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Preliminary evaluation of the efficacy and implementation of the new NHS complaints procedure

J. McCrindle Researcher, Queen Margaret College, Edinburgh, UK R.K. Jones Lecturer in Sociology of Health and Illness, Department of Management and Social Sciences, Queen Margaret College, Edinburgh, UK
The increase (28.8 per cent) in the number of complaints from pre-New NHS Complaints Procedure to the implementation of the new procedures in 1996 is a matter of concern because it is estimated that the current gure represents only 40 per cent of the number of people with some dissatisfaction. The Wilson Report prompted Government initiatives in producing a new NHS Complaints Procedure. The new procedure allows for complaints to be dealt with at a local level, or in a minority of cases through Independent Review. The new procedures, which were introduced in April 1996, oblige Trusts, GP practices and Health Boards to establish a Written Local Resolution process for handling complaints, responsibility for implementation lying with individual trusts. A preliminary assessment of the New Procedures was carried out in Lothian. A qualitative approach was utilised and semi-structured taped interviews lasting on average one hour ten minutes were administered to the six complaints officers. This study concentrates on how the six Lothian NHS Trusts are implementing the new procedure, the openness in complaints handling, and the awareness of how complaints can be used to improve standards. The conclusion is that Local Resolution 1 has been successful, and that complaints do receive a speedy response. The process is much simpler and easier for the lay population to access. Reservations remain, however, towards the Independent Review procedure.

Introduction
A new public sector philosophy and culture in the NHS has emerged from the Citizens Charter Complaints Task Force that was established in 1993. This is part of the wider Citizens Charter which seeks to improve standards in public service delivery generally, and emphasises that such services should be responsive to the needs of patients and the establishment of a comprehensive complaints procedure. The 28.8 per cent increase in complaints to the Health Service Commissioner between 1994/5 and 1995/96 (Woodyard and Darby, 1996) is regarded by many as an underestimate and that the true gure is much larger (McCarthy, 1992; Mulchay and Tritter, 1994). It is suggested that only 40 per cent of perceived grievances are articulated verbally or in writing. The publication of the Wilson Report in May 1994, Being Heard, was responded to in the March 1995 Government Report, Acting on Complaints, which resulted in the establishment of a new NHS Complaints Procedure, embodying the seven principles of the Wilson Report. These are: responsiveness; cost-effectiveness; impartiality; speed of response; accountability; quality enhancement; accessibility; simplicity; condentiality . These act as the golden rules of action. The responsibility for implementation lies with the Trusts. This preliminary study was carried out in Lothian, Scotland, in an attempt to evaluate the degree of success of the new implementations after a six months period, from April to September 1996. The key objectives of the Complaints Procedure in Scotland were: ease of access for patients and complainants; simplied procedure; ease of extracting lessons on quality from complaints; fairness for staff and complainants alike; more rapid open process;

honest, thorough approach resulting in satised clients; (Scottish Office, 1995)

Background
Historically, users of the NHS have been reluctant to complain for a variety of reasons including the position of health employees in the social hierarchy and various feelings that Doctor knows best. MORI (MORI Survey, 1995; The Citizens Charter Complaints Task Force, 1995) found that two-thirds of people in Scotland did not know how or where to complain in matters concerning the NHS and, of those who did complain, nearly half were uncertain about whom they should contact. In addition there has been considerable dissatisfaction within the NHS among the health professions and organisations representing patients and also among informed opinion regarding the arrangements for complaints handling (NAHAT, 1993; The Citizens Charter Complaints Task Force, 1995; The Wilson Report, 1995). Arrangements for handling NHS complaints, prior to the institution of the New Procedures in April 1996, were seen as too complex, failing to be user friendly, taking too long, being over-defensive, and often failing to give any satisfactory explanation of any conclusion reached. The importance of complaints for improving services is now part of quality management (Koch, 1991). For complainants they are a way of expressing opinions through a guaranteed response channel. They are also important for the commitment of resources by Trusts. For the public they are mechanisms for ensuring professional accountability , upholding a sense of justice, and safeguarding standards of service quality (Longley , 1993a; 1993b). The reasons why people complain are generally as follows: information a request to nd out what happened; acknowledgement and apology a request for public display of malfunction; prevention of recurrence will not happen again; apportioning blame and disciplinary action who did it and what is going to happen; compensation desire for litigation.

