Promoting a just culture | Parliamentary and Health Service Ombudsman (PHSO)

This guide sets out how to develop an organisation-wide culture that openly welcomes complaints and is accountable when mistakes happen.

It explains how to embed the most important cultural values that encourage colleagues to do two things:

view complaints as a vital tool for getting feedback from the people who use your service 
use this feedback to improve colleagues’ and organisational performance.

It also sets out what you can do to create a learning culture.

This guide is one of the Good complaint handling series, designed to help you meet the NHS Complaint Standards. Read this and the other Good complaint handling guides alongside the Model complaint handling procedure. 

What do we mean by organisational culture?

In this guide, the term ‘organisational culture’ refers to:

the values shared by everyone who works in your organisation
the way these values are applied in practice in your organisation’s policies and processes
the way they are applied through the behaviour and actions of each employee.

What do we mean by a learning culture?

In a learning culture, colleagues know (and regularly see) that the organisation always:

gives them the confidence to speak up when things go wrong, rather than blaming them
encourages colleagues to identify what learning can be taken from feedback and complaints to make continuous improvements, even when things have not gone wrong
regularly reviews feedback and complaints at senior level, and uses the resulting insight to improve systems or processes that support colleagues, rather than focusing on individual people’s mistakes
supports the mental and physical wellbeing of any colleague who is subject to a complaint by keeping them informed and engaged during the process
makes sure there is the right balance of accountability and learning for every staff member
translates learning from feedback and complaints into practical action that aims to improve services and develop colleague learning.

Why create a learning culture?

There are many benefits to creating a learning culture. Here are some of them:

People who use your service can see that your organisation responds proactively and openly to feedback and complaints and regularly uses learning from them to improve services.
Colleagues know to be open and accountable when mistakes happen and feel confident to speak up when things go wrong.
Colleagues are empowered to learn from the insights that come from feedback and complaints. They are supported to be accountable for their actions and use learning to improve.
Colleagues are trained to know what a learning culture looks and feels like in practice, and how to promote it in their work.
People who complain to your organisation feel they have been listened to and have had their concerns looked at openly, thoroughly and fairly.

What standards, regulations and guidance are relevant to this guide?

the Complaint Standards, which set out expectations to help you deliver good complaint handling in your organisation.
Managing Public Money
the corporate governance code for central government departments
the National Audit Office good practice guide: improving operational delivery in government
the Civil Service code
the Seven Principles of Public Life (the Nolan Principles).

Promoting a learning culture

Senior leaders make sure every colleague knows how they can create and deliver a just and learning culture for handling complaints. Colleagues and senior leaders demonstrate how they contribute to this culture through practical examples.

Senior leaders make sure appropriate structures are in place to deliver fair and robust complaint investigations.

Senior leaders make sure colleagues are supported and trained in all aspects of dealing with complaints, from identifying a complaint to issuing a response, so that they meet the expectations set out in the Complaint Standards. This should include how to manage challenging conversations and behaviour.

Appropriate governance structures are in place so that senior leaders regularly review information that arises from complaints and are held accountable for using the learning to improve services. There are clear processes in place to show how organisations do this, and this information is included in their annual reports.

Organisations put appropriate measures in place to capture feedback about the complaints process from service users who make complaints and from colleagues directly involved. They use this to demonstrate how the organisation has performed towards meeting the Complaint Standards.

Parent departments have meaningful strategic oversight of how their related organisations are performing. They know how these organisations handle complaints and how they meet the expectations set out in the Standards.

A4.14.1. Public sector organisations should operate clear accessible complaints procedures. They are a valuable source of feedback which can help shed light on the quality of service provided, and in particular how well it matches up to policy intentions. So all complaints should be investigated. ... Systems for dealing with complaints should operate promptly and consistently. Those making complaints should be told how quickly their complaints can be processed. Where groups of complaints raise common issues, the remedies offered should be fair, consistent and proportionate.

A4.14.1. Public sector organisations should seek to learn from their complaints. If an internal or external review, or a PHSO investigation, shows there are systematic faults, defective systems or procedures should be overhauled and corrected.

4.1.2 … Each public sector organisation needs clear leadership, normally provided by a board.

