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International J ournal ofHealth Care QualityAssurance11/ 2 [ 1998 ] 41–44©MCB University Press[ISSN 0952-6862 ]

Preliminary evaluat ion of t he ef f icacy andimplementat ion of t he new NHS complaintsprocedure

J. M cCrindleResearcher, Queen Margaret College, Edinburgh, UK R.K. JonesLecturer in Sociology of Health and Illness, Department of Management andSocial Sciences, Queen Margaret College, Edinburgh, UK

The increase (28.8 per cent) inthe number of complaints frompre-New NHS ComplaintsProcedure to the implementa-tion of the new procedures in1996 is a matter of concernbecause it is estimated thatthe current gure representsonly 40 per cent of the numberof people with some dissatis-faction. The Wilson Reportprompted Government initia-tives in producing a new NHSComplaints Procedure. Thenew procedure allows forcomplaints to be dealt with ata local level, or in a minority of cases through IndependentReview. The new procedures,which were introduced in April1996, oblige Trusts, GP prac-tices and Health Boards toestablish a Written Local

Resolution process for han-dling complaints, responsibil-ity for implementation lyingwith individual trusts. A pre-liminary assessment of theNew Procedures was carriedout in Lothian. A qualitativeapproach was utilised andsemi-structured taped inter-views lasting on average onehour ten minutes were admin-istered to the six complaintsofficers. This study concen-trates on how the six LothianNHS Trusts are implementingthe new procedure, the open-ness in complaints handling,and the awareness of howcomplaints can be used toimprove standards. The con-clusion is that Local Resolu-tion 1 has been successful,and that complaints do receivea speedy response. Theprocess is much simpler andeasier for the lay population toaccess. Reservations remain,however, towards the Indepen-dent Review proce dure.

IntroductionA new public sector philosophy and culture inthe NHS has emerged from the Citizen’s Char-ter Complaints Task Force that was estab-li shed in 1993. This is part of the wider Ci ti-

zen’s Charter whi ch seeks to improve stan-dards in public service delivery generally, andemphasises that such services should beresponsive to the needs of patients and theestablishment of a comprehensive complaintsprocedure. The 28.8 per cent increase in com-plaints to the Health Service Commissionerbetween 1994/ 5 and 1995/ 96 (Woodyard andDarby, 1996) i s regarded by many as an under-estimate and that the true gure is muchlarger (McCarthy, 1992; Mulchay and Tr itter,1994). I t i s suggested that only 40 per cent of perceived grievances are arti culated verballyor in wri ting.

The publi cation of the Wilson Report in May1994, “Being Heard”, was responded to in theMarch 1995 Government Report, “Acting onComplaints”, which resulted in the establi sh-ment of a new NHS Complaints Procedure,embodying the seven principles of the WilsonReport. T hese are:• responsiveness;• cost-effectiveness;• impartiality;• speed of response;• accountabili ty;• quality enhancement;• accessibili ty;• simplicity;• condentiali ty.

These act as “the golden rules of action”. Theresponsibil ity for implementation lies withthe Trusts. Thi s preliminary study was car-ri ed out in Lothian, Scotland, in an attempt toevaluate the degree of success of the newimplementations after a six months’ period,from Apri l to September 1996. T he key objec-tives of the Complaints Procedure in Scotlandwere:• ease of access for patients and

complainants;• simplied procedure;• ease of extracting lessons on quali ty from

complaints;• fair ness for staff and complainants alike;• more rapid open process;

• honest, thorough approach resulting insatised clients;(Scotti sh Offi ce, 1995)

Background

Histori cally, users of the NHS have been reluc-tant to complain for a vari ety of reasonsincluding the positi on of health employees inthe social hierarchy and various feeli ngs that“Doctor knows best”. MORI (MORI Survey,1995; The Citizen’s Charter Complai nts TaskForce, 1995) found that two-thirds of people inScotland did not know how or where to com-plain in matters concerning the NH S and, of those who did complain, nearly half wereuncertain about whom they should contact. Inaddition there has been considerable dissatis-faction within the NHS among the healthprofessions and organisations representing

patients and also among informed opini onregarding the arrangements for complaintshandli ng (NA HAT, 1993; The Citizen’s Char terComplaints Task Force, 1995; The WilsonRepor t, 1995).

Arrangements for handling NH Scomplaints, prior to the institution of the NewProcedures in A pri l 1996, were seen as toocomplex, fail ing to be user fr iendly, taking toolong, being over-defensive, and often fai li ng togive any satisfactory explanation of any con-clusion reached.

The importance of complaints for improvingservices is now part of quality management(Koch, 1991). For complainants they are a wayof expressing opinions through a guaranteedresponse channel. They are also important forthe commitment of resources by T rusts. Forthe publi c they are mechanisms for ensuri ngprofessional accountabili ty, upholding a senseof justice, and safeguarding standards of ser-vice qual ity (Longley, 1993a; 1993b).

