The parliamentary Public Administration Committee’s Twelfth Report,”More complaints please!” was published on 12th April 2014. Amongst the pages of the report, there were several references to the NHS, and some of these are included below.
Complaints about the NHS, and the handling of those complaints, were described by the Parliamentary and Health Service Ombudsman as a “toxic cocktail”, a combination of a reluctance on the part of citizens “to express their concerns or complaints”, and a defensiveness on the part of services “to hear and address concerns”. This was no more evident than in the shocking collapse of care at Mid Staffordshire Hospital, which prompted this inquiry.
This shaming case has lessons for the NHS, Whitehall and for public services as a whole. How complaints are handled determines the quality of the relationship between consumers and public services. The best performing organisations welcome complaints as a way of engaging consumers. A failure to recognise the importance of complaints leads to insufficient redress for the individual, limits the impact that complaints have in improving services, and alienates the public. In some parts of public services, there are encouraging signs of increased attention to good complaints handling. However, Government as a whole cannot be said to be complying with best practice in complaints handling or adapting to the needs and expectations of today’s citizen.
As so often in our Reports, we highlight that success depends on the right leadership. Government must ensure that leadership of public services values complaints as critical for improving, and learning about, their service. We welcome the Minister for Government Policy’s review of complaints handling in Government, and recommend that:
- there should be a minister for government policy on complaints handling;
- the primary objective of the Cabinet Office review of complaints handling in Government should be to change attitudes and behaviour in public administration at all levels in respect of complaints handling;
- in respect of complaints from MPs handled by ministers, replies must be accurate, clear and helpful. Confidential information should not be shared with third parties, and responsibility for responding cannot be delegated (which contributed to the blindness about Mid Staffordshire NHS Foundation Trust);
- the Government should create a single point of contact for citizens to make complaints about government departments and agencies; and
- the Government should provide leadership to those responsible for various parts of administrative justice, to ensure that there is a clear and consistent approach to sharing, learning and best practice.
Achieving change of this nature is a difficult but vital challenge, and one that must be addressed now if we are to avoid the “toxic cocktail” poisoning efforts to deliver excellent public services.
1. If a member of the public wishes to complain about a public service, he or she has the right to have their complaint respected, for their concerns to be addressed, and for any wrongdoing to be put right with fair redress and without undue delay. Those delivering the service should ensure that lessons are learnt from complaints to identify what needs to be improved. Our inquiry examined the extent to which this was an accurate representation of complaints handling in public services.
2. Members of Parliament are often the last resort for constituents who have a complaint about a public service, or other issue. We are frequently confronted by people in deep distress, suffering intense pain or loss, and who may be at the end of their tether. Many who complain do so for the most altruistic reasons; not to punish, or to gain something for themselves, but to try to ensure that the same experience they have suffered should not be inflicted on others. They want the system, and the people within it and who lead it, to learn and to benefit from their experience.
3. So often, as MPs, we find that complaints handling is more about understanding and empathy than process and outcome, and public services often fail to recognise this. All too frequently, complaints are greeted by a management who are defensive, even legalistic, and who see complaints as a hostile criticism, rather than as an opportunity to learn from failure. Even if a complaint is not upheld, there is always the opportunity to learn about why the complainant has complained, and a need to understand the motives and feelings of the complainant. To embrace this is both a challenge and an opportunity for every organisation that serves the public, but particularly in public services.
4. The shocking collapse of care at Mid Staffordshire Hospital, and the exposure of the failure of the Mid Staffordshire NHS Foundation Trust and NHS leadership to hear both the complaints of patients and their families, and the complaints of their own staff, led to the unspeakable disaster at that hospital. The Francis Report gave no comfort that a culture of denial did not exist across the NHS as a whole. A subsequent review of complaints handling by the Rt Hon Ann Clwyd MP and Professor Tricia Hart similarly found that the public “were unaware how to raise concerns or make complaints, either for themselves or on behalf of friends or relatives” and that delays in resolving complaints were “a huge source of frustration”. Complaints handling in the NHS was described by Dame Julie Mellor, the Parliamentary and Health Service Ombudsman (PHSO), as a “toxic cocktail”:
- This is a combination of reluctance on the part of patients, families and carers to express their concerns or complaints and a defensiveness on the part of hospitals and their staff to hear and address concerns. As a result opportunities to learn and improve care are lost.
- STILL SOME WAY TO GO
23. Despite some promising examples of good complaints handling in Government, we heard evidence, particularly from members of the public, to suggest that some departments and agencies are not consistently meeting good practice principles with regards to complaints handling. One submission suggested that the complaints system was obstructive and “only the most tenacious complainant would get to the end of it”. On learning from complaints, one individual said that:
- I can say categorically that no lessons have been learnt by those who are in authority. The same problems come up time and time again.
