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Personal practice: understanding the NHS complaints procedure
PERSONAL PRACTICE
Personal practice: understanding the NHS complaints procedure
Key learning points C
C
DB Shortland C
Carrie Stone
Patients often complain because they have misunderstood information they have received and therefore clear advice and good communication skills are extremely important. Complaints can often be prevented by informal discussions with the family when a problem is identified. There is a statutory instrument governing the complaints procedure in the NHS and it is helpful to understand this process and your hospital’s procedures when complaints are made.
Abstract At all levels of society there is a growing demand for greater transparency and accountability. Professional medical services have been particularly affected by these changing attitudes and, in response to this, the systems for managing patient complaints continue to evolve. Managing these complaints has become an increasingly time consuming and stressful part of a paediatrician’s duties. Whilst clear and concise explanations and good medical recording keeping are an important part of patient care and can help to avoid the misunderstanding so that cause patients to complaints and litigate, when complaints are made it is very important that paediatricians have a clear understanding of the hospital complaints procedures so that they can contribute effectively to the process and ensure that patients and their families receive timely and appropriate responses to their complaints.
making complaints about doctors. This survey found that complaints received against doctors were mainly related to communication and clinical care issues. Complaints about unprofessional behaviour were relatively rare. The doctors surveyed viewed unrealistic expectations of patients and patient anger towards them as the commonest causes of complaints. In April 1996 the new “NHS complaints procedure” was introduced. Following the obligation on hospitals to publicise their complaints procedure, there was a predictable increase in the number of complaints against medical staff. Using this process approximately 95% of complaints have been resolved, successfully and locally. The regulations were amended in 2009 to make the process more responsive to the wishes of complainants. The process was also simplified into a two stage process: local resolution or referral to the Parliamentary Health Service ombudsman if local resolution failed to resolve the matter to the complainant’s satisfaction. It is hoped that these changes will improve the successful resolution of complaints and therefore reduce the recourse to legal action. The Civil Procedure Rules may have influenced litigation in England and Wales, with the changes to the disclosure and inspection of medico-legal documents. In 2013 there were 9,866 complaints brought to the GMC about doctors and of these 185 complaints related to doctors who have a paediatric registered specialty. Of these complaints 97 were investigated as “Stream 1”, where a full investigation took place. There were 16 cases as “Stream 2”. For these complaints the GMC does not consider that a full investigation is warranted but may contact the doctor’s employer to see if there are concerns about a wider pattern of behaviour or practice. If adverse information is identified the case can be promoted to Stream 1. 72 cases were closed without further investigation. In 2013, of the case examiner decisions, six were concluded with advice, three issued a warning to the Paediatrician and six were referred for a full hearing. Of the five GMC fitness to practice hearings in 2013, one resulted in erasure from the register, one resulted in suspension, one resulted in a doctor practicing with conditions and two found no impairment. Minor complaints can be frustrating for paediatricians and a distraction from their other duties. More serious complaints can be time consuming, can fracture the professional relationship that paediatricians enjoy with patients and families and ultimately, albeit occasionally, can limit the doctor’s ability to practice. The way that doctors deal with complaints will become increasingly important as the ‘strengthened’ appraisal process
Keywords complaints; duty of candour; hospital complaints procedure; litigation
Whilst numerous studies have shown that approximately 10% of patients are “harmed” when receiving medical treatment the majority of these cases reflect “low-level harm” with the number of incidents of serious harm to patients being relatively low. Overall there is a high level of satisfaction with doctors. A recent survey showed that 84% of the public were satisfied with the care they had received from doctors within the last five years. Of the complaints received by hospitals only a minority (15%) reflected concerns about the practice of individual doctors. These figures should not, however, breed complacency. A proportion of patients did, however, have reason for being dissatisfied with a doctor over the previous five years, although these patients were unlikely to make a specific complaint. Moreover, only 16% of the public who had a cause to be dissatisfied had actually complained. The two most common reasons for a patient not complaining are that they do not understand how to complain and they do not feel that complaining is worthwhile. In a survey of complaints against doctors in Ireland (2006) 55% of the public surveyed had heard of the Irish Medical Council but, of these, 42% were not aware of any of its functions. At the time of making a complaint 82% of complainers to the Irish Medical Council were unaware of alternative systems for
D B Shortland MD FRCP FRCPCH DCH is a Consultant Paediatrician at Poole Hospital NHS Trust, Poole, Dorset, UK. Conflict of interest: none. Carrie Stone is Patient Liaison & Legal Services Manager, at Poole Hospital NHS Trust, Poole, Dorset, UK. Conflict of interest: none.
