a formal arrangement rather than a desirable entity or wish; The Information Standard will be used to audit or assess NHS organisations on an ongoing basis by the Healthcare Commission and this is supported by empirical evidence. The Information Standard will support the current development of policy in this area, as outlined in the DH Business Plan (this work contributes to strategic objective number three; Deliver a better experience for patients and users, including those with long term conditions). This will require a DSCN by October 2007, in order to make sure that systems are in place locally to provide the information for 2007/08. This proposed change is to a central data collection; we will require approval from ROCR (Review of Central Returns) for the 2007/08 collection, in terms of taking out part 1a of the KO41a. The standard is mandated (with the exception of the optional parts on ethnicity and general practice complaints broken down by subject); The frequency and medium of collection remain unchanged. We will work with the ISB to take forward future work on designing a new data collection. NATIONAL PROGRAMME FOR IT This is not a funded workstream within the National Programme for IT (NPfIT). The reliability of this data may be something that the NPfIT may wish to consider, although this is part of a wider issue about the compatibility of various systems and the capacity to support them on the national infrastructure. OPERATIONAL FIT At present, this data is entered into a spreadsheet and it is returned via . We do not envisage the changed standard to require any changes to this practice; compatible software suppliers are already aware of the changes (the paragraph on Commercial issues refers). There are named contacts within each organisation (Trusts and PCTs are sent the templates directly and the PCTs will request information from GPs, Dentists and independent providers). There are different systems in use. Some organisations link this to the Patient Administration System and some take data from other software (eg. Datix and other similar packages). The data is generally extracted from other systems, by complaints managers/officers (sometimes with information support). 2008).doc Page 7 of 20

8 IMPACT AND IMPLICATIONS The only implication for stakeholders, were this approved, should be to provide greater clarity. This will assist suppliers and reduce the number of queries received by both the policy team and the Information Centre. A summary of incoming queries has been passed to the Data Dictionary team. If the changed standard were not approved, we would remain reliant on clarifying queries on a case by case basis. KNOWN STANDARDS None INTERDEPENDENCIES None CONSULTATION AND SUPPORT We have briefed the Strategic Health Authority Complaints Leads on the ongoing review of the KO41 and we have also publicised our plans through the Voices for Improvement Action Network (VIAN) Quickplace site, which is accessed by health and social care complaints managers. We are in regular contact with the Healthcare Commission and Monitor, plus the Parliamentary & Health Service Ombudsman through routine liaison meetings and they are also members of the Individual Voices for Improvement (IVI) Policy Forum. The IVI Policy Forum was set up in Spring 2006, at the beginning of the IVI programme, in order that key stakeholders would meet at least quarterly to advice on policy issues. Moreover, the Healthcare Commission and Monitor were very closely involved in developing the NHS (Complaints) Amendment regulations 2006, which was the main factor in triggering the latest changes to the template and they support our overall approach to improving complaints handling locally. However, you may be aware that Monitor have not given their approval for us to request that Foundation Trusts complete the KO41a for 2006/07. We have maintained a dialogue with Monitor about the reforms to the complaints procedure and we are working with the Healthcare Commission to reinstate the KO41a on Monitor s Schedule 6, signalling their support for this standard. Ministers agreed that further consultation on the 2006 regulations was unnecessary, since the changes are not significantly different to those consulted on in We did, however, discuss the policy intentions and the drafting itself with key stakeholders to ensure that the changes would be workable. We remained in close contact with both the Healthcare Commission and Monitor, as well as discussing the Regulations with the Ombudsman. We have also met with other interested parties, such as Which (formerly the Consumers Association) and we have outlined our plans to the Strategic Health Authority Complaints Leads. The proposed changes will not affect service users. 2008).doc Page 8 of 20

