Complaint procedures.    Tom McFarlane.

 

 

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This is an important subject, both for the exam and for professional practice.

The NHS is often accused of "closing ranks" and being obstructive in the face of complaints.

Be sure to be honest and open.

But don't give opinions when you don't know all the facts.

And remember that it will be for a consultant or the complaints manager to collate all the data and give the response on behalf of the chief executive.

 

List of contents

  1. introduction

  2. abbreviations

  3. key facts for the DRCOG

  4. expanded information for the MRCOG and to help facts stick

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Introduction.

This has not featured in the DRCOG, but it could.

It has featured in the MRCOG OSCEs, particularly as part of a role-play.

It could also turn up as a viva.

Most trainees have zilch by way of experience of handling complaints.

And often a similar amount of knowledge of the systems and organisations involved.

So, an OSCE or a viva could be a killer unless you mug up on the subject.

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Abbreviations
CFL: Carers Federation Limited.
CQC: Care Quality Commission.
DOH: Department of Health.
GMC: General Medical Council.
ICAS: Independent Complaints Advocacy Service.
IPR: Independent Professional Review.
NHS: National Health Service.
Ombudsman: Parliamentary and Health Service Ombudsman.
PALS: Patient Advice and Liaison Service.
PCT: Primary Care Trust
POhWER:



POhWER. The acronym originally stood for "People Of Hertfordshire Want Equal Rights".
It began as a local advocacy service in that area.
Now it has gone national.
Another information gem for the cocktail circuit!
SEAP: Support Empower Advocate Promote.

          

 

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Key facts for the DRCOG.

 

Taking a positive view of complaints:

We don't like complaints.

It is like people saying that they don't like you and none of us likes rejection.

But try to see them as a useful contribution to improving services.

Although this requires saint-like properties when the complaint is unjustified and against you!

And remember that the vast majority of complainants are not looking for money or revenge.

The recurring themes are:

     recognition that there are grounds for complaint and that they have suffered in some way

     assurance that steps will be taken to ensure that no-one else suffers in the same way.

The first requires careful analysis; the second identification of the underlying problems and their remedies.

This leads to service improvement.

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Who can complain?

Patients or someone on their behalf, e.g.

 

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To whom should the complaint be made?

Any member of Trust staff or to the commissioning PCT.

 

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The NHS complaints procedure in a nutshell.

NHS complaint procedures changed significantly in 2009.

The new system has two tiers:

·        

There is a similar system for General Practice.

 

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Local resolution:

This means getting complaints sorted out via the mechanisms within the Trust.

The hope is that the vast majority of complaints will be dealt with in this way.

The Chief Executive has ultimate responsibility for complaints.

A complaints manager must be in post to run the system & investigate complaints.

 

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 Assistance for the complainant:

The Patient Advice and Liaison Service.

"PALS", is the local, in-house, support scheme.

Its main weakness is that it is run by staff belonging to the Trust.

Some patients may not trust it because of this lack of independence.

The Independent Complaints Advocacy Service,

"ICAS", is a completely independent service to support complainants.

 

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The second level if local resolution fails.

Health Service Ombudsman.

A complainant can complain to the Parliamentary and Health Service Ombudsman.

This is the second level of the complaints procedure.

And only applicable when local resolution has failed.

 

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Judicial Review.

You could apply to the courts for a judicial  review.

I have not heard of this being done.

It would be prohibitively expensive for most people.

 

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Member of Parliament.

A complainant may request that their MP look into the case.

This can cause the Trust a lot of hassle.

 

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The Patients Association.

You might think that this would support the complainant.

However, this is not its role.

It does not deal with individual complainants.

 

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General Medical Council.

Complainant may complain to the GMC about a doctor.

 

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Legal Action.

Complainant may take legal action.

 

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Going to the "media".

Newspapers and television and radio programmes love a medical story.

 

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Expanded explanation for the MRCOG and to help facts stick.

Introduction:

The "Key Facts for the DRCOG" section is the essence of what you need to know.

The following "fleshes out" the detail.

Things changed a lot in 2009.