PAEDIATRICS AND CHILD HEALTH --:-
1
Ó 2015 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Shortland DB, Stone C, Personal practice: understanding the NHS complaints procedure, Paediatrics and Child Health (2015), http://dx.doi.org/10.1016/j.paed.2015.02.011
PERSONAL PRACTICE
(part of the General Medical Council revalidation) will assess how consultants manage complaints and, where relevant, have appraised their practice and modified it accordingly. Consultants should ask for a summary record of all complaints, outcomes of these complaints and claims relevant to their personal practice over the preceding year to include in their appraisal file. If a patient is unhappy with the care or treatment that they have received they have a right to complain, to have their complaint investigated and to be given a full and prompt reply. Complaints can be instigated by current or former patients or by an individual acting on behalf of that patient. Patients may complain because they have misunderstood information they have received and, therefore, clear advice and good communication skills are extremely important. Any paediatrician who has had a complaint made against their practice should be aware that there are statutory processes governing the complaints procedure in the NHS and the paediatrician should understand these processes when responding to complaints. When responding to a complaint the paediatrician should understand the exact details of the complaint, remain professional and empathetic throughout the process and be open, honest and transparent in their dealings with the patient in line with recommendations from the National Patient Safety Agency “Being Open”. The complaints process varies between the four Countries of the United Kingdom. In England the NHS constitution outlines patient’s right lodging complaints and it clearly states that patients have the right to have their complaint dealt with efficiently and to know the outcome of any investigation regarding their complaint. The constitution also allows patients to complain to the Independent Parliamentary and Health Service Ombudsman if they are not satisfied with the way the NHS has dealt with their complaint and also to make a claim for judicial review if they feel they have been affected by an unlawful act or decision of an NHS body. They can claim for compensation if they have been harmed. Complainants in Scotland can refer their complaint to the Scottish Public Services Ombudsman if they are not satisfied with local resolution and in Northern Ireland, complaints that cannot be resolved locally can be referred for independent review through the “Complaints Convenor” of the local Health and Social Services Board. In Wales new procedures were introduced in April 2011 under the “Concerns, Complaints and Redress Arrangements” (2011). The aim of this regulation was to provide a clear and simple process and to introduce the redress arrangements in an attempt to reduce litigation. Complaints can come to our attention some weeks after a patient has been seen in clinic or discharged from the wards and when investigating these complaints it is quite often the case that the junior medical or nursing staff will either have anticipated this complaint or recognized that there were difficulties with the management of the case. It is important that staff raise their concerns with the consultant at the earliest possible time and preferably while the family are still in hospital. Although human nature may be to avoid confrontation, my personal experience has been that to have an open and honest discussion with the family can be very helpful in allaying their anxieties and in preventing a formal complaint. It can also be helpful for junior staff to be present when consultants are discussing the issues with the family, but they
PAEDIATRICS AND CHILD HEALTH --:-
should not be present if the complaint relates specifically to them. Junior doctors may have a good rapport with the family, can provide information about some of the clinical or administrative issues that are being discussed and the process can be a very valuable experience for juniors. Many consultant paediatricians would accept that dealing with complaints is one of the more complicated and stressful parts of their practice and to have had experience of this as a junior doctor will make them more confident in managing this aspect of their duties. Complaints can be very stressful for senior paediatricians and quite devastating for junior doctors. In these situations juniors should have an appropriate support mechanism which initially would be the supervising consultant, but the post graduate clinical tutors also have a valuable role as well. It is important to recognise that the basis of many complaints is that families want to know the facts about the medical treatment that they have received and believe that a formal complaint is the only recourse that they have to obtain this information. The root of this problem is often a failure of communication. This is frustrating for many paediatricians who recognise that an informal discussion with the family on the wards or involvement of the NHS PALS (Patient Advice and Liaison Service) could