interviews

Towards open complaints management

South Tees Hospital NHS Foundation Trust chief executive Professor Tricia Hart, co-author of the new report into the NHS complaints system, tells NHE why things have to change.

The NHS must fundamentally change its complaints management, with greater focus on patients and targeted action, a new review has urged.

It can no longer be acceptable for an NHS worker subject to a complaint to carry out their trust’s investigations into that same complaint – or for patient’s concerns to be ignored.

‘Putting patients back in the picture’, which received over 2,500 individual submissions and comments from patients, families and former NHS staff, calls for common quality standards to be adopted across all trusts for complaints handling and whistleblowing practice.

The review, led by Labour MP Ann Clwyd and Professor Tricia Hart, chief executive of South Tees Hospitals NHS FT, was commissioned by health secretary Jeremy Hunt in March after the publication of the Francis Report. They visited nine hospital trusts and a non-NHS organisation, held regional events to get patients’ organisations views and others to get patients’ own views, and had eight face-to-face meetings with prominent experts on complaint handling.

Patient-centred systems

The review calls for board level responsibility for complaints, for trusts to publish an annual complaints report, and for more information to be provided for patients on wards about the staff treating them and how to complain. It also suggests involving patients in designing trust’ complaints systems, and an overhaul of the Patient Advice and Liaison Service (PALS).

Professor Sir Mike Richards, the new chief inspector of hospitals, will be starting to look at these issues too.

Prof Hart welcomed the health sector’s response so far, with regulators, unions and universities already talking about what the report will mean for their roles. Progress towards the commitments will be measured in a second review next year.

“We’re really building up a head of steam, which is so positive for patients,” she told NHE in early November, soon after the report was launched.

Time for action

The new report was primarily about action, Prof Hart said. It includes a series of nearly 30 specific measures that dozens of the most influential health organisations have committed to. These pledges would “really hard-wire what we’re trying to achieve right across the healthcare system”.

She said: “There have been numerous reports focused on complaints, complaints management and complaints handling. We did not just want to put together another report focusing on the problem and some of the solutions, but then in the future, people would come back and say ‘Well what was achieved? What happened?’ and ‘Let’s do another review’. The country doesn’t need more reviews about the problem.”

A more coordinated approach is also essential to moving towards better complaints management. As Prof Hart noted, “hospitals don’t work as islands, they work within a system”.

Standardisation

A year may not seem enough time to achieve the significant changes recommended in the report, but Prof Hart said: “It’s not going to take years for organisations to have in place this ability for patients and the public to raise a concern.

“It’s not going to take years to have something in place by a patient’s bedside to record good or poor care; to have the chief executive signing off every complaint letter; for reports to go to a board, so that boards start to look at the qualitative data, as well as the quantitative.

“There’s always the high-fliers who start to move on things quite quickly, and those who take longer. Anne and I did not want a report that just made the best get even better – because that just gives the patient a postcode lottery, and that’s really hard. They should not expect better or poorer care because they live in a certain part of the country.

“It’s important that we’ve set up recommendations to help standardise procedures and processes, so it doesn’t matter whether you’re a patient in the south west or north east.

“It will take longer to ensure a culture change in behaviour and values and attitudes [at] hospitals grappling with, for example, huge financial challenges.”

She said hospitals will have to examine “what that means for how they can still achieve financial stability but still put the patients at the heart of what they are doing”.

Early recognition

Some of the recommendations suggest using a volunteer workforce to help facilitate better complaints procedures, such as ensuring that paper and pen are available next to every bedside, or that patients are aware of the names of the staff treating them. Prof Hart said: “That’s not about replacing qualified staff with volunteers at all, it’s about supplementing.”

In many cases highlighted in the report, patients who received poor treatment only wanted an apology, and to ensure no-one else has to undergo the same experience they did.

Prof Hart explained: “If we could try to have that conversation with both the complainant and their relative right at the very beginning, it doesn’t escalate. If we can resolve some of those issues quickly, people don’t want to go down the formal complaint route.

“But if they do, they want an open, transparent, timely conversation, and they want to ensure actions are put in place to ensure no other family suffers what they had to suffer.”

