Review of the NHS Complaints System SEAP s Submission 17 th June, 2013 Introduction Our position as the sole provider of NHS Complaints Advocacy across the South of England since 2006 has provided us with considerable insight into the variation of complaints handling practice across NHS commissioners and providers in the South. It has taught us the value and effectiveness of good, outcome focused complaints handling practice - the time/cost efficiencies for involved organisations, the resultant service improvements and consequently, and most importantly, the positive impact for complainants and other patients. This feedback has been based on our own experiences as an organisation feedback from staff, clients and stakeholders, and from data and observations from supporting clients with complaints against NHS organisations across the South of England. Appendix 1 sets out three scenario s of complaints handling illustrating good and poor practice. What common standards can be applied to the handling of complaints? Focus on outcomes/learning often the complaints process focuses on concerns without fully establishing what the complainant might wish to achieve from the process. By focusing on outcomes and learning the complaints handler can o Determine whether the NHS complaints process is appropriate. o Better focus on the areas of concern relevant to the outcome/s or what areas of concern can lead to positive change. o Clear focus on goals makes the complaints process more tangible for complainants particularly where there is a high level of emotion due to the significant impact of the issue. Emphasis on face to face local resolution meetings our experience has taught us that where meetings are held early in the process the likelihood of prompt resolution is significantly higher than if the process is followed via written communication. In most cases complainants are happy to have a meeting. Meetings should be recorded using audio recording equipment with a written summary of key action points/outcomes. Sometimes positive meetings are not accurately recorded and again, our experience shows that unfortunately this can serve to prolong the complaints process.. Review of the NHS Complaints System 1
Openness and transparency when communicating. Clearer explanation of the investigation process, who is involved, and, if appropriate, very clear explanations if there are to be delays in the process. Formal independent scrutiny of complaints handling this work has been undertaken informally by ICAS, using both process and comparative data to provide evidence of the effectiveness of good practice and to highlight process issues. Whatever body takes responsibility for this should be able to report firstly to the responsible manager and escalate to the Trust CEO or Board/CCG/NHS England Local Area Team if it is clear process recommendations are not being followed Prompt closure of complaints when it is clear that nothing more can be achieved through the process. We still experience providers continuing to invite further communication when it is clear that the process has been exhausted (the same questions still being asked despite having been answered), which serves to give the complainant unrealistic expectations and make closure increasingly difficult. Consistent methods of registering a comment or complaint that are easily accessible and understood. This is currently not the case. Following feedback the PHSO has altered its process to ensure that considerably more complaints that they receive are investigated. As a consequence of the PHSO s limited number of accepted cases, historically, they have had very little input into the monitoring of Local Resolution. Hopefully their new changes will provide additional feedback to NHS organisations who are not following good practice in complaints handling. How intelligence from concerns and complaints can be used to improve service delivery? and how this information can be made available to service users and commissioners? As above the outcomes should be the focus of all concerns what can be learnt? What is the solution to each individual concern? Where it is clear that a complaint has not highlighted outcomes this should be established at acknowledgement as standard practice. An apology for a failure must be accompanied with a service improvement outcome to quote a client there s no point apologising if you re not going to do anything about it. Alignment or commonality of data sets across all organisations involved in NHS Complaints to ensure combined reporting highlights trends or gaps in service as early as possible. NHS Complaints meetings to be held regularly (monthly/quarterly?) with external partners Healthwatch including NHS Complaints Advocacy (NHSCA) to discuss complaints intelligence trends and identified gaps in service. Healthwatch to monitor that service improvement commitments are implemented. Where there are failures in co-operating with improvement requirements or responding to raised issues with regard to trends, Healthwatch/NHS Complaints Advocacy to report to CQC/Monitor. Review of the NHS Complaints System 2
Where it is clear that there are trends/gaps in services, appropriate senior management should be involved in the discussions to ensure best possible insight and solution to identified concerns. Ensure that a senior (directorate level) member of staff is taking responsibility for the complaints department and for monitoring complaints and trends and ensuring all service improvements are implemented and reported to the Board. During the complaints investigation process all involved staff should be informed of the purpose of the process and encouraged to identify learning outcomes as a consequence of the concerns raised. Consideration should be given as to the objectivity of the person investigating the complaint and whether complaints should be investigated by an independent organisation. It seems clear that the general public perception of the complaints procedure is What s the point? It won t make any difference. This was further reinforced at the Healthwatch consultation events. Much of the general