The UK parliamentary and health service ombudsman, Dame Julie Mellor, has published her ‘review into the quality of NHS complaints investigations where serious or avoidable harm has been alleged’ [Guardian articles on this: here, december 2015, and here, february 2015].
The Guardian reported, “Dame Julie Mellor warns that three out of four investigations fail to identify serious failings in care as families are often met with ‘wall of silence’”. The ‘wall of silence’ phrase does not appear in the report unfortunately, but you know what they mean.
What the inquiry found was:
We found that 40% of investigations were not adequate to find out what happened. Not only are trusts not identifying failings, they are also not finding out why the failings happened in the first place. For example, trusts did not find failings in 73% of cases in which we found them, and in over a third of cases where failings were found, trusts did not find out why something went wrong. This is in marked contrast to the perception of 91% of NHS complaints managers who were confident an investigation could find out what had gone wrong.
To the extent that I have any qualifications to comment on this situation they arise from:
1 extensive experience in business as a systems analyst and consultant investigating and documenting various organisations’ procedures, and even more experience as a manager in a wide variety of roles for a wide range of customer-facing clients (such as retailers) where complaints have to be taken seriously (if only for legal reasons)
2 voluntary work with a local Healthwatch body, in which role I have reviewed a number of NHS and local authority documents relating to the provision of health and care services, including one trust’s draft ‘complaints and feedback policy’.
1 I reviewed one trust’s draft ‘complaints and feedback policy’ in March 2015. It was clearly based (word for word in many places) on an NHS England document, an ‘interim complaints policy’. Another trust—an acute unit—had, at that time, a complaints policy document which also, to all intents and purposes, was the NHS England exemplar. It seems likely that other trusts around the country were/are also using this NHS England document as the basis of their own policies.
The NHS England document has now been removed from their site, and the whereabouts of its successor—hopefully some form of final document—are not immediately clear. However, it is the draft version of the document that was current in the period of the ombudsman’s review.
The NHS England document ‘interim complaints policy’ is/was not fit for purpose. Indeed, it is so far below fit for purpose that, when I reviewed its incarnation in my local trust, my report ran to 22 pages even though I only had time to review bits of it.
2 If an NHS trust wishes to define a useful and safe policy on complaints handling, from which to derive good, auditable, procedures, it has appears to have two choices
- follow an existing example
- work it out for themselves.
It would be nice to think, even in these days of the governmental fragmention of the NHS, that there was a central document (created by NHS England, perhaps) which trusts up and down the country could use as the basis of their own purpose-built policy. However, for reasons I will give below, it cannot be found in the NHS England document I saw.
The alternative, that every trust sits down and works it out for themselves—a simple extrapolation of the government’s approach to the NHS—is as unrealistic as it is shocking. Few trusts have the expertise to work it out from first principles and, if they are reluctant or unable to buy in some consultancy, the chances that they will get it right are small.
So, point 1: It is not possible for a trust to consistently and adequately investigate complaints, particularly serious ones, if the managers in it do not have access to adequate exemplars of policy and procedure to follow.
They simply cannot know what to do, and therefore cannot be expected to do the job properly, other than by chance.
If the policy, and the procedures derived from it, are inadequate, the job of internal audit becomes difficult to the point of impossibility. So, there is no credible, reliable means of checking how complaints are handled within a trust.
This view is evidenced by the review’s findings: “We found that 40% of investigations were not adequate to find out what happened… Trusts did not find failings in 73% of cases in which we found them…”.
3 There are lots of problems with the ‘interim complaints policy’ document supplied by NHS England. Here are the two most egregious.
Firstly, the policy makes no mention of escalation.
If it does, it misunderstands ‘escalation’ to mean what to do if you, personally, can’t handle a complaint; answer: you give it to your boss. That isn’t what escalation means.
Escalation means having an audited and tested process whereby, if a complaint turns out to be more serious than had been originally gauged, the way it is handled, and the people who handle it, are changed and upgraded in a documented, tested way which is, itself, a procedure.
Even assuming that a trust has a policy for handling complaints which are clearly major from the start, compared with less serious ones, there is no policy for upgrading a complaint. I bet these are some of the complaints which the ombudsman’s review captured. Yet these are ones which are likely to cause the most problems for the trust and the one’s where a trust would have most need of a good procedure.
Last September, at the AGM of an acute trust, I pointed out to its chief executive that I thought its complaints policy was not fit for purpose. How do staff members upgrade a complaint?, I asked.