 An independent eye

One particularly worrying point in the report was how many trusts allowed the staff member subject to a complaint to then investigate that complaint.

Prof Hart said: “If you have serious complaints where there has been potential harm or, god forbid, the death of a patient, we think it’s really important that there can be external scrutiny.”

South Tees itself offers an external independent review, where clinicians from other organisations are brought in. Prof Hart said: “I think that’s really healthy.

“There can be real opportunity for a level of openness with patients and their relatives, but also for clinical colleagues.”

The rise of consumer power, through organisations such as Healthwatch England, could also help drive patient opinion forward and ensure complaints are handled in a more effective manner. The Friends and Family test was “a really good start”, she said, although cautioned: “It’s not a panacea and it’s a somewhat blunt instrument. But it’s a start and it sends a message to patients and the public but also to our staff, that we really do want to hear what people are saying. The only way we can improve services for people is by really listening to their experiences.”

Patients as decision-makers

She added: “The days of clinical staff just deciding on service delivery are long gone. We really have to work in proper partnership with our patients and users of our services to make continued improvements.”

This need was more and more accepted across the NHS, with a need to standardise this much more, right across the country.

Some forums, whether clinical or individual learning organisations, come together to really focus on quality, Prof Hart said. She gave the example of QUEST, a collection of FTs focusing on improving quality, of which South Tees is a member.

“The focus is very much on learning and sharing,” she added.

The recommendations

•  Staff providing basic care should be adequately trained, supported and supervised

•  Annual appraisals linked to the process of medical revalidation focusing on communication skills for clinical staff

•  Trusts should ensure a range of basic information and support available on the ward for patients

•  Patients should be helped to understand their care and treatment

•  Trusts should provide patients with a way of feeding back comments and concerns

•  Hospitals should actively encourage volunteers to help support patients who wish to express concerns or complaints

•  Trust chief executives and board members should have the necessary skills in communication

•  PALS should be re-branded and reviewed and adequately resourced in every hospital

•  Ensure any rebranded patient service is sign-posted and promoted in their hospital

•  Develop appropriate professional behaviour in the handling of complaints

•  Staff to record complaints and action that has been taken

•  Staff need to be adequately trained, supervised and supported to deal with complaints effectively

•  There should be NHS accredited training for people who investigate and respond to complaints

•  Trusts should actively encourage both positive and negative feedback about their services

•  It needs to be clearly stated how whistle-blowers are to be protected and gagging clauses should not be allowed in staff contracts

•  The development of the ‘cultural barometer’ should continue

•  The independent NHS Complaints Advocacy Service should be re-branded, better resourced and publicised

•  HealthWatch England should continue to bring together patients and representative groups

•  Every chief executive should take personal responsibility for the complaints procedure

•  There should be board-led scrutiny of complaints

•  There should be a new duty on all trusts to publicise an annual complaints report

•  Every trust has a legislative duty to offer complainants the option of a conversation at the start of the complaints process

•  Where complaints span organisational boundaries, trusts involved should adhere to their statutory duty to cooperate

•  Further work should be done to explore how we look for the right skills in the recruitment of chief executives and board members

•  Commissioners and regulators should establish clear standards for hospitals for complaints handling

•  There should be proper arrangements for sharing good practice on complaints handling between hospitals

•  Regulators and the PHSO should work more closely to co-ordinate access for patients to the complaints system

•  We recommend that a Duty of Candour is introduced

•  Hospitals should offer a truly independent investigation where serious incidents have occurred

•  When trusts have a conversation with patients at the start of the complaints process they must ensure the true independence of the clinical and lay advice and advocacy support offered to the complainant

•  Patient services and patient complaints support should remain separate

•  Patients, patient representatives and local communities and local HealthWatch organisations should be fully involved in the development and monitoring of complaints systems

•  Board level scrutiny of complaints should regularly involve lay representatives

•  Clear guidance for staff on how they should report concerns

•  A board member with responsibility for whistle-blowing should be accessible to staff on a regular basis

•  A legal obligation to consider concerns raised by staff, and to act on them if confirmed to be true

•  The CQC should investigate the ease with which staff can express concerns and how whistleblowing is responded to where it has taken place

•  The CQC should designate a board member with specific responsibility for whistleblowing