Complaints – Why “The Toxic Cocktail” ?

poison pic“What we found was that there is a toxic cocktail – patients felt reluctant to complain, because they can fear it will affect the care they get – and that if they do, they are met with a culture of defensiveness, where they don’t get the explanations they need, and the opportunity is lost to learn really powerful insights, which could improve the NHS.” So says the NHS Ombudsman talking to the Daily Telegraph about her new report on complaint handling in the NHS.

No surprises there – NHS complaint handling has been criticised many times over the years and no doubt will be again in the upcoming Clwyd/ Hart report. The question is why? Why is improvement in this area seemingly impervious to all efforts – exhortation, humiliation, congratulation, publication, excommunication, execution – well perhaps not the last one- yet.

The report itself tries to give an answer quoting a study by the Ombudsman that

has found that staff are reluctant to properly investigate complaints because they are afraid of challenging the NHS hierarchy, or drawing attention to failings by more senior colleagues, or that they will be punished for admitting to failings in patient care.

These three reasons are actually manifestations of the same thing. Complaint handling is the proxy battlefield for the old old struggle for power within the NHS system. All parties on the battlefield will always seek to claim that they are at war in the name of the patient – the patient as in ‘God is on our side’ – but at its heart the struggle is about who is in charge. Heirarchy is part of it but if that was all it was, the problem could be solved. However deference to the pressures of the conventional heirarchy – I am senior/ better paid/ have larger office/ been here  longer and you will do as I say – does not work in the NHS.

Successful Complaint Handling

Successful complaint handling environments are those where the complaint handler has the power to ignore heirarchy or functional fiefdoms and make a decision on their own authority. Taking a retail environment as an example, a relatively lowly complaints person at Head Office can agree a settlement or course of action without reference to the supermarket manager, senior buyer, regional operations manager, marketing department. They can then reclaim the cost of the complaint and the replaced goods from the supplier – even if there is no fault in the product. If the consumer does not like it, they will get an instant refund or exchange. The question of what went wrong – if anything – is to investigated later – the consumer solution comes first.

This ability to resolve the issue without reference to the rest of the operational heirarchy gives the consumer what they want quickly. It may well cause mutterings and a fair amount of grief amongst those whose voices have not been heard – especially blameless suppliers – but the business bites the bullet and moves on.  Subsequent investigations will establish where the failure of quality lies  but the consumer settlement is not dependent on flushing out the bad guys, getting them to put up their hands and cooperate in putting things right.

This ability to transcend heirarchy and operational channels is not available in a work place where professional interests exist that cannot be overridden in the interests of rapid settlements. A manager in a business concern has no such protection; no alternative identity or status beyond that conferred by his or her position in the business. The member of the profession will not readily if ever subordinate that status in the interests of the organisation where he or she works and certainly will never accept the judgement of some junior complaints manager lurking somewhere obscure in the bureaucracy of a detested management system. Why should they if in foregoing such protection they put themselves in harm’s way? Also in complex clinical matters, a quick decision by a complaint manager may actually get things seriously and expensively wrong.

That is why the Ombudsman is so vital. The Ombudsman has the missing ingredients: authority and resources to investigate. The status of this Office trumps the heirarchy of the single institution and its judgements are about organisations – they avoid for the most part questions of individual error in favour of actions by the organisation concerned. The Trust and its successor organisations carries the can which suits all the individuals concerned just fine.

Let us wait and see what happens post-Francis – who will be held accountable? Here we may well see how successful the professional protection mechanisms are and (equally interesting) how the implicit heirarchies between different professions work.  Will it only be the nurses who go to jail? Rows about Sir David Nicholson’s responsibilities in this area only underlined how dysfunctional professional relationships are within the system and how uncertain the lines of accountability and responsibility.

Important matters of professional status are at stake. The battle goes on. Complaints are just part of the munitions store drawn on by all sides and very small calibre non-armour piercing rounds at that.

The MAC Solution –

For our view on how to improve complaint handling in the NHS, see our blog from March this year. Here is a bit of what we said:

complaint handling based on the for-profit, competitive model will never work in the NHS. The penalties for accepting responsibility for complaint acknowledgement and solution that accrue to staff are too high. The people are scared and so is the organisation – living in fear of the ‘flood gates argument’.

The punitive culture applies not just internally – there are no shortage of vultures circling to blight careers be they Francis, the CQC, the Ombudsman, Clwyd, Hart and Uncle T Cobley and all. The NHS is short on recognition of success and past successes buy nothing for those who get associated with a complaint. The fastest way to fall victim to the complaint handling toxin is to take ownership – everybody sensible is heading for the hills.

Another challenge to NHS culture is that successful complaint handling intially demands a policy of exceptionalism – making a deal with an individual for treatment that another individual who grinned and bore it, did not get. This is NOT FAIR – but it is if action for individuals can be aggregated and used for the benefit of the others.

The incentive must change from negative – ie a focus on the person getting it wrong or who got caught owning a complaint – to the positive – get rewarded for service quality improvement and use of initiative with no punishment for the occasional error, misjudgement or a harsh word. The best way to dramatise this is to give an award to the ward/ GP practice/ clinic with the most complaints and the highest satisfaction scores on how it was sorted out.


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