have given the family the information they needed in a timely manner and prevented a complaint. During our paediatric careers we are all likely to have to deal with more significant complaints where informal discussions have not satisfied a family or been accepted by them as a true reflection of events and in these situations it is extremely important to follow the hospital complaints procedure which is governed by the Statute and Regulations and is therefore highly regulated and standardized between all organisations. This will involve a senior hospital manager taking overall charge of the process, liaising with the family, specifying the timescales and contacting all of the relevant clinical staff to obtain detailed reports that will form the basis of the response to the complainant. At this stage there is no necessity for the paediatrician to contact a medical defence organisation, but it can be helpful, particularly if there are specific anxieties about the care that the child received. The consultant will provide a written report for the investigating officer, which should be as detailed, objective and as evidence based as possible, but should also provide an honest opinion as to the validity of the complaint. This can be very important in forming the decision about what further action the Hospital will need to take. This report does not become part of the patients’ notes, but would have to be disclosed in the event of litigation or referral to the ombudsman. If, however, formal proceedings are issued against the Hospital, then the primary purpose of subsequent correspondence between the consultant and the legal services manager is to investigate the clinical negligence claim and at that point this correspondence does become privileged and is non-prejudicial. The consultant may be asked to provide further advice once other reports have been received and must be able to comment on the final response to the complainant before this is sent. This response may be all that is required or may lead to further (sometimes lengthy) correspondence between the hospital and the family. Where the hospital decides that the standard of care has fallen below what it expected it will recommend further
2
Ó 2015 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Shortland DB, Stone C, Personal practice: understanding the NHS complaints procedure, Paediatrics and Child Health (2015), http://dx.doi.org/10.1016/j.paed.2015.02.011
PERSONAL PRACTICE
action, which could include discussing the case at a governance meeting from an education perspective or, in more serious cases, invoke hospital procedures to investigate professional or personal competence. The process could identify professional needs for the paediatrician which can be addressed through mentoring, the appraisal process or the National Clinical Assessment Service. In rare cases a referral is made to the General Medical Council. There will be situations where the family decide to pursue a complaint through other routes, these can be: (a) The ombudsman; this route is usually chosen when a family perceive that their complaint has not been handled appropriately by the hospital. (b) The General Medical Council; a complainant can refer a paediatrician directly to the General Medical Council where the case is triaged and a decision taken whether to investigate further. At this point there is an investigation undertaken and a case examiner reviews the details. The potential outcomes of this investigation are to conclude the case, conclude the case with advice to the paediatrician, to issue a warning, to ask for undertakings to be agreed or to refer the case to the Fitness to Practice Directorate for a public hearing and decision as to the doctor’s future. The legal process; where a claim is being pursued. In 2014 the Department of Health introduced the “Statutory Duty of Candour” which will become a new CQC Registration Regulation. This reflects the Government’s commitment to greater openness and candour and to developing a culture dedicated to learning and improvement that continually strives to reduce avoidable harm. There will be a statutory Duty of Candour on all providers registered with the CQC. This is a key step towards implementing the recommendations from the MidStaffordshire NHS Foundation Trust Public Inquiry (The Francis Inquiry). The Duty of Candour will place a requirement on providers of Health and Adult Social Care to be open with patients when things go wrong. Providers should establish the Duty throughout their organisations, ensuring that honesty and transparency are the norm in every organisation registered by the CQC. In the regulations the harm threshold for Health Care is set at the threshold recommended by the by the Dalton/Williams Report to include “moderate harm”. This means that all harm that is classified as moderate or severe or where “ prolonged psychological harm “ has arisen gives rise to a Duty of Candour to the service user, or a person lawfully acting on their behalf. The Duty will also apply in cases of death, if the death relates to the incident of harm rather than to the natural course of the service user’s illness or underlying condition. It is expected that the CQC will be notified of these incidents that occur via reporting to the existing National Learning and Reporting System (NRLS). Given the complexities of medical care systems in the United Kingdom, the large number of patients treated within these systems and patients’ increasing awareness of their rights and increasing willingness to complain if they feel they have received suboptimal care, it is highly likely that the procedures for complaining against doctors will evolve further in future years. It is
