Ann Clwyd and Tricia Hart – the MP and the Prof – are to be congratulated on avoiding many of the elephant traps associated with calls for improved complaint handling. This is not a ‘tear it up and start again’ bit of populist barn-storming milking the sadness and emotion at the heart of the stories of patients and their families. So if they have resisted the temptation to seize the topic by the neck and give it a good shaking, then what have they done?
The report does acknowledge the emotional distress of both patient and carer in the hospital context. Given the experience with her dying husband, that Ann Clwyd had experienced, it would have strange if it had not. The recommendations though are restrained and they acknowledge the need to get beyond diagnosis to implementation.
Better handling – ‘appropriate professional behaviour’ – training for all: more feedback; more support for ICAS; annual complaints report (good idea); better recording (how? who?); protection for whistle blowers and support for a cultural barometer (do not hold your breath) and commitments from a range of NHS bodies. Big question: will the report produce change?
MAC suggestions – avoid dead ducks
We offered our suggestions at the time to the enquiry team. We said then and say again now -when it comes to complaint handling in the NHS, the mixture as before is a dead duck.
Lots of reasons, but top of our list is that the NHS needs to invent its own approach to complaint handling for its own circumstances and needs. Good complaint handling in the corporate, for-profit competitive world is based on agreeing, paying and moving on. It is not interested in ‘fair’; it is not interested in weighing the account of the customer against (say) the store manager; unless fraud or some other crime is suspected: the customer account is agreed with and item exchanged/replaced. This brisk and rather unfair process is not interested in right or wrong; it is interested in customer retention. To achieve this, relatively junior staff have the right to over-rule often more senior staff in the interests of a quick solution.
This way of doing things is not available to the NHS – perhaps because the organisation is an instrument of social harmony dedicated to dealing equably between citizens where to be fair is the paramount ethical driver and and more brutally and bluntly, the clinicians and other healthcare professionals will not wear being over-ruled and apparently disbelieved by a junior complaint handler in the management team who wants to strike a deal with a patient and/or their family. Hence the prevalence of escalation to the Trust Chief Executive and beyond to the Ombudsman.
Big question: what has to happen for the NHS to do things differently and well?
Say It Again – with some numbers this time
We need a good look at the money and reward the early complaint closures. Having checked the process and its costs, find out who is complaining about what. Clwyd/ Hart do not have a single piece of data in their report – not a number, not a £ sign, not a graph.
Admittedly this makes for an easy read and reminds us of the human beings that have suffered and not been heard. But this approach seems faint-hearted and sentimental when the report comes out in the same week as two conferences on the theme of Open Data. Check out the speakers for the Open Data Summit – no one from the NHS on the programme as far as I could see but other initiatives in the NHS and public health arenas are taking place now with a potential to transform practice and put data in patients’ hands. The new approach must have open data at its heart to give some real meaning to a discussion of candour. The duty to publish is more easy to implement than to insist that staff will spill the beans.
The report is all about hospitals – nothing about GPs. Clwyd/Hart quote research that 26% of us will not or have not complained because we did not want to be singled out as troublemakers. That would go double in a GP context where the cure for troublemakers is expulsion from the practice. There are no figures at all for GP complaints and measures of GP performance in this area.
And don’t forget whistleblowing
Finally – NHS staff. Protection for whistleblowers is good, but the key to better staff performance in the NHS is to stand the present situation on its head and look at reward and positive incentives. We said before:
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.
Diagnosis of what is wrong with complaint handling has been done to death. Calls for action abound. Every year the Ombudsman reports. Does complaint handling get better for patients while costing the NHS less? Nobody knows. When they do and marry the facts with the empathic behaviours of staff who have nothing to fear from the process, we will have transformed NHS complaint handling.
Introduce the positive culture around complaints that we recommend and this makes possible the NHS duty of candour that National Voices and others so strongly advocate. Without that confidence, staff will see the duty as just another stick to beat them – another duty whose impact falls disproportionately on the most junior and those nearest the patient and user.
This time next year?
Will next year be the time for all this when Clwyd and Hart come back after nothing much has happened and have another bite at the complaint handling cherry?
The Millar Adamson Craig Partnership supports user and public participation, trains lay representatives and develops responsive health, care and education organisations. Feel free to contact us to discuss the opportunities. Follow MAC on Twitter @publicinvolve and @parentinvolve