He actually replied that it was his personal decision whether a complaint was upgraded. He had just come back from two weeks’ holiday and there were several in his inbox waiting for his attention!
Had he been the chief executive of a business in which I had shares, I would have given him a very hard time. But, frankly, I felt then it would have been like kicking a deaf, blind puppy: not an action likely to achieve anything useful. In any case, what comes across as jaw-dropping complacency is really just an expression of how unaware of good practice he appears to be.
Point 2. How to escalate complaints which turn out to be more serious than originally thought is an essential part of any complaints handling policy.
4 The second problem is that the draft policy I reviewed makes no mention of what to do if a complaint needs to be passed to another trust, or to some other service provider.
Yet, someone might complain to their GP about treatment they were receiving from a non NHS provider (such as Turning point), contracted by the local authority (not the CCG), to whom the GP had referred them. That’s three different organisations, two of which are not NHS bodies, and one of which is not public sector. There is nothing in the draft policy I reviewed, or the document it is based on, which covers the communication between different bodies who are, or who might be, culpable, or who are simply needed to help resolve a complaint.
This is a recipe for a ‘wall of silence’, even if it is not the one complained of by the ombudsman.
It is impossible to see how a complaint of this sort—and many of them must be—can be adequately resolved, other than by chance.
Point 3. How to coordinate resolution of a complaint between relevant bodies is an essential part of any complaints handling policy.
5 I made many other points in my March review. I’d like to repeat one more of them here. Through the wonders of word searches, it was a simple matter to discover that the policy I reviewed did not contain the word ‘strategy’. The only conclusion is that the trust in question did not see that there might be (should be) a link between its overall strategy and its policy in this area. This is remarkable, if you think about it.
What needs to change?
6 The ombudsman’s review concludes with a section, What needs to change?
This is what it says (I have cut it, but not reworded it):
1 IPSIS [the new Independent Patient Safety Investigation Service] and NHS England should consider how the role of NHS complaints managers and investigators can be better recognised…
2 …IPSIS should develop and champion broad principles of a good investigation.
3 IPSIS should work with others to lead, inspire and share learning from its own investigations in order to improve the capability of the local NHS…
4 Trusts should demonstrate to their boards that they have clear objectives both for their organisations and their staff …
5 The Department of Health and NHS England should work with IPSIS to make clear who has accountability for conducting quality NHS investigations at a national and local level….
This isn’t good enough. In fact, it is remarkably bland.
I am afraid that “broad principles of a good investigation” won’t cut the mustard. The devil is in the detail. Procedures must be explicit and unambiguous.
To address that point, what needs to change is that:
Point 4. All NHS trusts should have good, workable, effective, fit for purpose, auditable policies and procedures for handling complaints and criticisms.
You can’t expect (or want) the doctor to whom a serious complaint is addressed to make it up on the spot.
Obviously, these same good, workable, effective, fit for purpose, auditable policies and procedures for handling complaints and criticisms should apply to all trusts, although probably there is a case for variations to cater for the differing of needs of acute units, clinical commissioning groups, mental health services and so on. To the extent that local authorities are also required to commission health services, they have to play by the same game.
And, what also needs to change is that:
Point 5. The extent to which complaints procedures are complied with in each trust should be capable of being audited by someone able to do that (and then it should be done).
In the first place, establishing and maintaining compliance with procedure is a management function within each trust, and there should be procedures to cover how that is done properly. An audit function should be involved to assess the consistency and adequacy of the whole process—including the management review of compliance with procedure—operated in each trust. I do not know whether the CQC is in a position to do this (I am sure they would like people to think they are) and clearly the ombudsman is the wrong person to ask. It would be nice to think that each trust had its own empowered, competent internal audit function, but something tells me that most don’t.
If trusts resolve complaints according to a policy derived from the interim NHS England document in use earlier in the year, it is inconceivable that there won’t be more problems of the sort described by the ombudsman.
It is absurd to expect every NHS trust in the country to work out best practice for themselves.
At best, each trust would have to buy in the same consultancy to tell them the same things—which is an unjustifiable waste of NHS resources. At worst it will be a shambles, as the current report has found.
There has to be a nationwide initiative to define policy and procedures regarding complaints handling which are fit for purpose. This isn’t difficult. Indeed, if you ask me, I’ll do it for you. Let’s have every trust being required to use a new, good enough, template.
What is needed is an injection of reality. These injections are really easy to get hold of—and cheap. Many businesses will give good examples of how to handle complaints well (of course, many can’t and won’t, but that is another story).
© 2015 Jeremy Marchant . amended 21 april 2016 . image: Free images