PAEDIATRICS AND CHILD HEALTH --:-
important that this happens but it is also important that doctors understand the reason for complaints and do everything they can within their practices to ensure that the patients are satisfied with the care that they receive and therefore do not need to complain. Whilst there is no single reason why patients complain a survey by the Irish Medical Council (2006) of complainants and doctors complained against showed a high level of agreement about the changes required to make regulation more effective and fair to both parties. These included increased transparency (recognizing that complainants wanted as much information as possible at the beginning of the complaint process), improved communication between all parties involved in the complaint and a graded response to complaints so that complaints which might be regarded as trivial or vexatious were dealt with differently those involving more serious issues around professional misconduct or competence. This survey, however, showed that 81% of complainants were dissatisfied with the outcomes of the complaints process with the most common reason being that they had wanted the doctor to receive a warning and to be sure that unsatisfactory practice would not be repeated. Two thirds of complainants reported that they did not achieve any of the outcomes that they wanted. In contrast, however, most doctors (83%) were satisfied with the outcome of the process. Although this survey related to complaints received by a regulatory body it is likely that the findings would be similar if patients were surveyed who had complained through hospital procedures. The processes for complaining against doctors remain complex as these complaints can arise through the hospital services (informal or formal) through regulatory bodies, through the Ombudsman or through the litigation system. It is clear that not all patients, or indeed doctors, understand these processes fully. For doctors to be effective in managing complaints they need to recognise potential conflicts between themselves and patients at an early stage, be proactive in managing this conflict and contribute effectively and in a timely manner should a formal complaint arise. A FURTHER READING ‘Being open’ e National Patient Safety Agency: Ref. 1097 November 2009. Explanatory memorandum to the NHS England, social care England and Local Authority Services and NHS complaints (England) regulations 2009. No: 309. Managing complaints about doctors: Stakeholder perspectives of the role of the Medical Council in Ireland December 2006. Paediatricians Handbook RCPCH 2014. Principles of good complaint handling: the parliamentary and Health Service Ombudsman February 2009. Statutory instrument (SI) 2009 No. 309, National Health Service (England), Social Care (England), the Local Authority, Social Services and NHS Complaints Regulations 2009. The Civil Procedure Rules. United Kingdom Legislation e Statutory Instruments 1998 No. 3132L 17: Supreme Court of England and Wales 1998.
3
Ó 2015 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Shortland DB, Stone C, Personal practice: understanding the NHS complaints procedure, Paediatrics and Child Health (2015), http://dx.doi.org/10.1016/j.paed.2015.02.011
Personal practice: understanding the NHS complaints procedure
Key learning points C
C
DB Shortland C
Carrie Stone
Patients often complain because they have misunderstood information they have received and therefore clear advice and good communication skills are extremely important. Complaints can often be prevented by informal discussions with the family when a problem is identified. There is a statutory instrument governing the complaints procedure in the NHS and it is helpful to understand this process and your hospital’s procedures when complaints are made.
Abstract At all levels of society there is a growing demand for greater transparency and accountability. Professional medical services have been particularly affected by these changing attitudes and, in response to this, the systems for managing patient complaints continue to evolve. Managing these complaints has become an increasingly time consuming and stressful part of a paediatrician’s duties. Whilst clear and concise explanations and good medical recording keeping are an important part of patient care and can help to avoid the misunderstanding so that cause patients to complaints and litigate, when complaints are made it is very important that paediatricians have a clear understanding of the hospital complaints procedures so that they can contribute effectively to the process and ensure that patients and their families receive timely and appropriate responses to their complaints.