International Journal of Health Care Quality Assurance 11/2 [1998] 4144 MCB University Press [ISSN 0952-6862]

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J. McCrindle and R.K. Jones Preliminary evaluation of the efficacy and implementation of the new NHS complaints procedure International Journal of Health Care Quality Assurance 11/2 [1998] 4144

In terms of handling complaints it is important to see what are regarded as key issues for service users. Leading factors identified by The National Association of Health Authorities and Trusts (1993) and by MORI (1995) were: speed of response 75 per cent; keeping complainant informed about progress 59 per cent; knowing who is dealing with the complaint 45 per cent; how helpful and friendly staff are 44 per cent; knowing the complaint will be dealt with fairly 44 per cent (Mulcahy and Tritter, 1994; Woodyard and Darby, 1996; Woolf, 1996); having clear complaints procedure 43 per cent; receiving a written explanation 39 per cent; receiving an apology if the organisation is wrong 29 per cent; having senior staff investigate 24 per cent; receiving compensation 15 per cent. The limitations of the complaints procedure prior to 1 April 1996 have been well documented (NAHAT, 1993; Nettleton and Harding, 1994; The Citizens Charter Complaints Task Force, 1995), and include charges of unwieldiness, unnecessary diversification because of formal and informal procedures, and an emphasis on trivialising or deflecting the complaint (Longley, 1993a; 1993b). Stacey (1992) reported that in 1991-1992 out of a total of 1,300 complaints to professional organisations only 58 were acted on 24 for health reasons and 34 for serious professional misconduct. The powers of the Health Service Commissioner were limited because there were certain complaints he could not investigate and the old NHS Authorities were not obliged to act on any findings. We can summarise the limitations of the old procedures as follows:

The road to reform


In view of the increasingly damaging evidence emerging the Secretary of State for Health established in June 1993 a Review Committee to investigate the existing NHS Complaints Procedure. The Wilson Report was published in 1994 as Being Heard, and recommended that a new Complaints Procedure was required which should have the following features: a comprehensive and integrated complaints system; comprehensive monitoring; re-assessment of self-regulation; increased lay control; Health Service Commissioner to be given power of clinical investigation; training for complaints personnel; separation of disciplinary elements from complaints procedures; a time limit of three months for implementation of complaints procedures; On 1 April 1996 a new NHS Complaints Procedure was introduced. This replaced the existing Hospital and GP Complaints Procedure with a single two-stage procedure. The main aims of the new NHS Complaints Procedure is to make complaining simpler, quicker, more accessible, and to encourage greater openness in the way that complaints are dealt with (Department of Health, 1995). The current NHS Complaints Procedure is divided into two main stages, and is applicable to all complaints about NHS services: a) local resolution, and b) independent review with the right to refer the matter to the NHS Commissioner if the complaint is still not resolved satisfactorily at the conclusion of the NHS Complaints Procedure.

Local resolution
The exibility of guidelines allows the hospital or GP practice to design their own procedures and allows on the spot resolutions by front-line staff. Failing resolution, and with more serious complaints, the complaints officer co-ordinates procedures and the complainant receives a written summary of the investigation and conclusions. If dissatised an Independent Review can be requested by the complainant.

Community health practitioners


limited to breach of contract; generally 13-week cut-off period for complaints; right of appeal by either party.

Independent Review
The complainant must lodge a more serious case within 20 days of being informed of the local resolutions conclusion. The Independent Review Panel consists of a lay chairperson, an independent lay member or representative of the purchaser (e.g. GP Practice or Trust) and, in the case of clinical complaints,

Complaints against hospitals


clinical complaints generally dealt with separately and by consultant concerned; less rigid time scale and designated officer decides on action; no right of appeal.

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J. McCrindle and R.K. Jones Preliminary evaluation of the efficacy and implementation of the new NHS complaints procedure International Journal of Health Care Quality Assurance 11/2 [1998] 4144

at least two independent successors. The Trust bears the cost.