I have given a bit of the history so that you will understand what has changed.

And be able to spot out-of-date stuff in other articles or books that you are using.

One's natural instinct is to be of no help to anyone making a complaint.

Especially if you are the focus of the complaint!

Why give them sticks with which to beat you?

However, you must put your human frailties behind you and act professionally.

 

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Do you need more information than is in this document?

As you go through this document, especially the web page version, you will find links to external sites. Some of them are just one page and give useful summaries.

E.g. the links to PALS and ICAS.

Some of the links may be useful to pad out the information on this web page.

This will particularly apply to doctors who have not worked in the NHS.

However, this document is designed to give you all the information you need.

Don't spend days wading through the external sites.

 

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Additional sources of information:

If you must, have a look at these, but it should not be necessary if you absorb the rest of this document.

CAB advice on complaints.

PALS summary of the new regulations 2009.

DOH document: Listening, responding, improving: a guide to better customer care.

DOH document: Clarification of the Complaints Regulations 2009.

 

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Complaint-handling as part of clinical governance.

When I was Medical Director of our Trust a regular feature on the Trust Board agendas for their meetings was a summary of complaints and legal cases.

It may seem negative, but real problems will often show up in complaints.

And most patients only complain to ensure that what happened to them does not happen to anyone else.

They are not looking for compensation.

There are similarities with patient satisfaction surveys.

We read them to hear how wonderful we are: heroic doctors and angelic midwives and nurses.

But it does not achieve much.

Far better to look at the criticisms.

Therein lie the problems you can do something about.

I well remember a satisfaction survey in our maternity department.

Most of it was plaudits.

But one woman complained about being separated from her husband as soon as she was admitted in labour.

This intrigued me and I asked the midwives what she was talking about.

It emerged that the policy was that the woman was taken into an admission room near the front door of the hospital as soon as she arrived.

The husband came too.

When it was established that she was in labour, she was transferred to the labour ward on the floor above by lift.

But the husband had to travel in a different lift.

And when he got to the labour ward it took some time to be re-united with his wife.

I asked what on earth the reason was for this bizarre behaviour and was told that it was policy.

And had been since time immemorial.

I struggled to work out what this was all about.

And then I remembered that when I first started in the hospital as a consultant, the labour ward was divided in two.

It had a sterile area and a non-sterile area.

The delivery rooms were in the sterile area.

The whole concept had echoes of the terror that gripped maternity hospitals in ancient times in relation to puerperal fever.

It is fascinating that the massive seriousness of puerperal fever and consequent dread live on as a kind of organisational memory.

See Semmelweis, MCQ 10, question 16.

Though it is also salutary to remember that sepsis has returned as the major cause of maternal mortality in the 2006-8 Maternal Mortality Report.

Back to my example.

There was a corridor in each section of the labour ward and a separate lift.

This made it possible for the woman to be sent in one lift to the sterile area while her husband went to the non-sterile.

The woman was put in a hospital gown on arrival.

This was enough to make it OK for her to be admitted to the sterile part where the delivery rooms were.

 The poor husband was not allowed in until he donned gown, hat, mask and overshoes.

Why he could not get these in the admission room and stay with his wife was not clear.

Anyway, the whole of this supposed sterile policy had been junked.

Shortly after I arrived I spoke to the Bacteriologist who said it was nonsense and to get rid of the gowns, hats etc.

This had been done years before the satisfaction survey, but the admissions policy had remained.

A good example that hospital rituals can live forever unless someone questions their value.

We will never come to love complaints.

But we should value them as having the potential to identify problems that need remedies.

 

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The need for truthfulness, impartiality, honesty and other saintly qualities .

The patient is entitled to complete, true and impartial advice.

If you appear to be economical with the truth or evasive, the patient will see you as dishonest.

This means that when you try to explain difficult facts, like what happened, they will not believe a word.

 Indeed, seeing you as dishonest may reinforce their belief that the complaint is valid and persuade they that you are a dodgy doctor and should be punished.

 

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Trusts and staff taking defensive stances.