making complaints about doctors. This survey found that complaints received against doctors were mainly related to communication and clinical care issues. Complaints about unprofessional behaviour were relatively rare. The doctors surveyed viewed unrealistic expectations of patients and patient anger towards them as the commonest causes of complaints. In April 1996 the new “NHS complaints procedure” was introduced. Following the obligation on hospitals to publicise their complaints procedure, there was a predictable increase in the number of complaints against medical staff. Using this process approximately 95% of complaints have been resolved, successfully and locally. The regulations were amended in 2009 to make the process more responsive to the wishes of complainants. The process was also simplified into a two stage process: local resolution or referral to the Parliamentary Health Service ombudsman if local resolution failed to resolve the matter to the complainant’s satisfaction. It is hoped that these changes will improve the successful resolution of complaints and therefore reduce the recourse to legal action. The Civil Procedure Rules may have influenced litigation in England and Wales, with the changes to the disclosure and inspection of medico-legal documents. In 2013 there were 9,866 complaints brought to the GMC about doctors and of these 185 complaints related to doctors who have a paediatric registered specialty. Of these complaints 97 were investigated as “Stream 1”, where a full investigation took place. There were 16 cases as “Stream 2”. For these complaints the GMC does not consider that a full investigation is warranted but may contact the doctor’s employer to see if there are concerns about a wider pattern of behaviour or practice. If adverse information is identified the case can be promoted to Stream 1. 72 cases were closed without further investigation. In 2013, of the case examiner decisions, six were concluded with advice, three issued a warning to the Paediatrician and six were referred for a full hearing. Of the five GMC fitness to practice hearings in 2013, one resulted in erasure from the register, one resulted in suspension, one resulted in a doctor practicing with conditions and two found no impairment. Minor complaints can be frustrating for paediatricians and a distraction from their other duties. More serious complaints can be time consuming, can fracture the professional relationship that paediatricians enjoy with patients and families and ultimately, albeit occasionally, can limit the doctor’s ability to practice. The way that doctors deal with complaints will become increasingly important as the ‘strengthened’ appraisal process
Keywords complaints; duty of candour; hospital complaints procedure; litigation
Whilst numerous studies have shown that approximately 10% of patients are “harmed” when receiving medical treatment the majority of these cases reflect “low-level harm” with the number of incidents of serious harm to patients being relatively low. Overall there is a high level of satisfaction with doctors. A recent survey showed that 84% of the public were satisfied with the care they had received from doctors within the last five years. Of the complaints received by hospitals only a minority (15%) reflected concerns about the practice of individual doctors. These figures should not, however, breed complacency. A proportion of patients did, however, have reason for being dissatisfied with a doctor over the previous five years, although these patients were unlikely to make a specific complaint. Moreover, only 16% of the public who had a cause to be dissatisfied had actually complained. The two most common reasons for a patient not complaining are that they do not understand how to complain and they do not feel that complaining is worthwhile. In a survey of complaints against doctors in Ireland (2006) 55% of the public surveyed had heard of the Irish Medical Council but, of these, 42% were not aware of any of its functions. At the time of making a complaint 82% of complainers to the Irish Medical Council were unaware of alternative systems for
D B Shortland MD FRCP FRCPCH DCH is a Consultant Paediatrician at Poole Hospital NHS Trust, Poole, Dorset, UK. Conflict of interest: none. Carrie Stone is Patient Liaison & Legal Services Manager, at Poole Hospital NHS Trust, Poole, Dorset, UK. Conflict of interest: none.
PAEDIATRICS AND CHILD HEALTH --:-
1
Ó 2015 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Shortland DB, Stone C, Personal practice: understanding the NHS complaints procedure, Paediatrics and Child Health (2015), http://dx.doi.org/10.1016/j.paed.2015.02.011
PERSONAL PRACTICE
(part of the General Medical Council revalidation) will assess how consultants manage complaints and, where relevant, have appraised their practice and modified it accordingly. Consultants should ask for a summary record of all complaints, outcomes of these complaints and claims relevant to their personal practice over the preceding year to include in their appraisal file. If a patient is unhappy with the care or treatment that they have received they have a right to complain, to have their complaint investigated and to be given a full and prompt reply. Complaints can be instigated by current or former patients or by an individual acting on behalf of that patient. Patients may complain because they have misunderstood information they have received and, therefore, clear advice and good communication skills are extremely important. Any paediatrician who has had a complaint made against their practice should be aware that there are statutory processes governing the complaints procedure in the NHS and the paediatrician should understand these processes when responding to complaints. When responding to a complaint the paediatrician should understand the exact details of the complaint, remain professional and empathetic throughout the process and be open, honest and transparent in their dealings with the patient in line with recommendations from the National Patient Safety Agency “Being Open”. The complaints process varies between the four Countries of the United Kingdom. In England the NHS constitution