Chapter 1 - A brief history of proposals for reform
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The "old" NHS complaints system
Developments in public and patient involvement
Developments in clinical negligence
The 'old' NHS complaints system
1996 Single complaints system introduced
1. The single complaints system, introduced in April 1996, was a radical improvement on a previously fragmented and partial system. For the first time the same complaints system covered hospital, community and primary care services (family doctors, dentists, opticians and pharmacists), and could handle concerns about both administration and clinical treatment. Complaints were first considered and responded to by the service provider. This first stage was known as local resolution. If complainants remained dissatisfied they could ask a convener (generally a non-executive member of the organisation complained about) to arrange a review by a panel of lay people, with access to any necessary clinical advice. This was known as the second, or independent review stage. But there was no automatic right to such a review. Where complainants remained dissatisfied, or had been refused an independent review, they could complain to the Health Service Ombudsman.
1999 - 2001 Evaluation and listening exercise
2. It soon became clear that there were major difficulties with the single complaints system. The Department of Health had always intended to evaluate the effectiveness of the system and commissioned a research study, which ran from 1999 to 2000. The results, published in September 2001, revealed that many complainants felt a high level of dissatisfaction with the operation of the system, both at the local resolution and independent review stages. The main causes of dissatisfaction were unhelpful, aggressive or arrogant attitudes of staff, poor communication and a lack of information and support. The most important structural failure was the 'perceived lack of independence in the convening decision and in the review process generally'. The results of the evaluation resonated strongly with the experience of the Ombudsman's office.
E.1980/03
In July 2001, following her dissatisfaction with the Trust's response to her complaint about her late mother's care, Mrs A requested an independent review. The panel was held in March 2002 and in September Mrs A received a copy of the lay chair's report. She wrote to the Trust chief executive complaining that it was superficial, inconsistent and almost unintelligible. Furthermore, it covered only two of the four issues the panel had agreed to consider and did not refer to the findings of the clinical assessors. It was also unclear what the final recommendations were. The Trust did not respond to Mrs A's letter.
The Ombudsman upheld the complaint. She criticised:
- the poor quality of the report;
- the failure of the lay chair to consult the other panel members;
- the convener and panel members for failing to call the lay chair to account;
- the SHA for failing to ensure the lay chair adhered to complaints guidance and produced reports of the required standard
The Trust and SHA apologised for their shortcomings
3. The Department of Health's evaluation report, NHS complaints procedure: national evaluation
, made 27 recommendations aimed at improvements throughout the system, including:
- a uniform national procedure, applied equally to primary care and hospital services, with clear and consistent time limits;
- dissemination of good practice, and more use of conciliation to achieve results swiftly and effectively;
- clear guidance on how the complaints procedure should be applied, and standard targets nationally for managing the performance of staff handling complaints;
- clear lines of responsibility for making sure the complaints system is run properly, with Chairs and Chief Executives answerable to the Department of Health for their performance;
- a responsibility on Trust Boards to ensure this work is funded properly, staff are trained appropriately to handle complaints and that their clinical governance framework reflects complaints work as core business;
- a system of quarterly reporting by complaints staff to the Trust Board, summarising the causes and trends underlying complaints, and making recommendations for action. These reports to be copied to relevant patient representative organisations, and the Board to be responsible for implementing recommendations;
- support from Primary Care Groups (PCGs) (predecessors of Primary Care Trusts - PCTs) for practices in managing the system, with a named individual responsible for handling practice complaints;
- regional NHS bodies, or a new independent national complaints authority, to be responsible for holding panels to account and managing their performance;
- wide circulation of the panels' final reports to relevant patient representative bodies and the Commission for Health Improvement (CHI), with the Trust Board being responsible for implementing any recommendations for remedial action;
- new options for how panels should be convened: by the Health Authority, neighbouring Trusts/Health Authorities, or introducing a separate regional or sub-regional panel.
2001 The Department consults on key questions
4. To coincide with the publication of the evaluation results, in September 2001 the Department of Health issued 'Reforming the NHS Complaints Procedure, a 'listening' document', which sought comments on the evaluation report's recommendations and set out key principles for an effective NHS complaints procedure.
5. Comments on the evaluation report's recommendations and the key questions were sought by 12 October 2001. As well as written responses, a series of regional events was held across the country to gauge views of NHS staff and patient groups and research was carried out with hard-to-reach groups.
2003 Proposals for the new procedure
6. The Department of Health's response, in January 2002, to the Report of the Public Inquiry into children's heart surgery at the Bristol Royal Infirmary said that they intended to have a new NHS complaints procedure in place by December 2002. However, no new procedure was proposed until April 2003, when the Department published 'NHS Complaints Reform, Making things right'. This described the vision of a new complaints procedure:
- open and easy to access - flexible about the ways people could complain and with effective support for people wishing to do so;
- fair and independent - emphasising early resolution so minimising the strain and distress for all those involved;
- responsive - providing appropriate and proportionate response and redress;
- providing an opportunity for learning and developing - ensuring complaints are viewed as a positive opportunity to learn from patients' views to drive continual improvement in services.
7. Making things right was not radically different from the listening document, although it did attempt to take account of subsequent developments in patient and public involvement. Responsibility for independent review would be placed with the new Commission for Healthcare Audit and Inspection (CHAI - now known as the Healthcare Commission), which was to regulate health services and so provide a link into the quality improvement process.