The reasons why people complain are gener-ally as follows:• information – a request to nd out what

happened;• acknowledgement and apology – a request

for public display of malfunction;• prevention of recurr ence – “will not happen

again”;• apportioning blame and disciplinary action

– “who did it and what i s going to happen”;• compensation – desire for l itigation.

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J . McCrindle and R.K. JonesPreliminary evaluation of the efficacy and implementation

of the new NHS complaints procedure

International Journal of Health Care QualityAssurance11/ 2 [1998] 41–44

In terms of handling complaints it i s impor-tant to see what are regarded as key issuesfor service users. Leading factors identifiedby The National A ssociation of HealthAuthorities and Tr usts (1993) and by MORI(1995) were:• speed of response – 75 per cent;• keeping complainant i nformed about

progress – 59 per cent;• knowing who is dealing with the

complaint – 45 per cent;• how helpful and friendly staff are – 44 per

cent;• knowing the complaint wi ll be dealt wi th

fairly – 44 per cent (M ulcahy and Tr itter,1994; Woodyard and Darby, 1996; Woolf,1996);

• having clear complaints procedure – 43 percent;

• receiving a wr itten explanation – 39 percent;

• receivi ng an apology if the organisation iswrong – 29 per cent;

• having senior staff investigate – 24 percent;

• receiving compensation – 15 per cent.

The li mitations of the complaints procedureprior to 1 April 1996 have been well docu-mented (NAHAT, 1993; Nettleton and Hard-ing, 1994; The Citizen’s Charter Complaints

Task Force, 1995), and include charges of unwieldiness, unnecessary diversi ficationbecause of “formal” and “informal” proce-dures, and an emphasis on tr ivi ali sing ordeflecting the complaint (L ongley, 1993a;1993b).

Stacey (1992) repor ted that in 1991-1992 outof a total of 1,300 complaints to professionalorganisations only 58 were acted on – 24 forhealth r easons and 34 for serious profes-sional misconduct. The powers of the HealthServi ce Commissioner were li mited becausethere were certain complai nts he could notinvestigate and the old N HS Authoritieswere not obliged to act on any fi ndings. Wecan summari se the limitations of the oldprocedures as follows:

Community health practit ioners• li mited to breach of contract;• generally 13-week cut-off period for com-

plaints;• ri ght of appeal by either par ty.

Complaints against hospitals• clinical complaints generally dealt with

separately and by consultant concerned;• less rigid time scale and “designated offi-

cer” decides on action;• no right of appeal.

The road to reformIn vi ew of the increasingly damaging evi-dence emerging the Secretary of State forHealth established in J une 1993 a ReviewCommittee to investigate the existing NHSComplaints Procedure. The Wilson Reportwas published in 1994 as “Being Heard”, andrecommended that a new Complaints Proce-dure was requir ed which should have thefollowing features:• a comprehensive and integrated complaints

system;• comprehensive monitori ng;• re-assessment of self-regulation;• increased lay control;

• Health Service Commissioner to be givenpower of clinical investigation;

• traini ng for complaints personnel;• separation of discipli nary elements from

complaints procedures;• a time limi t of three months for implemen-

tation of complaints procedures;

On 1 April 1996 a new NHS Complaints Proce-dure was introduced. This replaced the exist-ing Hospital and GP Complaints Procedurewi th a single two-stage procedure. The mainaims of the new NHS Complaints Procedure isto make complaining simpler, quicker, more

accessible, and to encourage greater opennessin the way that complaints are dealt wi th(Department of Health, 1995).

The current NH S Complaints Procedure isdivi ded into two main stages, and is appli ca-ble to all complaints about NHS services: a)local resolution, and b) independent reviewwith the ri ght to refer the matter to the NHSCommissioner i f the complaint i s still notresolved satisfactori ly at the conclusion of theNHS Complaints Procedure.

Local resolution

The exibil ity of guideli nes allows the hospi-tal or GP practice to design their own proce-dures and allows “on the spot” resolutions byfront-line staff. Fail ing resoluti on, and withmore serious complaints, the complaintsofficer co-ordinates procedures and the com-plainant receives a wri tten summary of theinvestigation and conclusions. I f dissatisedan Independent Review can be requested bythe complainant.

Independent Review The complainant must lodge a more seri ouscase wi thin 20 days of being informed of thelocal r esolution’s conclusion. T he Indepen-dent Review Panel consists of a lay chairper-son, an i ndependent lay member or represen-tative of the purchaser (e.g. GP Practice or

Trust) and, in the case of clinical complaints,

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J . McCrindle and R.K. JonesPreliminary evaluation of the efficacy and implementation

of the new NHS complaints procedure

International J ournal of Health Care QualityAssurance11/ 2 [1998] 41–44

at least two independent successors. The Trust bears the cost.