Limitations and implications of the new procedure


The emphasis on resolving complaints via front-line staff may mean that there may occur unsatisfactory recording and monitoring: Under Stage 2 patients have no automatic right to have their case reviewed by a panel. This is at the discretion of the Convener. The Ombudsman and the Independent Review only make recommendations and do not implement service change. Public perceptions may view the defendant(s) as being inclined to close ranks. In addition, although the introduction of such new procedures ought to encourage greater response such increases may be viewed by the public and press as: more complaints = poorer services. The NCP (New Complaints Procedure) has the following implications: all staff need to be knowledgeable about the new system; training in the practical application is required; friendly to ethic and impaired complainants; ease of access of information and support for claimant; professional sensitivity to needs of minority groups.

An increase in the number of grievances after the implementation of the New Complaints Procedure compared to those prior to the New Complaints was expected. Using quantitative methods complaints for April 1996 were compared with 1995. The complaints officers, three male and three female, were employed by the six NHS Trust Hospitals covering the Lothian region in Scotland.

The ndings
The main ndings of this initial study can be summarised thus: the Local Resolution stage is working and is seen as a benet to both patients and staff; the six Trusts have all implemented training programmes for all levels of staff; all Trusts have widely published and publicised literature advising people of their complaints processes. No Braille facilities exist at present although some have implemented literature for minority groups; Trusts are meeting the target times for complaints handling, although this is an area which causes concern, as does the monitoring of complaints; Complaints officers have reservations about the Independent Review stage of the process; Complaints officers think that a denite advantage to the new procedure is that there is now an end of the complaints process; The ndings from the quantitative study showed 652 complaints for 1 April to 30 September 1995 compared with 823 for the same period in 1996, an increase of 20.7 per cent; Types of complaints made against the units were: Community service: Probably complaints about services such as day centres for the elderly (Complaints officer Trust 1) Out-patient units: Usually like waiting times (Complaints officer, Trust 4) Day patients: Issues such as delays in planned operations or the time they have been on the waiting list and their operations are cancelled at the last moment (Complaints officer, Trust 2) In-patients: Anything, from a feeling of lack of staff to issues like patient privacy, communication problems, etc. (Complaints officer, Trust 4) A & E: The length of time patients have to wait (Complaints officer, Trust 2) Different bases for collecting data (more resolved at Local Resolution and the recording of oral complaints, for example) make it difficult to compare gures:
I think the publicity has raised peoples awareness and while they may well have

Methodology and data collection


A qualitative approach was adopted. Semistructured taped interviews using pre-prepared interview schedules and lasting approximately 1 hour 15 minutes were administered to the six complaints officers of each of the six Trusts comprising the Lothian Health Board in Scotland. The interview is a popular tool of qualitative research and is well-documented (Mulchay and Tritter, 1994; Nettleton and Harding, 1994; Schatzman and Strauss, 1973; Spradley, 1979; Woodyard and Darby, 1996). Using Glaser and Strauss (1967) guidelines data were collected by tape recorder, transcribed verbatim, analysed simultaneously, coded and categorised into emerging themes. Comparison of the data was continually carried out until saturation occurred and no new data emerged. A master list of themes was generated, some of which were governed by the questions on the interview schedule. These master themes were then evaluated against the objectives and guidelines for introducing the new procedures.

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J. McCrindle and R.K. Jones Preliminary evaluation of the efficacy and implementation of the new NHS complaints procedure International Journal of Health Care Quality Assurance 11/2 [1998] 4144

had the same questions and concerns in the past, they are now expressing those concerns. Now that we have procedures in place for recording even oral complaints this can account for an increase. It is dangerous to say that there has been an increase just because of the new procedure. (Trust 5) Our complaints have gone up by about 40 per cent, although a number of factors account for this. The general public and patients are much more aware of their rights, more aware that public organisations are more accessible. There has been much more over publicity regarding the changed complaints procedure as Trusts were bound to actively publicise the changes, all of which has increased peoples awareness. It should be borne in mind though that the number of complaints in relation to the number of patients seen is insignicant (Trust 1).