reported information regarding complaints is with regard to demographic profiling, types of concerns/grievance and outputs (numbers). Also it seems that in some areas complaints/concerns are still being misreported as comments. Complaints should be regarded in a positive light providing the public with the opportunity to feed back experiences to help improve services, and it should be promoted to the public in this way. If nobody says anything, nothing changes. There still seems to be a culture of defending complaints because of potential liability. Outcome reporting should be a standard part of any regular reporting. Outcome based reports should be both quantitive and qualitative using a cross section of case examples of outcomes this would bring more meaning to the reports and make them more accessible. NHS complaints advocacy should also be making sure that outcomes are a part of standard reporting both to Healthwatch and to Local Authority commissioners and that these reports also have a balance of quantitive and qualitative information and are accessible in a wide variety of formats for the public. Reports should be published as patient experience reports rather than being buried in more generic annual reports. Where possible all reports should be published in accessible formats and platforms mail shots, e-mail shots, presentation and internet. The role of the Trust Board and senior managers in developing a culture that takes the concerns of individuals seriously and acts on them: Senior managers should be ultimately accountable to the Board for complaints that occur in their departments and responsible for ensuring all staff are aware of the purpose of complaints an opportunity to learn as opposed to negative criticism. Review of the NHS Complaints System 3
Senior Managers should attend a regular session in the patient experience office dealing with enquiries and issues first hand. We are aware that this happens in some Trusts in some cases the CEO attending sessions. Trust Boards should be reviewing complaints on a regular basis with a particular focus on monitoring the number of complaints achieving positive outcomes, identifying what those outcomes are, scrutinising areas where complaints are not leading to outcomes and ensuring that the good practice areas are embedded across their Trust. o Good Outcome examples o Elderly care nurses Following a number of complaints with regard to feeding, the Nursing Director implemented training where nurses were asked to feed each other, as they would better understand patient experience o Hospital Family Clinic The Clinical Director implemented a family clinic on a ward for relatives to speak to consultants/registrar, following concerns raised about standards of care which had been improved but not communicated.. o The above examples demonstrate inexpensive, innovative improvements that have had a positive impact for patients. In the case of the second example, this demonstrates excellent complaints handling whilst the concerns raised weren t upheld the Trust has sought to understand why the complaint was made, identified the underlying issues and subsequently implemented appropriate improvements. In both cases the clients were delighted with the outcomes. Appendix 1 sets out good, average and poor practice complaints handling scenarios Senior managers should ensure that all new staff in their departments receive training with regard to complaints purpose, process -- as part of their induction. This would provide the staff with better understanding and context and more likely to be open about receiving complaints. The skills, behaviours and support that staff need, to ensure that the concerns of individuals are at the heart of their work: All NHS staff should receive complaints awareness training as part of their induction, this should be mandatory and updated every 2 years. This could be provided by the NHS advocacy service in their area which would develop working relationships and common purpose.. Impartial approach to ensure that they are providing information in an objective way, option based rather than recommendations. Solution focused looking to solve the problem rather than exacerbate it. Empathetic and diplomatic. Able to listen and communicate flexibly. Able to challenge colleagues articulately and fairly. Review of the NHS Complaints System 4
Able to access support from an appointed representative if they are being complained about. There appears to be significant inconsistency in the pay for Complaints Managers across the country. Where pay is low the lack of seniority gives very little teeth to the employee, particularly where the complaint is against a consultant or other senior figure. There should be a minimum set salary that reflects the considerable responsibility of the role and there should also be national guidelines with regard to the job description and responsibilities. Complaints managers should also be directly reporting to a senior (directorate level) member of staff to ensure adequate support when investigating complaints made against other senior members of staff. We are seeing much better outcomes where the complaints teams are falling directly under the nursing directorate for example. Similar issues have also been raised with regard to Practice Managers they have little seniority within often small teams and yet frequently seem to have sole responsibility for complaints and implementation of change. The Senior Practitioner should have far more accountability and be ultimately responsible for complaints to ensure they are taken seriously by all members of staff. How complainants might more appropriately be supported during the complaints process through, for example, advice, mediation and advocacy: The biggest current concern is not so much appropriate support being available for complainants, but complainants having the confidence to make a complaint without fear of negative consequences Despite the likelihood that they are most susceptible to poor service experience due to the complexity and intensity of service, vulnerable people (particularly the elderly, learning