The guide explains that best practice for boards in central government departments includes leading the department’s business and determining its culture. They should also ensure good management of the department’s resources financial, assets, people and keep an overview of its arm's length bodies activities” (please see parent department guide for further detail)”

What the corporate governance code, as referred to in Managing Public Money says

1.2.2 As the Corporate governance code makes clear, the minister in charge of a department is responsible for its policies and business … They … determine the policy of the departmental group … choose which areas of business to delegate to officials, and on what conditions … have general oversight of other bodies on whose behalf they may answer in parliament, including the department's arms length bodies (ALB).

Practical actions that senior leaders can take:

Ensure that organisational behaviours support system working.
Get to know your service users.
Have information that tells you which parts of the system are struggling.
Create clear responsibility and accountability for fixing problems.
Make it clear that everyone is responsible for solving problems.
Build your organisation’s understanding of what different types of service users need or want and keep it up to date.
Focus performance measures on what users want.
Understand what matters for end users and make that the critical requirement when designing and improving services.
Create accountability for solving process problems.

Leading in Practice, published in 2023 by the Committee on Standards in Public Life, features practical case studies on ethical public sector leadership and prompts for leaders to discuss and reflect on their leadership and organisational practices.

What you need to do

Complaints give organisations a vital and direct insight into the quality of their services. They can offer a quick route to identifying how to improve a service, sometimes with changes that can be implemented immediately. But too often, organisations do not value or prioritise them.

The role of senior leaders

Good complaint handling must be led from the top. That means senior leaders need to follow best practice in handling and learning from complaints.

For example:

Welcome all types of feedback.
Be engaged in complaints.
Be involved in the way complaints are handled.
Understand and act on the insight complaints provide.
Put a clear, straightforward complaints process in place.
Make sure colleagues are trained, supported and empowered to handle complaints fairly, openly and with maximum accountability.
Make sure effective governance systems are in place so that senior leaders regularly oversee complaints.

At a fundamental level, senior leaders must actively make sure all their colleagues understand and recognise the core values of a fair and learning culture. These values must also be demonstrated in practice, to build trust throughout the organisation.

Tip: How to embed these core values

- Include these values in your complaints policy. This will help them become normal practice whenever someone makes a complaint.
- Train all colleagues on how your organisation values and handles complaints. This includes explaining their role in embedding these values and how to challenge any colleagues who do not uphold them.
- Include this content in any induction programme, so that new colleagues are immediately aware of your organisational values.

Case study: leading with integrity and exploring values-based behaviour Department for Environment, Food and Rural Affairs (Defra)

In the Leading in Practice review by the Committee for Standards in Public Life, the Permanent Secretary from Defra explained how she leads ‘with integrity and understanding, and living by the Civil Service Code’.

At Defra, leaders held discussions on values-based behaviour. The leaders then held similar discussions with their teams, which led to long-term changes. For the executive team, this meant a private check-in session before the weekly formal meeting to share problems and dilemmas in a safe space.

Senior leaders also took part in an activity about how they connect with Civil Service values, linking them to their personal values and what they do at work.

Source: Leading in Practice, the Committee for Standards in Public Life

In an organisation with a well-developed learning from complaints culture, senior staff play an active role in complaint handling. This often involves providing assurance and signing off or reviewing complaint responses.

Where this is not possible (for example, because of the size of the organisation), senior leaders must put in place processes to make sure colleagues escalate any complaints about serious or significant issues, for them to oversee and act on.

Senior leaders must make sure feedback and complaints insight is embedded into governance processes. This enables the organisation to continuously assess, monitor and improve the quality of its services.

Tip: Embrace the positive
Board members have a duty to ask questions, and offer constructive challenge, and scrutinise. This scrutiny should be viewed as tool for driving improvement, not as a threat.

What is the role of the board?

It is a fundamental requirement that senior staff and (where appropriate) the organisation’s board see(s) regular reports on complaints. These need to provide periodic data on:

the number of complaints received
how many cases have been resolved at the frontline stage to the satisfaction of the complainant
the number of cases being looked at in more detail
details of cases that have been closed, including any findings or learning identified and what actions are being taken to improve
details of cases referred to the Parliamentary and Health Service Ombudsman (PHSO), including updates of any recommendations from PHSO for the organisation to take forward.

Senior staff and boards should always review complaints data and insight alongside relevant periodic data from other sources of insight such as staff surveys, claims and general feedback. They should use this triangulated analysis to identify any patterns or themes that indicate where system or service improvements can be made.

If your department or organisation has an independent tier as part of its complaint procedure, you should see that as a valuable source of insight into how your organisation is dealing with and learning from complaints. If this is the case, an appointed non-executive board representative with responsibility for overseeing complaint handling should meet with your tier regularly. At these meetings, they should listen to their views and examine the evidence they have collated on how well the organisation is handling and learning from complaints.