Conclusions
The complaints officers had varied experience, some having handled complaints in one way or another for years, and others assuming the role at the introduction of the New Procedures. The level of the person appointed may also indicate the Trusts commitment to effective complaints handling. The monitoring of complaints appears to be an issue of concern to Trusts. The implementation guidelines state that Trusts must provide the Boards of Trusts and the Scottish Office (ISD) with quarterly details of formal complaints, while giving consideration to the collection of local data on oral complaints. A further issue is the limited number of categories on the ISD forms, which either forces some complaints into categories or makes it impossible to allocate others to any of the existing categories. It is hoped that the introduction of an amended Monitoring Form will address this issue of categories. Training was identied as being essential to making the new procedures effective. However, while recognising the importance of staff training, no extra resources were provided to Trusts to train staff. As a result, while the NHSME recommended a full one and a half-days training most Trusts have trained senior staff and nominated staff, who in turn train their respective teams. All training was done inhouse. One of the key objectives of the procedure is a rapid response within 20 days. All the Trusts had misgivings about this area and, although most of the complaints were dealt with within this time period, there were some cases where it was difficult to comply with the limitation, especially with complex medical and social cases. However, these were few in number. Local Resolution is at the heart of the New Complaints Procedure, operating initially

with on-the-spot responses to complaints, and, second, the Independent Review. Most cases are resolved on-the-spot which is a measure of its success. On the other hand, although only a small percentage of cases go to Independent Review, it is an expensive process which some see as a reection of Stage 1 failure in the sense that an effective Stage 1 would have dealt successfully with any complaints. All the complaints officers felt that they were successful in dealing with complaints. Review of the procedures was seen as an ongoing and necessary process. They see complaints as a positive source of information to be used in the maintenance and improvement in standards of service provision. Arrangements for handling complaints must be impartial and seen to be so. The fact is that the perception and appearance of impartiality is more important than the reality in determining peoples decisions about whether to make or pursue a complaint. The quicker and earlier complaints are resolved the more money is saved and the less bad publicity the Trust receives. Complaints are free market research and should be viewed positively, resulting, as they often do, in service improvements.

References
Department of Health (1995), Acting on Complaints, HMSO, London. Glaser, B. and Strauss, A. (1967), The Discovery of Grounded Theory, Aldine, New York, NY. Koch, H. (1991), Total Quality Management in Health Care, Longman, London. Longley, D. (1993a), Out of order, Health Service Journal, Vol. 102 No. 26. Longley, D. (1993b), Public Law and Health Service Accountability, Oxford University Press, Oxford. McCarthy, P. (1992), Grievances, Complaints and Local Government, Avebury, Oxford. MORI SURVEY (1995). Mulcahy, L. and Tritter, J. (1994), Hidden depths, Health Service Journal, Vol. 104, p. 5411. NAHAT (1993), National Association of Health Authorities and Trusts. Nettleton, S. and Harding, G. (1994), Protesting patients, Sociology of Health and Illness, Vol. 16 No. 1. Schatzman and Strauss (1973), Field Research Strategies, Prentice-Hall, London. Spradley, J. (1979), The Ethnographic Interview, Holt, Rinehart and Winston, New York, NY. Stacey, M. (1992), Consumer complaints, Social Science and Medicine, Vol. 8, pp. 429-35. The Citizens Charter Complaints Task Force (1995). The Wilson Report (1995). Woodyard, J. and Darby, M.A. (1996), Vicious circles, Health Service Journal, 26 September. Woolf, Lord (1996), Access to Justice, HMSO, London.

Thanks are due to the following Complaints Officers, Patient Liaison Officers and Directors of Operations who so willingly gave their valuable time: Richard Walter, East and Midlothian NHST; Jackie Warburton, Edinburgh Healthcare NHST; Hazel MacKenzie, Edinburgh Sick Childrens NHST; Dora Donaldson, Western General NHST; John Jack, West Lothian HST; Robert Purves, Royal Inrmary of Edinburgh NHST. [ 44 ]