Many people suspect that hospital staff close ranks and will do anything to make a complaint go away.

To close ranks is another phrase from the military and it means a group of soldiers coming closer together to create a defensive formation.

Exactly what the complainant fears may happen!

So you must avoid anything that could heighten this suspicion.

If you are completely open and give them all the information they need, they will see that you are an honest person.

The will make dealing with the complaint much easier and more likely to be satisfactory to all parties.

 

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Historical background:

Major changes were made to the complaints procedures in the early 2000s and again in 2006 and 2009.

 Before these changes complaint procedures were seen to give too much power to Trusts.

A Trust had a local mechanism to deal with complaints.

If this did not resolve matters, the Trust could arrange an Independent Professional Review.

This brought in outside experts to assess the complaint.

But it was for the Trust to decide whether or not to have an IPR and the complainant had no rights in the matter.

This was obviously unfair.

The need for change was outlined in the DOH’s document: NHS Complaints Reform. Making Things Right in 2001.

You don't need to read it!

Hospitals were instructed to establish a PALS to provide patients with support and assistance by 2002.

 This was strengthened by the creation of ICAS, of which more below.

The second tier of the complaints procedure was taken away from Trusts.

If local resolution failed, patients could request review by the Healthcare Commission.

This was an independent body which took over the process of independent review to make it fairer by being genuinely independent.

 

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The new system and how things have changed.

Complaint procedures changed to the latest version in 2009.

The old system had three tiers:

·                    

The new system has two tiers:

·                

You will notice that the Healthcare Commission no longer features.

It was abolished in 2009.

The Care Quality Commission which replaced it will not deal with complaints.

Instead, the Ombudsman will take on what was the Healthcare’s role in providing a second tier to the complaints procedures.

The other main changes were those mentioned above about time-scales and when a complaint can be treated as informal.

In a role-play, you would only mention the new system.

You might not have been enthralled by the above history lesson and the role-player will certainly not be.

 

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Who is responsible for overseeing arrangements within Trusts?

Someone must be responsible for ensuring that the arrangements for dealing with complaints are up to standard.

The expectation is that this will be someone at Trust Board level.

The Chief Executive is responsible for the management of complaints.

The handling and investigation will be done by a complaints officer.

 

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Who can complain?

Patients or someone on their behalf, e.g.

 

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To whom should the complaint be made?

Any member of the Trust’s staff or to the commissioning PCT.

For those not familiar with PCTs, commissioning and providing etc., read on.

In the old days each area had a health authority.

Each year it got a dollop of money related to the population size, mix of ages etc.

It then decided how to spend it and ran the services.

In Mrs Thatcher’s time it was decided that the system needed competition to drive greater efficiency.

Each area got a body to which the money was given and responsibility for how it should be spent.

But it did not provide any services.

It was a purchaser or commissioner of services.

Services were provided by providers, such as hospitals.

The idea was that purchasers were free to buy services from any provider, not just the local hospital.

The purchasers are mainly the PCTs which are responsible for about 80% of the total NHS budget.

 

 

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Are all complaints to be treated in a formal way?

A complaint made to a member of “front-line” staff, e.g. a nurse may be resolved there and then.

If the complainant is satisfied, the complaint can be treated as informal.

And is no need for further action such as formal documentation.

Staff need to use their judgement about what is serious enough to need formal treatment

An obvious example being an issue that might impact on patient or staff safety.

A verbal complaint that is resolved within 24 hours will usually be treated as informal.

Complaints received by letter or e-mail must be treated as formal.

In the DOH document: Clarification of the Complaints Regulations 2009, common sense rules.

It states:

 

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Documentation of complaints.

All complaints must be documented.

As noted below, Trusts must compile annual reports.

 

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Is there a time limit on complaints?

The complaint must be made within:

If there are reasonable grounds for the complaint not being made within this time limit, Trusts are encouraged to investigate the complaint as it would others.

 

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Time-scale for responding to complaints.

The complainant must be:

 

 

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“Sign-off”

Once the complaint has been investigated, the complainant must get a “sign-off” letter.

This tells how the complaint has been dealt with.