24. In May 2013 PHSO published data on the number of complaints that it received relating to every UK government department in 2012, in letters sent to permanent secretaries. These letters listed some of the common failures in complaints handling that the PHSO had found through her work, which included:
· failure to respond to complaints within a reasonable length of time;
· failure to provide accurate and timely information;
· poor customer service;
· grudging apologies;
· failure to resolve issues;
· poor record-keeping;
· poor decision-making;
· failure to learn from mistakes; and
· providing incomplete, unhelpful or confusing responses.
- 28. The evidence of a failure of leadership to value complaints and to take them into account is all too clear. The Francis Report highlighted serious failures with the complaints process and the performance of the Mid Staffordshire Hospital Trust Board, saying that the Board “did not listen sufficiently to its patients or its staff or ensure the correction of deficiencies brought to the Trust’s attention”.A review of NHS governance of complaints handling by PHSO in 2013 found that of 94 Tr usts, only 20% reviewed learning from complaints and took resulting action to improve service, and fewer than two-thirds used a consistent approach to reviewing complaints data.
42. As part of our inquiry we took evidence from Sir David Nicholson, the then Chief Executive of NHS England, and Chris Bostock, Policy Lead for NHS Complaints at the Department of Health. Sir David accepted that the “toxic cocktail” exists within the NHS: a reluctance on the part of citizens “to express their concerns or complaints” and a defensiveness on the part of services “to hear and address concerns”, and he said that there is a “real issue” about defensiveness and a lack of transparency. Sir David said that the need for openness is not always recognised in the NHS and went on to say that, while more data is being published, and more people are connecting with NHS services and each other about their experiences through social media, the leadership within the NHS is “having difficulty coming to terms with that” and is “slightly” behind. He accepted that it comes down to leadership and culture:
- Undoubtedly, in broad terms, the NHS leadership is not equipped to handle some of the big issues that are coming forward, so we need to tackle that leadership. We need to work really hard on the culture of the system overall, because as you are going through that transition the importance of setting the right tone from top to bottom of the organisation is increasingly important. You need to make sure that you are learning the lessons and getting innovation from the system as a whole.[
43. Sir David also explained how the NHS Leadership Academy, which aims to develop outstanding leadership in health in order to improve people’s health and their experiences of the NHS, is focussed on addressing some of these cultural issues:
- One of the things we found in the NHS was that there is a particular type of leadership, which in the jargon is described as ‘pace-setting’. It is about getting stuff done, setting targets, hitting them and then getting the next one and driving the organisation forward. If you look at NHS management, it is predominantly pace-setting, when in fact, to deal with the world that we are talking about in the future, being responsive to patients, engaging with local populations and creating services around individual patients, there are different styles that you need. We have got a major task to shift NHS leadership from the predominantly pace-setting to something else. That is a really important precondition for making this happen, and we have set up a leadership academy to enable us to do that.
44. Dr Johnny Marshall, Director of Policy at the NHS Confederation, told us that in his experience of having been on an NHS Leadership Academy course, he had felt it understands “the task in hand” and made sure he looked across “the whole range of leadership skills, not just the pace-setting style, which is perhaps the natural style within the NHS”. Brenda Hennessy, however, said she doubts whether it would “reach down” to people such as ward managers “who will typically manage about 60 or 70 nurses delivering front line care”.
45. In respect of the NHS, we heard some examples of how behaviour and attitude towards complaints handling and customer service is being addressed. Claire Murdoch told us that:
- A few years ago […] we were scrutinising complaints and felt that there were too many about staff attitude, a lack of care, a lack of compassion. We looked at a range of data and decided, yes, there was a problem with, for example, our band five staff nurses. What we did then, five years ago, was change the recruitment process for staff nurses. They now go through, and have done for five years in my trust, a daylong assessment centre process, where we test the numeracy and literacy before coffee. If those newly qualified nurses pass their numeracy and literacy tests, we keep them on for the rest of the day, where patients and experienced staff will test them for, even then, compassion, aptitude, attitude and motivation.
46. Sir David Nicholson acknowledged shortcomings in NHS attitudes and behaviour in respect of complaints. He adopted encouraging language, but we are far from convinced that the NHS leadership knows how to change attitude and behaviour throughout the NHS. This is a huge challenge for the NHS leadership. We look forward to the Health Select Committee’s findings on the question of leadership, attitudes and behaviour in its inquiry into the handling of complaints and concerns in the NHS.
47. An attitude that welcomes complaints is important. This means challenging defensive behaviour to create relationships that are open and collaborative. Strong and positive leadership is essential to achieve this, which includes removing the fear of blame and increasing the confidence of those handling complaints. If staff are to listen to complaints with attention and compassion, and to handle them with intelligence and sensitivity, they must be trusted to use their judgement and respected when they do so. This is the way to help the organisation to learn.