9 GOVERNANCE Governance for the changes to the data collection will be overseen, at a strategic level, by the Head of the Responsive & Accountable Services Workstream, Meredith Vivian, the Chair of the Making Experiences Count Project Board and Sponsor for this change. Incoming data is validated and published by the Health & Social Care Information Centre. All data is provided anonymously and is aggregated by organisation, as well as being sourced from existing data. 1. Security; KO41a Data is not transferred outside the organisation, except once aggregated and submitted using the template. KO41b Trusts write out to GPs, Dentists and independent providers to request this data. Local security should not be an issue, as there are routine processes in place for the transfer of data to the PCT. 2. Confidentiality and consent (including third party consent) issues; The only issue that might have some bearing on confidentiality, would be a case where an organisation might consider bringing in a temporary member of staff to collate this data, which does sometimes occur in general practice. However, the extent to which they would have access to confidential information would depend on what systems were in place (ie. if they were in a position to go back through paper files or what authorisation they had to access IT systems). The template does not require any identifiable information and we do not publish at individual general practice level. 3. Existing legislation, guidelines and standards relating to governance; Local governance for this collection will fall within Trust clinical and corporate governance arrangements, as assessed by the Healthcare Commission as part of their annual healthcheck. 4. Ethics. There are no ethical issues; this data collection has been ongoing for a number of years and patients should be aware that data is collected on complaints. The data is not attributable to any individual, once it is entered into the spreadsheet. STANDARD SPECIFICATION The KO41 Central Return is represented as a data set in line with the current process of submitting the KO41 Central Return via . The data set provides links to existing NHS Data Model and Dictionary data definitions, codes and classifications that derive the KO41 aggregated data set return. The NHS Data Dictionary Change Proposal has been developed in line with the changes made for the 2006/07 exercise. The proposed template, intended for use during the 2007/08 collection, is attached at Appendix C. IMPLEMENTATION The additional worksheet in the KO41a has already been implemented in the service. We will shortly be seeking ROCR approval for changes to the template for the 2007/ ).doc Page 9 of 20

10 collection, which equate to a reduction in burden and we aim to consult on this and any future changes through the Strategic Health Authority Complaints Leads and the Voices for Improvement Action Network. There will be implications for the service from April 2008 onwards, once implementation for the 2007/08 exercise commences. Following implementation of the 2009 regulations, the new data collection will be implemented, in terms of requesting retrospective data using the new process, from April Safety The Government made a commitment in the White Paper Our health, our care, our say (January 2006) to develop a comprehensive complaints system across health and social care that will focus on resolving complaints locally with a more personal and comprehensive approach to handling complaints. This means the development of more easily accessible, simple and straightforward arrangements for both health and social care that will encourage and empower people to come forward with complaints; and which will inform organisational learning. Partnership/ openness must be a key theme: patients, health professionals, policymakers and healthcare leaders should be working together to prevent avoidable harm in healthcare. The KO41 data is published on the Information Centre website and is used by the Department of Health, Strategic Health Authorities and the Healthcare Commission (as this is part of Core Standard C14 in Standards for Better Health, upon which the Annual Healthcheck is based). We do need to maintain confidence in the quality of the data, prior to the review of any information requirements and we aim to do this by making a comprehensive entry in the Data Dictionary. 2008).doc Page 10 of 20

11 APPENDIX A Guidance for the Hospital & Community Health Services Complaints return 2006/ KO41(a) 1) The KO41(a) should be completed with information about written complaints about hospital and community health services made by, or on behalf of, patients in the period 1 April 2006 to 31 March A written complaint is one that is either made in writing to any member of Trust or PCT staff, or is originally made verbally and subsequently recorded in writing. Once it is so recorded, it should be treated as though it had been made in writing from the outset. Oral complaints and comments/suggestions that do not require investigation should not be included. 2) Complaints received during the previous year, but carried over to the current year should be excluded. 3) NHS Trusts and Primary Care Trusts should complete the KO41(a) return, as PCTs are responsible for handling complaints about the hospital and community health services they provide as well as complaints made to them about commissioning issues. NHS Trusts will make their own return about complaints dealt with by them. 4) If a written communication contains more than one complaint that requires separate investigation then each should be recorded separately. However, where a single complaint covers several aspects of care/treatment received, the complaint should be recorded only once, under the principal cause of complaint. 5) If the complaint is transferred to another organisation, the organisation that deals with it should record it. 6) DO NOT INCLUDE investigations instigated by outside agencies, for example the Police, Health Service Commissioner or Coroners Court. 7) Data on the ethnic group of both complainant (this should always be about the patient and not the person complaining on the patient's behalf) and staff complained about (where a complaint is about an individual as opposed to a service or administrative arrangements, etc) has been collected since April This information will help the Department of Health to begin developing a picture of the extent to which ethnicity affects the likelihood of complaining or of being complained about. In most cases, the information will be readily available from medical or personnel records, but where it is not every effort should be made to obtain it from either the complainant or the staff member involved. The ethnic groups listed in Parts 4 and 5 of this return are consistent with those set out in Data Set Change Notice 21/2000 "CDS, HES & Workforce: Ethnic Data". 8) Complaints regarding GP Out Of Hours Services. a) Complaints received regarding GP practices who provide Out Of Hours (OOHs) under 2008).doc Page 11 of 20