outlines patient’s right lodging complaints and it clearly states that patients have the right to have their complaint dealt with efficiently and to know the outcome of any investigation regarding their complaint. The constitution also allows patients to complain to the Independent Parliamentary and Health Service Ombudsman if they are not satisfied with the way the NHS has dealt with their complaint and also to make a claim for judicial review if they feel they have been affected by an unlawful act or decision of an NHS body. They can claim for compensation if they have been harmed. Complainants in Scotland can refer their complaint to the Scottish Public Services Ombudsman if they are not satisfied with local resolution and in Northern Ireland, complaints that cannot be resolved locally can be referred for independent review through the “Complaints Convenor” of the local Health and Social Services Board. In Wales new procedures were introduced in April 2011 under the “Concerns, Complaints and Redress Arrangements” (2011). The aim of this regulation was to provide a clear and simple process and to introduce the redress arrangements in an attempt to reduce litigation. Complaints can come to our attention some weeks after a patient has been seen in clinic or discharged from the wards and when investigating these complaints it is quite often the case that the junior medical or nursing staff will either have anticipated this complaint or recognized that there were difficulties with the management of the case. It is important that staff raise their concerns with the consultant at the earliest possible time and preferably while the family are still in hospital. Although human nature may be to avoid confrontation, my personal experience has been that to have an open and honest discussion with the family can be very helpful in allaying their anxieties and in preventing a formal complaint. It can also be helpful for junior staff to be present when consultants are discussing the issues with the family, but they
PAEDIATRICS AND CHILD HEALTH --:-
should not be present if the complaint relates specifically to them. Junior doctors may have a good rapport with the family, can provide information about some of the clinical or administrative issues that are being discussed and the process can be a very valuable experience for juniors. Many consultant paediatricians would accept that dealing with complaints is one of the more complicated and stressful parts of their practice and to have had experience of this as a junior doctor will make them more confident in managing this aspect of their duties. Complaints can be very stressful for senior paediatricians and quite devastating for junior doctors. In these situations juniors should have an appropriate support mechanism which initially would be the supervising consultant, but the post graduate clinical tutors also have a valuable role as well. It is important to recognise that the basis of many complaints is that families want to know the facts about the medical treatment that they have received and believe that a formal complaint is the only recourse that they have to obtain this information. The root of this problem is often a failure of communication. This is frustrating for many paediatricians who recognise that an informal discussion with the family on the wards or involvement of the NHS PALS (Patient Advice and Liaison Service) could have given the family the information they needed in a timely manner and prevented a complaint. During our paediatric careers we are all likely to have to deal with more significant complaints where informal discussions have not satisfied a family or been accepted by them as a true reflection of events and in these situations it is extremely important to follow the hospital complaints procedure which is governed by the Statute and Regulations and is therefore highly regulated and standardized between all organisations. This will involve a senior hospital manager taking overall charge of the process, liaising with the family, specifying the timescales and contacting all of the relevant clinical staff to obtain detailed reports that will form the basis of the response to the complainant. At this stage there is no necessity for the paediatrician to contact a medical defence organisation, but it can be helpful, particularly if there are specific anxieties about the care that the child received. The consultant will provide a written report for the investigating officer, which should be as detailed, objective and as evidence based as possible, but should also provide an honest opinion as to the validity of the complaint. This can be very important in forming the decision about what further action the Hospital will need to take. This report does not become part of the patients’ notes, but would have to be disclosed in the event of litigation or referral to the ombudsman. If, however, formal proceedings are issued against the Hospital, then the primary purpose of subsequent correspondence between the consultant and the legal services manager is to investigate the clinical negligence claim and at that point this correspondence does become privileged and is non-prejudicial. The consultant may be asked to provide further advice once other reports have been received and must be able to comment on the final response to the complainant before this is sent. This response may be all that is required or may lead to further (sometimes lengthy) correspondence between the hospital and the family. Where the hospital decides that the standard of care has fallen below what it expected it will recommend further
2
Ó 2015 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Shortland DB, Stone C, Personal practice: understanding the NHS complaints procedure, Paediatrics and Child Health (2015), http://dx.doi.org/10.1016/j.paed.2015.02.011
PERSONAL PRACTICE