Using complaints panels

Well-developed organisations set up a complaints panel to make sure senior leaders regularly listen to complaint stories and keep up the momentum in learning from complaints and monitoring performance.

Complaints panels are made up of senior leaders and colleagues who are responsible for handling complaints. Panel members meet regularly to:

review complaints data
discuss cases of interest
review actions to improve services as a result of learning from complaints.

This approach has several benefits:

It helps make sure complaints remain a high priority in the governance process.
It enables senior colleagues to provide assurance on what the organisation is doing to monitor, assess and improve the quality of services.
It supports and develops colleagues to reflect on learning from complaints.

Case study: keeping complaints high on the leadership agenda

The Civil Aviation Authority (CAA) has a Consumer Panel to provide a consumer perspective on all aspects of the CAA’s work.

The key activities of the Panel are to:

- Help the CAA to understand fully, and take account of, the interests of consumers in its policy development and decisions.

- Use existing CAA research, request the CAA undertakes new targeted research and gather intelligence, to understand the aviation consumer experience.

- Provide the CAA with feedback from a consumer perspective on the effectiveness of its policies and practices.

Tip: Promote an equal balance

Well-developed organisations promote an equal balance between:
- encouraging colleagues to take responsibility for their actions
- supporting colleagues to learn and improve from all types of feedback.

Make sure your colleagues have the opportunity to provide meaningful input into complaints about them, or complaints that affect their role.

For example:

Make sure every colleague complained about is supported and engaged during the handling of a complaint.
Create effective ways for staff feedback to be captured and shared alongside complaints, claims and general feedback at board level and other senior leadership meetings.
Build a strong partnership with staff representatives and networks to make sure feedback is used to support individuals and promote wider organisational learning.

Find out more

‘Being Complained About’, published by the University of Glasgow, provides practical approaches to how organisations can effectively support colleagues who are subject to a complaint.

Make sure there is a close connection between the monitoring of complaints and all other feedback channels, such as compliments and customer satisfaction surveys. This provides a detailed triangulation of important feedback to make sure you can confidently understand the quality and impact of your services on user experience.
Organise your teams so that colleagues responsible for feedback and complaints can work together closely.
In larger organisations make sure all complaints and feedback analysis is managed within the same division (usually where the governance and/or quality improvement functions sit) and report to senior staff. Where this is not possible, make sure that all relevant colleagues regularly collaborate to share insight and are responsible for joint reporting to senior leaders.
In smaller organisations make sure there is resource allocated for analysing all this type of feedback. The triangulated results should be reported back to senior leaders on insights and how these can be used for improvements.

Case study: how HMRC monitors and reports on performance against its Charter

The HMRC Charter outlines what customers can expect from HMRC and what HMRC expects from its customers. HMRC monitors performance against the Charter by specific service standards, customer surveys and other data, linked to wider HMRC performance measures.

HMRC’s customer experience committee publishes a report each year, assessing HMRC’s performance against the Charter. This includes progress and priorities for further improvement.

The committee also reviews HMRC’s performance at its quarterly meeting. These quarterly reviews are informed by feedback from its independent tier organisation (the Adjudicator) which sits on the committee and from a group of tax professionals. The tax professionals also meet quarterly with HMRC to provide their views on HMRC’s performance against the Charter.

Reporting on feedback and complaints insight is an essential pathway to building trust with colleagues and service users alike. It shows that your organisation highly values learning from complaints.

Make sure there is an open and transparent relationship with colleagues and service users. This includes feeding back results and learning to all colleagues and externally to service users.

Regularly communicate all actions that have been taken and explain how these have made a difference to learning and improvement. This shows colleagues and service users that feedback and complaints make a difference. It also helps people who complain know your organisation listens and is responsive and open to learning from feedback.
Regularly share report summaries of complaints learning activity with colleagues, with users through your website and with service-user interest groups.

Tip: You can use this reporting in your annual reporting cycle to show how you have used feedback and complaints to improve your services.

Your organisation should regularly evaluate and improve how it captures and processes information related to monitoring its services, including complaints.

You should set up mechanisms to capture feedback about the complaints process itself, from people who have complained and from colleagues who have been involved in the process.

Tip: To do this, gather feedback through surveys or interviews with people who have been involved in your complaints process. You can measure the findings against the expectations set out in the UKCG Complaint Standards.