Introduction
Across the NHS, leaders are grappling with intense operational pressure, system reform and rising public expectations. Yet one priority must remain paramount: patient experience cannot be a peripheral concern. It is central to improving care and patient safety, restoring trust and strengthening the system for the future.
We recently spoke to senior NHS leaders and their teams at NHS trusts across England. We asked how they handle complaints, what those complaints tell them and how they use those insights. Our discussions highlighted a set of consistent themes about what is working well, where challenges persist and what needs to change. We heard that:
- leadership matters
- complaints are increasing and patient-clinician relationships are more strained than before
- a defensive culture across the NHS shapes behaviour
- regulation supports improvement, but confidence varies
- system changes must not diminish focus on the patient experience
- digital change must be shaped by users.
By sharing what we’ve heard, we hope to support senior leaders at NHS trusts to prioritise how they learn from complaints as a core driver of improvement and patient safety.
Leadership matters
Staff and clinicians consistently emphasised the importance of visible, engaged leadership from the top in setting the tone for how complaints and patient experience are handled. In organisations where complaints are used effectively for learning, Boards routinely see samples of patient complaints, senior leaders engage directly with complainants, and themes from complaints are reviewed alongside quality and safety data. Chief executives and chief nurses value complaints as a way of understanding the patient experience in their organisation and informing how they continuously improve patient safety and care.
What good practice looks like
Trusts described strong governance arrangements, including monthly quality committees and the active engagement of their Boards. Some trusts applied multidisciplinary oversight of complex clinical cases and used data analytics, including AI-enabled analysis, to identify patterns and risks emerging from complaints data.
This visibility from the top signals to staff that listening, learning and improvement are priorities, and helps to create a culture where it is safe to acknowledge mistakes.
Rising complaints and the patient-clinician relationship
All the trusts we spoke to said the volume of complaints is rising. Some reported increases of up to 100%. Trusts also told us they are getting more complaints written using AI. Technology can help people explain their concerns more clearly. But AI-generated complaints can also contain errors and be overly long creating additional work for complaints teams. Complaints are also becoming more complex overall.
Many clinicians reported increased strain in their relationship with patients. Our discussions explored how clinicians, particularly those newer to practice, were encouraged to listen carefully to patients’ concerns to understand their experiences and expectations, and respond empathetically to build trust, while also managing the pressure of challenging behaviour from patients themselves. One Trust described incidents of racist behaviour from patients directed at staff, which led to the closure of their Patient Advice and Liaison Service (PALS) drop-in service. Dealing with difficult, abusive and sometimes violent behaviour from patients was an increasing challenge for many of the trusts we spoke to.
Some complaints teams reported defensive attitudes and a lack of engagement from clinical staff when dealing with complaints, which led to delays in responding to complaints. We heard several reasons for challenges in engaging clinical staff, including:
- a lack of ring-fenced time to deal with complaints
- service pressures
- workplace stress
- burnout arising from vicarious trauma
- morale problems in some service areas.
We also heard examples of good practice, where engaged clinicians acted quickly to resolve complaints and made sure that they and their teams learned from feedback.
What good practice looks like
Identifying and addressing the causes of rising complaints is challenging and takes time. But one Trust spoke about ‘dealing with stuff in the moment’ - catching patient concerns before they escalate and develop into complaints by addressing misunderstandings that may have arisen from poor communication between the clinician and patient.
Many trusts recognised the need for more training for early-career clinicians to develop skills in listening to patients and addressing patient distrust or concerns, building the confidence and resilience to do so in their foundation years.
We also heard some good examples of supporting clinicians to improve their engagement in the complaints management process. One Trust told us how the appraisal process was an effective mechanism for discussing complaints, allowing clinicians time to reflect and identify what they could do differently. We heard that a consistent approach to dealing with complaints helped manage expectations and led to better outcomes.
Defensive culture shaping behaviour
Leaders spoke openly about a defensive culture across the NHS, often reinforced by high-profile media coverage and regulatory scrutiny. This can influence how a Trust responds to complaints, make candour more difficult and increase anxiety about complaints, even when staff are acting in good faith. National reputation also has a local impact, with serious failures elsewhere often leading to more complaints locally.
What good practice looks like
Organisations that manage this well focus on tone and openness. Trusts told us how they support staff to have honest conversations with patients, emphasise learning rather than blame, and recognise that clear, compassionate communication can reduce escalation and build trust.
We also heard how building patient voice into service design and delivery leads to more positive experiences and a reduction in complaints.
Regulation supporting improvement with varying confidence
Leaders broadly recognised the role of regulation in raising standards, but also raised concerns about burdens on time, inconsistency and varying degrees of confidence in inspection approaches. Variability between regions and questions about methodology were seen as undermining trust.
Senior leaders also described how regulatory approaches for underperforming organisations can unintentionally stifle improvement, limiting their ability to move forward.
What good practice looks like
Where regulation works best, it is complemented by strong internal learning systems. We heard about trusts using complaints and patient feedback to demonstrate improvement. They saw a clear benefit in working collaboratively with regulators to embed learning and evidence improvements.
Prioritising patient experience
Senior leaders described overwhelming competing priorities, fragmented systems and in particular, uncertainty about the role and capacity of Integrated Care Boards. While neighbourhood health is widely seen as the right direction, the infrastructure and resources are not yet in place. Patient experience is recognised as critical but Trust leaders did not always see it prioritised in national reform.
What good practice looks like
Organisations that maintain focus on patient experience actively triangulate complaints, safety data and patient voice at both organisational and system level. They invest in outreach, work with community groups and use learning from complaints to inform strategic decision‑making.
Digital transformation and patient-centred design
Digital transformation is one of the NHS’s biggest challenges. Leaders are optimistic about AI as part of wider data-enabled learning. Better use of complaints, safety data and patient feedback would help target improvement action where it is most needed. They support future rollout of the Single Patient Record across providers to support more co-ordinated care. Access to accurate, reliable information at the right time is essential to delivering safer care. Leaders also emphasise that technology choices must meet real needs and improve patient experience.
What good practice looks like
Effective organisations involve patients early to make sure that systems accommodate the patient journey and focus on technology that supports effective communication rather than creating complexity. Patient experience is seen as essential to making digital change safe, inclusive and effective.
Conclusion
The issues driving complaints - communication, delays, discharge and basic standards of care – remain familiar. What stands out is how organisations respond. Where leadership is visible, learning is prioritised and patient voice is taken seriously, complaints become a powerful driver of improvement rather than a source of risk.
As the NHS continues to reform, these examples of good practice offer practical insight into how patient experience must remain central, even in the most challenging conditions.