disabled and those with mental health issues) are less likely to complain. This is due either to the lack of choice with regard to community care people would rather suffer a poor service than have no service - or fear of repercussion. o Promote the ability to report concerns anonymously of NHS provider to Healthwatch/NHSCA whilst this would prevent the opportunity for the NHS provider to address the individual issues, it would still form part of the reported evidence base. o Intensive promotion of complaints advocacy services to vulnerable groups. An advocate not only provides support to the individual and empowers them to speak out, but advocates are also independent witnesses which may encourage patients to go through the process. o Complaining will not affect treatment or care is a prominent part of complaints legislation and NHS complaints related promotional material. o The way complaints are dealt with and complainants treated would go a long way to reassure people, that is, they are treated with respect and their views are valued. o Independent support for people to raise issues and concerns instead of or before they become a complaint. This would support those who feel that Review of the NHS Complaints System 5
complaints are a step too far and makes it less threatening. It also gives staff the opportunity to resolve problems at the time, before it becomes a complaint. Although this should be undertaken by PALS, our experience is that practice isn t consistent and some clients feel reluctant to discuss issue with PALS as they are not independent. Patients also seem far less likely to complain about their GPs, it would seem that this is partly due to it being an ongoing relationship and also the fear of being removed from the practice list on the basis of irrevocable breakdown in relationship o CCG/NHS England to become responsible for all GPs receiving complaints awareness training looking at the positive aspects of feedback create cultural change in viewpoint of complaints. o Promote the ability to report concerns anonymously of NHS provider to Healthwatch/NHSCA whilst this would prevent the opportunity for the NHS provider to address the individual issues, it would still form part of the reported evidence base. o Complaining will not affect treatment or care is a prominent part of complaints legislation and NHS Complaints related promotional material o Amend the NHS General Medical Services Contracts Regulations so that patient removal on the grounds of irrevocable breakdown in relationship are subject to request (make a case for) and scrutiny and authority from CCG/NHS England? All support services should also be focused on complainant outcomes in order to determine remit and signpost effectively. Many people are drawn to the NHS Complaints process, however sometimes the outcomes they are seeking in response to their concerns are outside of the remit of the process. It is important to ensure the complainants outcomes are established at the outset to ensure focus on goals and prevent the complainant from getting lost in concerns and often feelings. In establishing the outcomes early more effective signposting will occur and reduce the risk of people being bounced from pillar to post due to non establishment of aims. NHS providers should be more proactive in providing mediation (not widely advertised and usually only supplied on request), particularly where patients receiving ongoing care have lost trust because of a number of accumulated concerns. Whilst the patient could use the NHS Complaints process to address their concerns, often the only outcome they want is to regain trust/be reconciled with the service and mediation might be a more effective means of achieving this. The handling of concerns raised by staff, including support for whistleblowers: Entitlement to an independent representative (primary care) or in the case of large trusts an internally appointed/elected representative. All concerns raised to be reported to an independent body either CQC, Monitor, CCG or NHS England. Review of the NHS Complaints System 6
Concerns about the new complaints advocacy system: With the devolution of NHS complaints advocacy to local authorities, there are a number of issues we would like to flag for your consideration. Local accountability reporting complaints data and trends locally will highlight poor practice and through Healthwatch and Health and Wellbeing Boards, could lead to greater accountability and pressure for change.. Loss of a National Brand this is causing confusion amongst the public. There are a number of different names for the advocacy services and different access points. Postcode approach to accessing advocacy Local authorities are required to provide advocacy for their residents who may not access services in their area. As the NHS develops more regional specialist centres, fewer people will receive secondary care services in the Local Authority area in which they reside. Patients should have the right to access advocacy services where they receive treatment or in their home county. There needs to be common approaches among all LA commissioners. Reporting trends: There needs to be a common data set that enables trends to be identified locally, regionally and nationally. As it stands now, each advocacy service may receive one complaint about a hospital and not flag it as significant, but if all the complaints were put together, alarm bells may ring. Summary A complaints process that is handled well leads to client satisfaction, public confidence that the NHS is listening and prepared to learn from mistakes and improved services. Most NHS complaints are about finding out why things have gone wrong and wanting mistakes to be acknowledged. Some people want to hear the word sorry and want their experiences to be a catalyst for positive change and improvements in the NHS so others can benefit. This should also be the driver for NHS Boards. Complaints and complainants need to be considered as important contributors to improving patient care. Marie Casey Chief Executive SEAP 17 th June, 2013 Review of the NHS Complaints System 7