12 the new General Medical Services (GMS) contract should NOT be recorded on the KO41(a) return. They should be submitted on the K041(b) (General Practice Health Services) return. b) Where PCTs directly employ doctors (or others) to provide OOHs then these complaints should be recorded on the KO41(a) return under the service area Other Community Health Services c) Where a PCT commissions the OOH service from an independent provider, e.g. Primecare, then complaints made to the PCT should NOT be recorded on the KO41(a) return. They should be submitted on the K041(b) (General Practice Health Services) return. 9) Local Resolution (LR) is the first stage of the complaints procedure when front-line staff should aim to provide the fullest possible opportunity for investigation and resolution of the complaint, as quickly as is sensible in the circumstances. 10) Attached to the is the spreadsheet which needs to be populated and returned by the deadline. The spreadsheets contain validations and it is important that the sums of the different parts correspond. 11) Further information on the current NHS complaints procedures can be obtained from the Department of Health website: COMPLETING THE FORM: Open the spreadsheet which has been ed to you. It contains 9 sheets: 1) Contacts Please enter the contact details of the person responsible for completing this return. 2) Part 1a The number of complaints received within the period 1 April 2006 to 31 August 2006 needs to be completed and the numbers resolved within 20 working days, as well as those for which Local Resolution action took longer than 20 working days; and those still being investigated under Local Resolution procedures in this same period. - The sum of the three local resolution actions must equal the total number of written complaints for each service area. - The sum of the figures for each column must equal the total line (line 99). Please refer to the table below for definitions of service area. Service area Hospital acute services: Inpatient Definition Admitted Specialist Management/Patient Care provided by a consultant, midwife or nurse Hospital acute services: Outpatient Attendance at a clinic session provided by a consultant or his team 2008).doc Page 12 of 20

13 Hospital acute services: A&E Elderly (geriatric) services Mental health services Maternity services Ambulance services Community hospital services NHS Direct Walk in centres PCT commissioning Consultant-led activity with full resuscitation facilities and designated accommodation for the reception of accident and emergency patients Care of older people (by a specialist or his team) Care of the mentally ill (by a psychiatric specialist or his team) Care of patients during pregnancy including provision of antenatal and postnatal services, as well as care following miscarriage Hospital provided transport services staffed by trained ambulance staff Care provided in a community setting, which may not include accident and emergency facilities Telephone (and online) advice and information service with access to nursing staff Provision of healthcare advice and treatment for minor illnesses/injuries at drop-in centres Purchasing of services on a contract for patients in an area covered by a particular Primary Care Trust. 3) Part 1b The number of complaints received within the period 1 September 2006 to 31 March 2007 needs to be completed and the number resolved within 25 working days, as well as the number of those for which Local Resolution action took longer than 25 working days with the consent of the complainant and without the consent of the complainant; and those still being investigated under Local Resolution procedures for the same period. - The sum of the four local resolution actions must equal the total number of written complaints for each service area. - The sum of the figures for each column must equal the total line (line 99). 4) Part 2 Record the total number of written complaints received during the year for each category of profession listed. The final "other" option should be used for any complaint which has not been specified elsewhere in Part 2. - The sum of the figures must equal the total line (line 99). - Please note that the total number of written complaints received in line 99 must equal the total number of written complaints received in line 99 in Part 4. Please refer to the table below for definitions of profession. 2008).doc Page 13 of 20