And must include a copy of any report that has been written.

The Trust must explain what actions it intends to take.

The letter will usually be from the Chief Executive.

But can be from someone to whom the Chief Executive has delegated responsibility.

 

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How does the Trust ensure that lessons are learned?

Someone has to be given responsibility to ensure that lessons are learned.

This has to be someone senior for them to have the necessary clout.

Trusts must produce annual reports:

 

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Assistance for the complainant: PALS & ICAS.

The NHS Plan was introduced in 2000.

One aspect was that every Trust would have a Patient Advice and Liaison Service, PALS, by 2002.

 PALS staff provide patients with:

Formal complaints are dealt with by the complaints manager, who is a Trust employee.

A patient wishing to complain will be put in touch with the complaints manager.

And should be offered support from PALS & ICAS.

ICAS is part of the NHS.

But the service is provided by three organisations that are not part of the NHS.

They are:

This is intended to ensure that ICAS functions independently of the NHS.

The staff of these bodies are not NHS employees.

They will provide support such as discussing a problem and its possible solutions.

They could accompany a patient to a meeting with a complaints manager.

Keeping the people involved separate from the NHS is intended to prevent “clashes of interest”.

Would an NHS employee acting on behalf of a complainant ever be compromised in their dealings against the NHS?

 

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Local resolution:

It is hoped that most problems will be solved at local level.

This may be PALS staff or the complaints manager clearing up some confusion or misunderstanding.

It could be the result of the complainant meeting with the consultant / head of midwifery etc.

If local resolution fails,

 

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Health Service Ombudsman:

The next section is what used to apply to the Ombudsman to give you a flavour of their traditional role and how things changed radically in April 2009.

I think it may help you to understand the current situation if you know a bit about the history.

Note that the Ombudsman originally just dealt with the processes involved:

The following is what I originally wrote.

“There is a lot of misunderstanding about the role of the Ombudsman.

The usual misconception is that she is some kind of super-judge who will make a final decision about whether the complaint is valid or not.

In fact, the ombudsman makes judgements about whether an organisation handled a case properly.

It is about the administrative processes.

So, she might say that

She will not say that the baby came to harm because the CTG was abnormal at 14.00 hours.

Or the Caesarean section was unwisely delayed until 18.00.

This might make the Ombudsman seem fairly toothless and useless.

But she can put a lot of pressure on the Trust to make it do what she wants.

And she publishes an annual report.

To be named in it is a huge embarrassment for a Trust and a humiliation for its senior managers.

They definitely do not want that on their curricula vitae!”

 

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The Ombudsman since 1st. April 2009.

The Ombudsman now takes on clinical issues as well.

She will say that the CTG was abnormal at 14.00 hours.

And that staff were slow to act upon the findings to the possible detriment of the baby.

This is a radical change, but she has not been given additional teeth.

She cannot make a Trust pay compensation, fire the doctor involved etc.

She can recommend that the Trust look again at the problem, pay compensation etc.

But the Trust can ignore her, though this is unlikely and some sort of compromise will be agreed.

She would be likely also to provide some recommendations about the problem could be avoided in the future.

An obvious example being improved staff training.

 

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Judicial Review.

You could apply to the courts for a judicial  review.

I have not heard of this being done, but I am no legal expert.

Public bodies, including Trusts, are subject to this review process:

So, a judicial review would be possible, but very expensive.

 

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Legal action:

It would be perfectly human to be tempted to avoid giving information about how to sue you!

It is essential that you give the patient all the information they need.

And it does no harm in demonstrating that you are honest and fair.

In real life or an OSCE station telling a patient about complaint procedures, you would give the following information:

·      

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Impact of legal action on NHS complaint procedures.

This is dealt with in:  ”Reform of Health and Social Care Complaints: Proposed changes to the Legislative Framework” from 2008.

Don’t even think about reading it!

Up until this document, NHS complaint procedures went on hold:

This changed in 2008.

Now the principle is that the complaint procedures should carry on

Obviously, you are not in a position to judge the possible effects.