Limit ations and implications of t henew procedure

The emphasis on resolving complaints viafront-line staff may mean that there mayoccur unsatisfactory r ecording and monitor-ing:• Under Stage 2 patients have no automatic

right to have their case reviewed by a panel. This is at the discretion of the Convener.

• The Ombudsman and the IndependentReview only make recommendations and donot implement service change.

• Public perceptions may view thedefendant(s) as being incli ned to “closeranks”. In addition, although the introduc-tion of such new procedures ought toencourage greater response such increasesmay be viewed by the public and press as:more complaints = poorer servi ces.

The NCP (New Complaints Procedure) has thefollowing implications:• all staff need to be knowledgeable about the

new system;• traini ng in the practical application is

required;• fri endly to ethic and “impair ed”

complainants;• ease of access of information and support

for claimant;• professional sensitivity to needs of minori ty

groups.

Methodology and dat acollectionA quali tative approach was adopted. Semi-structured taped interviews using pre-pre-pared interview schedules and lasting approx-imately 1 hour 15 minutes were administeredto the six complaints officers of each of the six

Trusts compri sing the Lothian Health Boardin Scotland. The interview is a popular tool of quali tative research and i s well-documented(Mulchay and Tr itter, 1994; Nettleton andHarding, 1994; Schatzman and Strauss, 1973;Spr adley, 1979; Woodyard and Darby, 1996).Using Glaser and Strauss’ (1967) guideli nesdata were collected by tape recorder, tran-scri bed verbatim, analysed simul taneously,coded and categorised into emerging themes.Compari son of the data was continually car-ried out until saturation occurred and no newdata emerged. A master li st of themes wasgenerated, some of whi ch were governed bythe questions on the interview schedule.

These master themes were then evaluatedagainst the objectives and guideli nes for i ntro-ducing the new procedures.

An i ncrease in the number of grievancesafter the implementation of the New Com-plaints Procedure compared to those pri or tothe New Complaints was expected. Usingquantitative methods complaints for Apri l1996 were compared wi th 1995.

The complaints officers, three male andthree female, were employed by the six NHS

Tr ust Hospitals coveri ng the Lothian regionin Scotland.

The ndings The main ndings of this ini tial study can besummarised thus:• the Local Resoluti on stage is working and is

seen as a benet to both pati ents and staff;• the six Trusts have all implemented train-

ing programmes for all levels of staff;• all T rusts have widely published and publi -

cised li terature advising people of theircomplaints processes. No Brail le facili tiesexist at present al though some have imple-mented li terature for minority groups;

• Trusts are meeting the target times forcomplaints handli ng, although this is anarea which causes concern, as does themonitori ng of complaints;

• Complaints officers have reservations aboutthe Independent Review stage of theprocess;

• Complaints officers think that a deniteadvantage to the new procedure is that thereis now an end of the complaints process;

• The ndings from the quantitative studyshowed 652 complaints for 1 April to 30 Sep-tember 1995 compared with 823 for the sameperiod in 1996, an increase of 20.7 per cent;

Types of complaints made against the unitswere:• Community servi ce: “Probably complaints

about services such as day centres for theelderly” (Complaints officer T rust 1)

• Out-patient units: “Usually l ike waitingtimes” (Complaints officer, Trust 4)• Day patients: “Issues such as delays in

planned operations or the time they havebeen on the waiting list and their operationsare cancelled at the last moment” (Com-plaints offi cer, Trust 2)

• In-patients: “Anything, from a feeli ng of lackof staff to issues li ke patient privacy, com-munication problems, etc. (Complaintsofficer, Trust 4)

• A & E: “The length of time patients have towait” (Complaints officer, Trust 2)

Different bases for collecting data (moreresolved at Local Resoluti on and the record-ing of oral complaints, for example) make itdiffi cult to compare gures:

I think the publicity has rai sed people’sawareness and whi le they may well have

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J . McCrindle and R.K. JonesPreliminary evaluation of the efficacy and implementation

of the new NHS complaints procedure

International Journal of Health Care QualityAssurance11/ 2 [1998] 41–44

had the same questions and concerns in thepast, they are now expressing those con-cer ns. Now that we have procedures in place

for recording even oral complaints this canaccount for an increase. It i s dangerous tosay that there has been an increase justbecause of the new procedure. (Tr ust 5)

Our complaints have gone up by about 40per cent, although a number of factorsaccount for thi s. The general public andpatients are much more aware of theirri ghts, more aware that public organisa-tions are more accessible. There has beenmuch more over publicity r egarding thechanged complaints procedure as T rustswere bound to actively publi cise thechanges, all of which has increased people’sawareness. It should be borne in mind

though that the number of complai nts inrelation to the number of patients seen isinsignicant (Trust 1).