14 Profession Medical (including surgical) Dental (including surgical) Professions supplementary to medicine Nursing, Midwifery and Health Visiting Scientific, Technical and Professional Ambulance crews (including paramedics) Maintenance and Ancillary staff PCT Administrative staff / members (exc GP admin) Trust Administrative staff / members Other Medical specialties (including surgical subspecialties) Dental specialties (including surgical subspecialties) Allied Health Professionals (physiotherapists, occupational therapists, speech and language therapists, chiropodists/podiatrists, dietitians, prosthetics and orthotists, art, drama and music therapists (arts therapists), radiographers (diagnostic and therapeutic), orthoptists and paramedics) Care provided by nurses, midwives and health visitors Services provided by scientists, technicians and professional advisors and support staff Services provided by ambulance crews (including trained paramedics) Workmen, cleaners, porters, catering staff. Primary Care Trust employed staff (not general practice-based staff) Hospital Trust employed staff Other 5) Part 3 Record the total number of written complaints received during the year for each subject category listed. The final "other" option should be used for anything which has not been specified elsewhere in Part 3. - The sum of the figures must equal the total line (line 99). 6) Part 4 Record the total number of written complaints received during the year from patients in each of the ethnic groups listed. Please note that it is the ethnicity of the patient that needs recording (even if someone is complaining on the patient s behalf). Use line 17 to record the number of written complaints where ethnic category is not stated. - The sum of the figures must equal the total line (line 99). - Please note that the total number of written complaints received in line 99 must equal the total number of written complaints received in line 99 in Part 2. 7) Part 5 Record the total number of written complaints received during the year against staff in each of the ethnic groups. Use line 17 to record the number of written complaints were ethnic category is not stated. 2008).doc Page 14 of 20

15 - The sum of the figures must equal the total line (line 99). - If the complaint is about a team, please record the ethnicity of each team member. 8) Comments The comments section is there for you to provide any further clarification or remarks you may wish to make in reference to specific parts of the data supplied or more general comments which you may have. 9) Validation_Errors This will reveal any errors when the Validate Data button is pressed on any of the Parts sheets. Validating Data Once all parts have been completed, go to the Part 1a sheet and click the Validate Data button. This will run a set of validation rules and any errors in Part 1a will pop up in the Validation_Errors sheet. To correct the errors, go back to the Part 1a sheet, amend accordingly, and then click the Validate Data button. Continue to do so until there are no errors. Repeat the above for the sheets for Part 1b, Part 2, Part 3, Part 4 and Part 5. Once the spreadsheet is error free, save it and the file to the following address: surveyteam@ic.nhs.uk For queries regarding validation and submission of the return, please contact: Jonathan Ellison Lily Bond Richard Webster or surveyteam@ic.nhs.uk For queries on definitions and Hospital and Community Health Services Complaints, please contact: Deborah Harrison or deborah.harrison@dh.gsi.gov.uk 2008).doc Page 15 of 20

16 APPENDIX B Guidance for the General Practice (including Dental) Complaints return 2006/ KO41(b) 1) This return should be completed with information about written complaints about general practice (including dental) health services (formerly family health services) made by, or on behalf of patients in the period 1 April 2006 to 31 March Complaints about hospitals and community health services should be entered on form KO41(a). 2) For the purposes of this return, a written complaint is one that is either made in writing to any member of GPHS practice staff or PCT staff, or is originally made orally but is subsequently recorded in writing. Once it is so recorded, it should be treated as though it had been made in writing from the outset. 3) One written communication may contain more than one complaint and each should be recorded separately. However, where a single complaint covers several aspects of care/treatment received, the complaint should be recorded only once, under the principal cause of complaint. 4) In most cases, it should be clear when a complaint refers to a general practice health service practitioner or a GPHS administrative decision. An example of the former is where a patient complains about an aspect of care or treatment received at a practice or surgery. An example of the second is where a patient complains about an administrative action of the PCT in connection with the provision of general practice health services. 5) DO NOT INCLUDE investigations instigated by outside agencies, for example the Police, Health Service Commissioner or Coroners Court. 6) LR stands for Local Resolution, which is the first stage of the complaints procedure when front-line staff should aim to provide the fullest possible opportunity for investigation and resolution of the complaint, as quickly as is sensible in the circumstances. For general practice health service practitioner complaints, LR includes the practice based complaints procedures and any action by the PCT to facilitate resolution of a complaint before it proceeds to the Independent Review. IR stands for Independent Review, the second stage of the procedure, where an independent panel considers the complaint. Please note that the KO41b no longer requires information on IR. 7) Complaints received regarding GP practices who provide Out Of Hours (OOHs) under the new General Medical Services (GMS) contract should be recorded on the K041(b) return. Where a PCT commissions the OOH service from an independent provider, e.g. Primecare, then complaints made to the PCT should be submitted on the K041(b) return. 8) Data on the ethnic group of both complainant (this should always be about the patient and not the person complaining on the patient's behalf) and staff complained about (where a complaint is about an individual as opposed to a service or administrative arrangements, etc) 2008).doc Page 16 of 20