8. In November 2003 the Health and Social Care (Community Health and Standards) Act 2003 received Royal assent paving the way for CHAI to be set up; regulations to be made about complaints procedures in both health and social services; and for the Health Service Ombudsman to consider complaints about the handling of NHS complaints by any person or NHS body.
2004 Partial implementation
9. In December 2003 draft regulations for the new NHS procedure were issued for consultation. The intention had been to implement the regulations on 1 June 2004. However abbreviated regulations, the National Health Service (Complaints) Regulations 2004, were eventually laid before Parliament on 9 July 2004 and came into force on 30 July. Ministers had decided on a phased implementation to take account of recommendations of the Shipman Inquiry. The Inquiry's 5th report was likely to address complaints handling in some detail and was due to be published later in 2004. Reports from other inquiries about doctors who had repeatedly failed to observe proper standards of care were also expected later in 2004.
10. The July 2004 Regulations left the local resolution stage of the complaints procedure broadly unchanged. They consolidated and rationalised the statutory requirements for local resolution by NHS bodies and introduced a reformed independent review stage to be carried out by the Healthcare Commission. The Department intends to issue revised regulations in 2005 following consideration of the 5th Shipman report.
Inquiries
11. Whilst the new complaints procedure was in gestation there were a number of inquiries into situations where serious failings in systems or in standards of clinical care continued for lengthy periods and affected significant numbers of patients.
12. The Bristol Inquiry reported in 2001, the Neale and Ayling Inquiries in September 2004, the final part of the Shipman Inquiry in January 2005, and the Haslam and Kerr Inquiry reports are expected later in 2005.
13. Each of the inquiries has considered why existing systems, including the complaints system, did not mean that the problems were fully recognised and acted upon far sooner. Each has pressed for a more patient-focused approach. They have also produced specific recommendations on complaint handling.
14. The Neale and Ayling inquiries called for:
- advocacy;
- an independent element to the system;
- early resolution of complaints;
- accessible and easily-used systems;
- better communication;
- training in complaints handling for all staff;
- special training in handling sensitive matters for Patient Advice and Liaison Services (PALS) and Independent Complaints Advocacy Services (ICAS) staff;
- the establishment of systems to ensure that complaints about the same practitioner working in different organisations could be linked.
15. The Shipman Inquiry report recommended key changes to handling complaints about GPs including:
- all complaints about GPs should be reported to the PCT and patients could lodge complaints direct with the PCT; and
- PCTs should develop the ability to investigate complaints properly and refer to the Healthcare Commission where necessary.
Developments in public and patient involvement
16. Between 1999 and 2004, there were significant developments in public and patient involvement which had implications for complaint handling.
PALS and ICAS set up and Community Health Councils (CHCs) abolished
17. In 2000 the NHS plan proposed the creation of patient advocates and patient forums in every hospital to help services become more focused on patient needs.18. Patient Advice and Liaison Services were to be in place in every NHS Trust and PCT by April 2002. PALS provide on the spot advice and information to patients, often helping to resolve concerns before they become complaints. PALS are not intended to be directly involved with formal complaints under the complaints procedure, but often act as a gateway to another new creation - the Independent Complaints Advocacy Services, which were specifically designed to support complainants through the complaints procedure. Contracts were issued to independent advice/advocacy organisations to provide ICAS across the country from September 2003.
19. In effect PALS and ICAS were intended to take over the CHCs' role of helping complainants. CHCs were abolished in December 2003.
2003-2004 CPPIH and Patients Forums are set up then CPPIH is to be abolished
20. While PALS and ICAS were being put in place, a new national statutory body, the Commission for Patient and Public Involvement in Healthcare (CPPIH), was established in January 2003. Its role was to ensure that NHS services take account of the views of the public, providing and facilitating a framework for public involvement and acting as a champion for patients nationally. It did this, in the main, by setting up Patient and Public Involvement Forums whose role was to provide direct independent input into the day-to-day management of health services. They were introduced in NHS Trusts and PCTs during 2003. Then, in July 2004, the Secretary of State announced that CPPIH was to be abolished, as part of a wider review of the Department's 'arm's length bodies'. Patients Forums would continue but, to date, it has not been decided what other arrangements will be provided to support and advise them. The Department began a consultation exercise on this issue in November 2004.
2003-2004 Developments in clinical negligence
21. In June 2003 the Department of Health published a report by the Chief Medical Officer, 'Making Amends - A consultation paper setting out proposals for reforming the clinical negligence system'. It recognised that the present system is unfair, slow, costly in legal fees and encourages defensiveness. The report proposed a new NHS-based system of redress for patients who had been harmed by NHS care, as an alternative to litigation. It would be run by a body building on the work of the NHS Litigation Authority (NHSLA), which currently deals with medical negligence litigation on behalf of NHS Trusts. Initially it would be limited to packages of care and payments to families of neurologically impaired babies and to those treated in hospital or community health settings but not by primary care services. In general, payments would be limited to £30,000, but more may be available for neurologically impaired babies. It recognised that those seeking financial redress should also have explanations, apologies and information about action to prevent recurrence of the problem, which they often did not receive when taking legal action.
22. In July 2004 the Department's review of arm's length bodies said that the NHSLA would be reconstituted to oversee the NHS redress scheme, and further details on the operation of the scheme would be published later in 2004.