Conclusions The complaints officers had varied experi -ence, some having handled complaints in oneway or another for years, and others assum-ing the role at the introduction of the NewProcedures. The level of the person appointedmay also indicate the Tr ust’s commitment toeffective complaints handling.

The monitori ng of complaints appears to bean issue of concern to Trusts. The implemen-tation guideli nes state that Trusts must pro-vide the Boards of Trusts and the ScottishOffice (ISD) wi th quarterly details of formalcomplaints, whi le giving consideration to thecollection of local data on oral complaints. Afurther issue is the limited number of cate-gori es on the ISD forms, which either forcessome complaints into categories or makes itimpossible to allocate others to any of theexisting categori es. It i s hoped that the intro-duction of an amended Moni toring Form willaddress this issue of categori es. Tr aining wasidentied as being essenti al to making thenew procedures effective. However, whilerecognising the importance of staff training,no extra resources were provided to Trusts totrain staff. As a result, while the NHSMErecommended a full one and a half-day’s train-ing most Trusts have trained senior staff andnominated staff, who in turn train theirrespective “teams”. A ll training was done in-house.

One of the key objectives of the procedure isa rapid r esponse withi n 20 days. Al l the Trustshad misgivings about this area and, althoughmost of the complaints were dealt wi th wi thinthi s time period, there were some cases whereit was diffi cult to comply with the limi tation,especially with complex medical and socialcases. However, these were few in number.

Local Resolution i s at the heart of the NewComplaints Procedure, operating ini tially

wi th “on-the-spot” responses to complaints,and, second, the Independent Review. Mostcases are resolved “on-the-spot” whi ch i s ameasure of its success. On the other hand,although only a small percentage of cases goto Independent Review, i t i s an expensiveprocess whi ch some see as a reection of Stage 1 failure in the sense that an effectiveStage 1 would have dealt successfully with anycomplaints.

All the complaints officers felt that theywere successful in dealing with complaints.Review of the procedures was seen as an ongo-ing and necessary process. They see com-plaints as a positive source of information tobe used in the maintenance and improvementin standards of service provision. Ar range-ments for handling complaints must beimparti al and seen to be so. The fact is thatthe perception and appearance of imparti ali tyis more important than the reali ty in deter-mining people’s decisions about whether tomake or pursue a complaint. T he quicker andearl ier complaints are resolved the moremoney is saved and the less bad publi city the

Trust receives. Complaints are free marketresearch and should be viewed positively,resulting, as they often do, in service improve-ments.

ReferencesDepartment of Health (1995), Act ing on Compla in t s , HM SO, London.

Glaser, B. and Strauss, A . (1967), T he Discover y of Gr ounded Th eory , Aldine, New York, NY.

Koch, H . (1991), To t a l Q u a l i t y M a n a g em en t i n Hea l th Care , Longman, London.

L ongley, D. (1993a), “Out of or der”, Health Ser vice J o u r n a l , Vol. 102 No. 26.

L ongley, D. (1993b), Publ i c Law and H ea l th Ser v ice Accoun tab i l i ty, Oxford University P ress,Oxford.

McCar thy, P. (1992), Gr ievances, Compl ai nts and Loca l Gover nm ent , Avebury, Oxford.

MORI SURVEY (1995).

Mulcahy, L . and T ritter, J . (1994), “Hidden depths”,Heal th Ser v ice Jour na l , Vol. 104, p. 5411.NA HAT (1993), National A ssociation of Health

Authori ties and Tr usts.Nettleton, S. and Harding, G. (1994), “Protesting

patients”, Sociology of Heal th an d I l ln ess ,Vol . 16 No. 1.

Schatzman and Strauss (1973), Fi eld Resear ch Strategies, Prentice-Hall , L ondon.

Spradley, J . (1979), T he E thn ograph i c In ter v iew,Holt, Ri nehart and Winston, New York, NY.

Stacey, M . (1992), “Consumer complaints”, Soci alScience and M edi cine , Vol . 8, pp. 429-35.

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Woolf, Lord (1996), A ccess to Ju stice , HM SO,London.

Thanks are due to thefollowing Complaints Offi-cers, Patient Liaison Offi-cers and Directors of Opera-tions who so willingly gavetheir valuable time: RichardWalter, East and MidlothianNHST; J ackie Warburton,Edinburgh Healthcare NHST;Hazel MacKenzie, EdinburghSick Children’s NHST; DoraDonaldson, Western GeneralNHST; John Jack, WestLothian HST; Robert Purves,Royal Inrmary of EdinburghNHST.