17 has been collected since April This information will help the Department of Health to begin developing a picture of the extent to which ethnicity affects the likelihood of complaining or of being complained about. In most cases, the information will be readily available from medical or personnel records, but where it is not every effort should be made to obtain it from either the complainant or the staff member involved. The ethnic groups listed in Parts 3 and 4 of this return are consistent with those set out in Data Set Change Notice 21/2000 "CDS, HES & Workforce: Ethnic Data". 9) Further information on the current NHS complaints procedures can be obtained from the Department of Health website: COMPLETING THE FORM: Open the spreadsheet that is attached to the you have received. The spreadsheet contains 7 sheets: 1) Contacts Please enter the contact details of the person responsible for completing this return. 2) Part 1 Record the total number of written complaints received during the year against all the GMPs and GDPs with which the PCT has service contracts. For GMPs, this will be included in their annual reports. GDPs will be required as part of their terms of service to submit these figures to the PCT. Returns on the total number of complaints against Pharmacists and Opticians are not required. - The sum of the figures in lines 01 to 03 plus line 06 must equal the total line (line 99). - Please note that the total number of written complaints received in line (99) must equal the total number of written complaints received in line (99) in Part 3. 3) Part 2 GPs do not have to provide information on the subject of complaint to the PCT, but we have not yet been able to tackle this. It would be advantageous if you were able to obtain this information where possible. Record the number of written complaints received in Part 1 by subject of complaint (please refer to the table below for definitions of each subject of complaint). Please note the following: - The sum of the figures must equal the total line (line 99). Subject of complaint Communications / attitude Premises Definition A contact made either face to face or by telephone, facsimile, or website and issues relating to verbal/non-verbal characteristics, or content. The physical environment and psychological effect of the site occupied 2008).doc Page 17 of 20

18 by the practice/service. Practice / surgery management General Practice administration Clinical Other Decisions made by the practice manager about the operation of the practice/service (eg. access to individual practitioners, appointments, opening hours, locum cover). Activities undertaken by the reception and administrative staff within the practice. Clinical decisions, advice and treatment provided by a care professional within the practice. Any other issues not covered by the above categories. 4) Part 3 Record the total number of written complaints received during the year from patients in each of the ethnic groups listed. Please note that it is the ethnicity of the patient that needs recording (even if someone is complaining on the patient s behalf). Use line 17 to record the number of written complaints where ethnic category is not stated. - The sum of the figures must equal the total line (line 99). - Please note that the total number of written complaints received in line (99) must equal the total number of written complaints received in line (99) in Part 1. 5) Part 4 Record the total number of written complaints received during the year against staff in each of the ethnic groups. Use line 17 to record the number of written complaints where ethnic category is not stated. - The sum of the figures must equal the total line (line 99). - If the complaint is about a team, please record the ethnicity of each team member. 6) Comments The comments section is there for you to provide any further clarification or remarks you make wish to make in reference to specific parts of the data supplied or more general comments which you may have 7) Validation Errors This will reveal any errors when the Validate Data button is pressed on any of the Parts sheets. Validating Data Once all parts have been completed, go to the Part 1 sheet and click the Validate Data button. This will run a set of validation rules and any errors in Part 1 will pop up in the Validation_Errors sheet. To correct the errors, go back to the Part 1 sheet, amend accordingly, and then click the Validate Data button. Continue to do so until there are no errors. Repeat the above for the sheets for Part 2, Part 3 and Part 4. Once the spreadsheet is error free, save it and the file to the following address: surveyteam@ic.nhs.uk 2008).doc Page 18 of 20

19 For queries regarding validation and submission of the return, please contact: Jonathan Ellison Lily Bond or For queries on definitions and General Practice (including Dental) Complaints, please contact: Deborah Harrison on or 2008).doc Page 19 of 20

20 Template for 2007/08 APPENDIX C 2008).doc Page 20 of 20