action, which could include discussing the case at a governance meeting from an education perspective or, in more serious cases, invoke hospital procedures to investigate professional or personal competence. The process could identify professional needs for the paediatrician which can be addressed through mentoring, the appraisal process or the National Clinical Assessment Service. In rare cases a referral is made to the General Medical Council. There will be situations where the family decide to pursue a complaint through other routes, these can be: (a) The ombudsman; this route is usually chosen when a family perceive that their complaint has not been handled appropriately by the hospital. (b) The General Medical Council; a complainant can refer a paediatrician directly to the General Medical Council where the case is triaged and a decision taken whether to investigate further. At this point there is an investigation undertaken and a case examiner reviews the details. The potential outcomes of this investigation are to conclude the case, conclude the case with advice to the paediatrician, to issue a warning, to ask for undertakings to be agreed or to refer the case to the Fitness to Practice Directorate for a public hearing and decision as to the doctor’s future. The legal process; where a claim is being pursued. In 2014 the Department of Health introduced the “Statutory Duty of Candour” which will become a new CQC Registration Regulation. This reflects the Government’s commitment to greater openness and candour and to developing a culture dedicated to learning and improvement that continually strives to reduce avoidable harm. There will be a statutory Duty of Candour on all providers registered with the CQC. This is a key step towards implementing the recommendations from the MidStaffordshire NHS Foundation Trust Public Inquiry (The Francis Inquiry). The Duty of Candour will place a requirement on providers of Health and Adult Social Care to be open with patients when things go wrong. Providers should establish the Duty throughout their organisations, ensuring that honesty and transparency are the norm in every organisation registered by the CQC. In the regulations the harm threshold for Health Care is set at the threshold recommended by the by the Dalton/Williams Report to include “moderate harm”. This means that all harm that is classified as moderate or severe or where “ prolonged psychological harm “ has arisen gives rise to a Duty of Candour to the service user, or a person lawfully acting on their behalf. The Duty will also apply in cases of death, if the death relates to the incident of harm rather than to the natural course of the service user’s illness or underlying condition. It is expected that the CQC will be notified of these incidents that occur via reporting to the existing National Learning and Reporting System (NRLS). Given the complexities of medical care systems in the United Kingdom, the large number of patients treated within these systems and patients’ increasing awareness of their rights and increasing willingness to complain if they feel they have received suboptimal care, it is highly likely that the procedures for complaining against doctors will evolve further in future years. It is
PAEDIATRICS AND CHILD HEALTH --:-
important that this happens but it is also important that doctors understand the reason for complaints and do everything they can within their practices to ensure that the patients are satisfied with the care that they receive and therefore do not need to complain. Whilst there is no single reason why patients complain a survey by the Irish Medical Council (2006) of complainants and doctors complained against showed a high level of agreement about the changes required to make regulation more effective and fair to both parties. These included increased transparency (recognizing that complainants wanted as much information as possible at the beginning of the complaint process), improved communication between all parties involved in the complaint and a graded response to complaints so that complaints which might be regarded as trivial or vexatious were dealt with differently those involving more serious issues around professional misconduct or competence. This survey, however, showed that 81% of complainants were dissatisfied with the outcomes of the complaints process with the most common reason being that they had wanted the doctor to receive a warning and to be sure that unsatisfactory practice would not be repeated. Two thirds of complainants reported that they did not achieve any of the outcomes that they wanted. In contrast, however, most doctors (83%) were satisfied with the outcome of the process. Although this survey related to complaints received by a regulatory body it is likely that the findings would be similar if patients were surveyed who had complained through hospital procedures. The processes for complaining against doctors remain complex as these complaints can arise through the hospital services (informal or formal) through regulatory bodies, through the Ombudsman or through the litigation system. It is clear that not all patients, or indeed doctors, understand these processes fully. For doctors to be effective in managing complaints they need to recognise potential conflicts between themselves and patients at an early stage, be proactive in managing this conflict and contribute effectively and in a timely manner should a formal complaint arise. A FURTHER READING ‘Being open’ e National Patient Safety Agency: Ref. 1097 November 2009. Explanatory memorandum to the NHS England, social care England and Local Authority Services and NHS complaints (England) regulations 2009. No: 309. Managing complaints about doctors: Stakeholder perspectives of the role of the Medical Council in Ireland December 2006. Paediatricians Handbook RCPCH 2014. Principles of good complaint handling: the parliamentary and Health Service Ombudsman February 2009. Statutory instrument (SI) 2009 No. 309, National Health Service (England), Social Care (England), the Local Authority, Social Services and NHS Complaints Regulations 2009. The Civil Procedure Rules. United Kingdom Legislation e Statutory Instruments 1998 No. 3132L 17: Supreme Court of England and Wales 1998.
3
Ó 2015 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Shortland DB, Stone C, Personal practice: understanding the NHS complaints procedure, Paediatrics and Child Health (2015), http://dx.doi.org/10.1016/j.paed.2015.02.011