Appendix A Local Resolution complaints handling and ICAS support scenarios. The examples below illustrate good, average and poor practice in complaints handling when the complaint is with a single organisation Good Practice complaints handling scenario with typical advocate input Advocate meets with client to identify specific concerns, impact and desired outcomes. Advocate drafts letter and sends to client for approval or amendments. Trust responds within 3 days with suggestion of meeting with client and appropriate members of staff within 2 weeks to clarify concerns and outcomes. Meeting with Trust client and advocate answer questions that can be answered, clarify the remaining and take away to be investigated. Further meeting arranged within an agreed timescale with client. Meeting attended with appropriate Trust staff, client and advocate outstanding concerns addressed and where there are identified failures, service improvements are agreed. Meeting audio recorded with agreed outcomes listed at end. CD sent to client with covering letter listing outcomes, responsibilities and timescales. Advocate discusses case with client and client decides they are satisfied with case and case is closed by advocate. Evaluation form sent to client by SEAP ICAS. This case scenario dependent on travelling, complexity and capability of client would require anything between 5 20 hours work and almost certainly take less than 6 months to complete. Average complaints handling case scenario with typical advocacy input Advocate meets with client to identify specific concerns, impact and desired outcomes. Advocate drafts letter and sends to client for approval or amendments. Trust responds by letter within 3 days informing client/advocate of their intent to reply to the letter within 1 ½ months Response letter received from Trust around 1 ½ months later. Advocate phones client to discuss their view of the letter. Advocate is informed that whilst the letter has answered some questions, they are not satisfied with the response and that they have not addressed all of the outcomes. Advocate discusses options with client and agree to request meeting. Advocate discusses the points of dissatisfaction with client what the remaining questions are and what outcomes need to be addressed. Advocate drafts an agenda of questions with concerns and outcomes and sends to client for approval or amendments. Client phones and makes adjustments to agenda client confirms approval and agenda sent to Trust requesting meeting. Trust responds a week later with suggestion of date 1 month ahead. Meeting attended with appropriate Trust staff, client and advocate outstanding concerns addressed and where there are identified failures, service improvements are agreed. Client partially satisfied some additional concerns Notes taken of meeting rather than audio recording. Review of the NHS Complaints System 8
Draft notes sent to client 2 weeks after meeting, notes have missed out certain aspects of meeting. Advocate and client agree what has been missed and write back to Trust with amendments and additional concerns. Further response from Trust amending notes to satisfaction, answering his remaining questions and informing them that they cannot do any more and inform client of their right to go the PHSO (Ombudsman) with contact details. Advocate discussion with client client might go to the PHSO, if they wish to raise their remaining concerns. If client resolved case closed and evaluation sent. This case scenario dependent on travelling, complexity and capability of client would require anything between 15 50 hours work and almost certainly take more than 6 months to complete, particularly if there was more than one organisation involved. Poor practice in NHS Service complaints handling with typical advocate input Advocate meets with client to identify specific concerns, impact and desired outcomes. Advocate drafts letter and sends to client for approval or amendments. Trust responds by letter within 3 days informing client/advocate of their intent to reply to the letter within 2 months No response letter received from Trust 2.5 months later. Client calls advocate and advocate agrees to follow up Trust - Advocate informed that the reports are delayed from staff and it will be at least another 2 weeks. Advocate informs client, client concerned that they are hiding something. Response letter received 3 weeks later. Advocate contacts client to discuss letter client feels that the letter has not addressed any of the concerns and is defensive. Client feels that the Trust is hiding something. Advocate discusses options client might be too upset to consider meeting and might often request medical records at this stage. Further letter drafted to client letter more specific with regard to concerns and outcomes and requesting response to each individual point. Letter agreed and sent to Trust. Trust acknowledge and inform client that they will respond in 1 month. Response received 1.5 months later, on discussion with advocate, client angry at delay and whilst acknowledge that some questions are answered feels that the letter is still defensive and not conciliatory. Options discussed, despite anger/upset client feels that a meeting would be their best option. Draft agenda written on basis of outstanding questions, concerns and outcomes raised by client, sent to client which are agreed and sent to Trust. Trust comes back with meeting date 2 months later client not sure who some Trust staff in attendance are clarification sought. Meeting attended client is by now upset and concerned as to length of process and the lack of satisfactory answers and the meeting is unproductive. At this stage there might be, despite information being given by advocate a lengthy exchange of letters before case is finally taken to the PHSO This case scenario dependent on travelling, complexity and capability of client would require anything upward of 50 hours work and certainly take more than 6 months to complete. Some cases of this nature have been in the Local Resolution stage of the process for over 2 years. Review of the NHS Complaints System 9