So the Trust must consult with

 

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The General Medical Council.

 A doctor can be reported to the GMC.

The consequences can be severe.

Like being struck off the register.

But a sick or drug-addicted doctor could get the help they need.

There are similar bodies for other professional groups.

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The media.

 Complainants may go down this route.

It rarely helps.

The media are only interested in the story for a day or two.

And they may take an interest in the complainant.

Particularly if it is discovered that they have something newsworthy.

Like being a drug abuser.

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Member of Parliament.

A complainant may request that their MP look into the case.

This can work.

The MP can ask questions about the matter in the House of Commons.

And annoy the Secretary of State for Health or other Government ministers.

They will respond by causing the Trust a lot of hassle.

 

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The Patients Association.

You might think that this would support the complainant.

However, this is not its role.

It does not deal with individual complainants.

It manages campaigns for improvements to health.

But not individual cases.

 

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Information leaflets:

In real life you would have given the patient too much information for them to remember easily. The hospital should have an information leaflet with all of this information in it. If you can’t find it, ask PALS! In the exam, OSCE stations often have a mark for mentioning information leaflets.

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How to handle a viva.

Prepare for a viva by making out a card or other revision aid with the main points well before the exam.

 Put it on your list of last-minute revision topics.

Write down the main headings while at the preparatory station.

Watch your time management.

Remember that the examiner is not allowed to prompt you or give any other encouragement.

That would make the station quite stressful, unless you knew the subject well.

 

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How to handle a role-play.

You might be asked to deal with a complaint in a role-play. To make a tasty OSCE, the complaint would be against you! This could mean breaking bad news, the angry patient and complaint procedures all in the same station. You need to have worked up skills for the first two and know the facts for the third.

You need to clarify if the patient is making a formal complaint. Or is she just unhappy about some aspect of her treatment and wanting to have more information and some kind of explanation?

Your fundamental need is absolute honesty. Make no attempts to justify yourself. Don’t be tempted to blame someone else. Do not make up fairy stories: it was an exceptionally difficult operation and you bled much more than normal…...

First you apologise for them being caused distress. Note, you don’t pre-empt assessment of the complaint by apologising for what you have done. Clinical incidents happen without you doing anything wrong.

Say that matters of this kind are always treated very seriously by the Trust. Words like the following: when an operation does not go entirely to plan, a clinical incident form is filled out. This records details of what happened. The form is sent to the risk management team. It is their job to investigate the incident. They will talk to everyone who was involved to find out what happened. (Give examples: the surgeon, the theatre staff, the anaesthetist, the midwives etc.) Then they ensure that everything is done to make things as safe as possible for patients in the future.

You tell them that the incident will also be fully investigated by the consultant. You offer to arrange for them to meet the consultant. Tell them that if there are disciplinary or training consequences for you, the consultant will let them know.

 

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Dealing with a formal complaint.

You must explain that they are entitled to make a formal complaint, if they wish to do this.

You will explain how they go about it:

You make it as easy as possible for them to register the complaint.

You give them the address and contact phone number of the complaints manager.

In a role-play, you would offer to phone the complaints manager to arrange an appointment.

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Advice about how to prepare the complaint.

Advise them to sit down and decide the detail of the complaint. Most will find it useful to have someone help them with this – a relative or a friend. They may want assistance from PALS or ICAS.

They should concentrate on the main issues and not include irrelevant stuff, like disapproving of the colour of the nurses’ uniforms or the quality of the food. Some mistakenly feel that complaining about a host of issues demonstrates how universally useless the Trust is. The effect in real life is to dilute the complaint, submerge the main issues in trivia and make the complainant appear a professional malcontent.

They also need to be clear about what they hope to achieve by making the complaint. Many will just want recognition of the hurt inflicted on them and an apology, with an assurance that everything possible will be done to ensure it does not happen to someone else. Others may want punishment of the “guilty” and others financial recompense.

 

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Give advice on all the ways to complain.

Depending on the scenario and the time available, you would explain about the other aspects of the complaints procedure: the Ombudsman, the GMC, legal action, the media etc.

 

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