48. We recommend that the NHS Leadership Academy acts now on the need to rectify shortcoming in NHS attitudes and behaviour in respect of complaints handling. This is urgent so it can address one of the main findings of the Francis Report.
Section 5 Complaints processes: keep it simple
65. Evidence confirmed to us that empathy and understanding are vital for successful complaints handling, but systems and process must be simple, straightforward and easy to access. A consistent theme in previous reviews of complaints handling has been the difficulty encountered by citizens when confronted with the plethora of internal complaints processes, independent reviewers, complaint-handlers and ombudsmen, as well as the full range of tribunals and the administrative court. The situation is further complicated by the general lack of understanding of the difference between such terms as ‘complaint’, ‘review’ and ‘appeal’.
Feedback’, ‘review’, ‘complaint’, or ‘appeal’?
66. Many of the past criticisms of the complaints processes were repeated in the evidence we heard. The Local Government Association said that “the phrase ‘complaints’ itself supposes a potentially confrontational situation. The Administrative and Justice Tribunals Council (AJTC) suggested that there was “a general lack of definitional agreement on terms such as ‘inquiry’, ‘grievance’, ‘complaint’, ‘claim’, ‘dispute’, ‘appeal’ etc”.
67. Academics Professor Trevor Buck, Dr Richard Kirkham and Brian Thompson drew attention to the way in which this confusion was exacerbated by the different ways that complaints and appeals were dealt with:
- This complaints/appeal distinction causes problems. It is not understood by the public who are confused about what they can do and who they may approach when they have a grievance. In terms of policy planning and operations, different government departments take the lead for complaints and appeals, and in turn those departments are subject to parliamentary oversight by different select committees.
68. In PASC’s previous Report, When Citizens Complain, the then Committee recommended that all government organisations use the widest possible definition of complaint—that of “any expression of dissatisfaction that needs a response, however communicated”. The Government in its response agreed that a wide definition was desirable but stressed the need for flexibility given the large number of public organisations.
69. ‘Complexity’ and ‘confusion’ were recurring words in the evidence we heard about complaints processes, particularly from individual members of the public. The administrative justice system is currently constructed in such a way that someone with a grievance could be directed down a number of different paths, for example an internal complaints process or an appeal process. An integrated approach to administrative justice is lacking, and this is reflected in the confusion in the language. A complaint is a complaint. Whenever a citizen experiences dissatisfaction with a public service, nobody should be shy of the term “complaint”, particularly where a complainant is seeking restitution or to alert management of a service’s shortcomings. Other euphemistic terms for “complaint” should be banned.
70. Following the abolition of the Administrative and Justice Tribunals Council, which played an important role in providing an independent overview of the administrative justice system, it is all the more important that the minister responsible for government policy on complaints handling strengthens ties with others in Government who are responsible for various parts of administrative justice, to ensure that there is a clear and coherent approach to sharing, learning and best practice. This means adopting common terms, such as “complaint”, which everyone can understand.
Simplifying the complaints process
71. The Local Government Ombudsman noted that for complaints to make a difference “the public must first be able to access the complaints system”. Richard Lloyd, Executive Director of the organisation Which?, told us that:
People are telling us that it is harder to navigate their way around the system. It is often very unclear where you should go and to whom you should take your complaint if it is not resolved properly locally. There is a whole range of ways in which there are barriers to people complaining.
72. The Local Government Association illustrated in its evidence the complexity of complaints arrangements, suggesting that in one London borough a general complaints service existed, but in addition there were specific procedures for adult social care, children’s social care, schools, code of conduct breaches by councillors or co-optees, disputed parking fines; planning decisions; and complaints about council staff. Which? gave a similar example in its evidence:
- if a user has a complaint about their care home or home care agency, there are currently up to five different bodies that they could be expected to report their complaint to—their provider, the local authority, the Local Government Ombudsman, the CQC [Care Quality Commission] or Local Healthwatch.
82. The exposure of the failure of Mid Staffordshire Hospital, the Mid Staffordshire NHS Hospital Trust and of NHS leadership to hear both the complaints of patients and their families, and the complaints of their own staff, defines what must change in the leadership of the NHS and its component parts. This also has lessons for Whitehall and public services. Good complaints handling ensures that individuals achieve fair and swift redress, and creates systematic improvement. It also encourages citizen engagement with service providers. Complaints become a positive dialogue rather than a negative dispute.
- 83. As so often in our reports, we highlight that success depends on the right leadership. Government must to ensure that leadership of public services values complaints as critical for improving, and learning about, their service. Only if the leadership adopts a positive attitude toward complaints will all parts of the service adopt the same attitude with those they lead and with the public they serve. To achieve this change is a difficult but vital challenge, and one that must be addressed now if we are to avoid what PHSO referred to as the “toxic cocktail”—a reluctance on the part of citizens “to express their concerns or complaints” and a defensiveness on the part of services “to hear and address concerns” — poisoning efforts to deliver excellent public services.