Chapter 3 - Key elements of a new system
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94. It is only right that, if we are to express such significant concerns about present system, we should also make clear what we believe needs to be done. The essential elements in the new system should be those that ensure:
- coherent and comprehensive coverage;
- customer focus, accessibility, flexibility and transparency;
- a quality service;
- leadership, culture and governance;
- the provision of just remedies;
- improvements in service as a result of learning from complaints.
To be effective such new arrangements must be introduced in a planned and project managed way.
95. It is not for us to set out how these outcomes should be achieved, that is a matter for the Department of Health, working with others such as the Healthcare Commission and local NHS bodies. We would certainly want to work with the Department to share our knowledge and learning and expand the principles which we propose must underpin the system.
Coherent and comprehensive coverage
96. So that complainants can complain easily about a single provider, two or more NHS providers, or organisations which provide social care as well as health care, there must be a consistent approach to the handling of complaints across all providers of NHS services, irrespective of where those services are delivered, including primary care, NHS Foundation Trusts and independent providers of NHS services, as well as in social care. But that is not enough. There needs also to be a clear commitment that all these organisations will collaborate to address complaints in a joined up way and arrangements must be built into the system to achieve this.
Customer focus, accessibility, flexibility and transparency
97. All users of health and social care services should know how to complain and access to the complaints process must be equally available to all groups in our community. Complainants need to feel confident that a properly made complaint will not have an adverse effect on their future relationships with the service providers, particularly where s/he is their GP. Complainants who do not wish to complain direct to family health practitioners, should be able to complain to PCTs. Complainants must know how they can pursue their complaint where they are dissatisfied with the result achieved locally, or at the Healthcare Commission. The new approach should be based on listening to complainants and offering support and advocacy to enable them to pursue their concerns in the best possible way.
98. The system should allow for a flexible approach to complaint resolution tailored to different complaints and complainants' needs. It should encourage skilled staff to adapt the investigation and outcome to their varied circumstances. Key issues raised by the complainant must be addressed in any response and explanations given orally or in writing in terms which the complainant can understand. Responses should be timely, and any targets must be carefully constructed to avoid introducing perverse incentives. Targets should cover both timescales and the quality of the service and outcome.
Quality service
99. Those working throughout the NHS should be open about mistakes and failures by individuals or systems. Acknowledging and addressing mistakes should be encouraged not punished. Complainants and staff need to feel confident that they will be treated fairly, given an opportunity to contribute to the process and provided with support and feedback.
100. The initial investigation must be adequate to enable a full, carefully considered response to the complainant, and opportunities for early resolution should be taken. Investigations must be evidence-based and sufficiently rigorous to be used as an initial investigation for subsequent parts of the complaints system and the redress scheme or in deciding whether the body needs to consider other action in the interests of patient safety or improving performance. Those handling the complaint need to have the authority and skills to decide how detailed an investigation is required for each complaint and to carry out the investigation: in some cases this will involve seeing records, interviewing staff and taking clinical advice. Arrangements to obtain appropriate advice are required, as is access to mediation, where appropriate.
101. Delivery of a new high quality local complaints service will require a new focus on the training and competence of complaints staff, for an enhanced role and responsibility in complaints investigation. Managers and front-line staff should also be well-motivated and trained in customer service and complaint handling.
Leadership, culture and governance
102. This will involve the Boards and Chief Executives of NHS bodies creating a culture of openness and learning. There should be clear standards of behaviour set and followed by the leadership of each local organisation, and the monitoring of performance on complaints by managers and by the Board. Managers need to ensure that arrangements for complaint handling are well connected with clinical governance and quality improvement activity.
Just remedies
103. All levels of the complaints system should include provision for a full range of remedies for justified complaints, including explanations, apologies, specific actions or treatment for the patient, changes to prevent recurrence and, where appropriate, financial compensation. Redress should be designed to put the complainant back in the position they would have been in had the service failure or maladministration not occurred; or, if that is not possible, to compensate them appropriately.
Improvements in service
104. Recommendations arising from complaints should lead to practical improvements in service, and progress on implementation and effectiveness should be monitored. As well as reporting to the Board, NHS bodies need to build in systems locally to feed back learning from complaints to directorates/teams. Inquiries have highlighted the need for systems to be in place to ensure that those (fortunately rare) clinicians who repeatedly harm or pose a risk to patients are identified, wherever they are working.
105. The Healthcare Commission is in a strong position, in collaboration with others, to identify and drive forward learning from complaints nationally.
106. And our Office is committed to making an active contribution to the improvement of services from the evidence we gather.
Implementation
107. Implementation needs to be planned in more detail and with sufficient time for NHS and other organisations to be informed about what is expected of them. Patients, complainants and those supporting them need to be given clear information about the changes and the implications for them, well in advance of the change taking effect. Detailed guidance should be in place well before implementation of new procedures, together with training for staff. Transitional arrangements should be well thought through and clearly publicised.
