interviews

A lot to complain about

There is something deeply wrong with the complaints systems across health and social care, research suggests, with complexity, fragmentation, inconsistency and defensiveness too often the rule. NHE examines what is being done to improve the situation, and hears from Healthwatch England’s director of policy and intelligence, Dr Marc Bush.

The health and care complaints system is “utterly bewildering” for most people, Healthwatch England said earlier this year, based on research into how the system works in practice and previous surveys with those who had experienced poor care.

Of 2,076 adults surveyed by YouGov, fewer than half of those who’d had a poor experience of care between 2010 and 2013 actually reported it or complained – either because they didn’t know how (43%) or because they thought it would be ignored or make no difference (49%).

Compounding the problem is the vast array of possible ways to complain: Healthwatch England identified 75 types of organisations in England with a role in complaints handling and support.

Dr Marc Bush, its director of policy and intelligence, told us: “Given the sheer complexity of the complaints system, it is unsurprising that people frequently tell us they feel like they need a doctorate to get their concern heard by the right organisation.

“It took real effort from Healthwatch England to identify and map who all these different organisations are, and what exactly their roles are in complaints handling. The fact that 75 groups of organisations are involved highlights just how complicated it is for patients.”

It is now involved in efforts to simplify the system and improve the experience for patients who want to complain.

Dr Bush said: “There is often an attitude of defensiveness; providers don’t encourage people to raise concerns and make complaints.

“But this misses the value that concerns hold for providers and professionals. Listening to concerns and acting on complaints ensures that services pick up on problems before things reach crisis point – too often those signals are going unheard at the moment. There needs to be a cultural shift among providers so that complaints can be welcomed, valued and dealt with.”

Complaints Programme Board

The Complaints Programme Board (CPB), on which Healthwatch England sits, was established by the Department of Health in December 2013, following a report by Ann Clwyd MP and Professor Tricia Hart on complaints handling commissioned in the wake of the Francis Report.

NHE interviewed Professor Hart, South Tees Hospital NHS FT chief executive, in our October/November 2013 edition, and we printed her report’s recommendations in full.

That report was one of six commissioned by the government that eventually informed its ‘Hard Truths’ response to Francis (the others were the Berwick, Keogh and Cavendish reports, plus the NHS Confederation’s ‘Challenging Bureaucracy’ document, and the Lewis/Lenehan Children and Young People’s Health Outcomes Forum work).

The world as it is, and as it should be

The CPB’s work – and that of Healthwatch England’s in this area – can broadly be split into two: one strand focusing on short-to-medium term improvements to the existing system (accepting that things don’t change overnight), and another looking further ahead to overhaul the whole system.

Short-term work includes Healthwatch England’s commissioning of Citizens Advice to produce consumer-facing advice and information on complaints, and to bring together existing information into one place. Local Healthwatch groups can then adapt and tailor that.

Citizens Advice is also providing training resources for its own staff and Healthwatch’s, to ensure staff are well-trained to deal with people making complaints, and have the right information on signposting and on advocacy.

Longer term, Dr Bush said: “People want a complaints system that’s independent and transparent, so it’s really important that providers are clear what’s being done with their complaint – what the process is, who and how it’s dealt with, and that they’re kept in the loop; and they want it to be much more joined up.

“The onus is currently on the individual to know where to go, to keep fighting and push their complaint through. We think the responsibility must be on the system as a whole, to ensure that once somebody’s raised a concern, that it’s acknowledged and dealt with.”

 A single portal?

The exact shape of such a system is not yet clear: there are discussions, however, about a ‘single portal’ for all health and care complaints.

It is not yet clear whether that could be a formal organisation in its own right, or more like a ‘front door’, which then directs complaints to the appropriate place.

A single ombudsman is another idea under discussion – but “the devil’s in the detail”, Healthwatch England says.

It is working on its own report, due in the autumn, assessing the current situation and building a case for long-term change in the system.

But any new system must ensure that complaints are used as a source of information and learning.

The CPB, which meets monthly, has been considering ways of introducing a single shared way of recording and categorising complaints across the system to make this easier.

A report earlier this year for the National Quality Board noted: “We have started exploring the scope to align more data sets across the system, including, potentially complaints data collected by the Health Service Ombudsman, NHS England and Healthwatch England, along with what is already collected by the HSCIC, and shared with CQC.

“There is no easy way to achieve this but through our partnership approach we hope to be able to move to this place collaboratively and are exploring this through a data sub-group of the CPB.”

Complaints advocacy

Another strand of the CPB’s work is on improving standards in complaints advocacy. These services are commissioned by local authorities and are a statutory requirement.

But, Dr Bush said, “there are inconsistencies in quality among the locally-commissioned complaints advocacy services, and issues around availability, access, sustainability, and a general low level of public awareness that those services exist”.

He explained: “People who in their everyday lives are articulate, confident and assertive aren’t necessarily when it comes to their health or care needs. That’s partly because the system is so complicated, but it’s also because they may be unwell, stressed or be in crisis, so it’s crucial they have support when they need it.”

Some of the better services are run by local Healthwatch groups, it is suggested, while others are run by the organisations involved under the old ICAS (Independent Complaints Advocacy Services). Big players include SEAP, POhWER, and VoiceAbility.

The CPB is developing national standards for delivery, “to provide service users with a realistic expectation of what to expect from these services and to enable individual local authorities to better manage the performance of advocacy providers”.

It also wants to work with the LGA and Healthwatch England to ensure the new standards are met, and to raise public awareness about the NHS complaints advocacy services.

Too many local authorities are unclear at the moment on the responsibilities and the need to monitor and improve the complaints advocacy services that they commission, it is suggested, with too much “copy and paste” from previous guidance and treating it like a tick-box exercise.

There is inconsistency in funding, and in the fact that there is no obligation on them to commission complaints advocacy services for social care. There are different rules on which advocacy service applies to you depending on where you live and what local authority area your treatment may have been in.

Healthwatch Northumberland has been identified as one of the better complaints advocacy services, both on service delivery but also on information sharing. It has good relationships with local PALS (patient advice and liaison services), with providers and the local authority. NHE has heard examples of information on complaints being fed back to providers in the region in a clear way, enabling trends and concerns to be identified and acted on.

The support people need

Healthwatch England’s chair Anna Bradley said in March: “A key improvement would be a straightforward and independent advocacy service to provide the support people need to make their voices heard.”

We asked whether we should take that as a call for a radical overhaul of complaints advocacy, or even a single national system.

Dr Bush said: “It’s still a question we’re thinking through, as these services are really challenged at the moment and it means people are not getting the support they urgently need.

“We already know that there needs to be a right for people who use social care service to get complaints advocacy, like there is in the NHS. Also, there definitely needs to be more of a national brand so that people know what’s out there, and there needs to be more consistency in funding, practice and standards.”

The Complaints Programme Board’s work

From most developed (completed or ‘considerably advanced’ by March 2014), to work not expected to be complete until March 2015:

• Setting of standards for complaints advocacy

• NHS Constitution supplement

• Revised statement on how to handle complaint cases where litigation is threatened

• Publishing of complaints data more easily into the NHS electronic data system

• Transparency, governance and good practice at trusts and by boards

• Review of PALS

• Evaluation of NHS complaints advocacy arrangements

• Regular and standard way to survey complainants

• Compliance issues: more personal responsibility by chief executives and boards on complaints handling, and more clinical involvement in investigation and resolution of complaints

• Building complaints into CQC regulation and inspections

• The future of the Public Services Ombudsmen

• Development of patient-led vision and universal expectations on complaints handling

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