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Reforming complaints systems: UK and New Zealand
COMMENTARY
Reforming complaints systems: UK and New Zealand The long-awaited report into the UK’s National Health Service complaints system1 published early this month describes high levels of dissatisfaction among users. An inquiry into New Zealand’s (NZ) procedures, the Cull report, described a similar picture.2 Despite this similarity, two different policy responses emerged. Both reports follow high-profile public scandals about errant doctors. The reports come in a climate of increasing public concern and concomitant demands for more effective and transparent systems of scrutiny and assurance. The attempts from both countries to address these expectations take different forms. The UK report follows a trend towards insular but detailed consideration of one aspect of the overall system of public protection.3–5 By contrast, the NZ report looks at complaints procedures as part of an examination of the bigger picture. The regulatory landscapes in the UK and NZ are populated with multiple agencies set up to act on concerns about standards of care. The Cull report notes: “Currently, fourteen organisations potentially can each undertake an investigation into the same adverse medical event, contemporaneously or cumulatively without reference to the other”. The regulatory landscape in the UK looks similar with new organisations such as the National Clinical Assessment Authority, to address concerns about doctors’ performance; the Commission for Health Improvement, to address issues of organisations’ competence; and the National Patient Safety Agency, to act as a watchdog for adverse events. In view of this crowded landscape the Cull report was given a radical remit, which is reflected in the proposal for one investigative process for all health-service-related complaints. This system would incorporate a “one-stop shop” for complaints, adverse events, and concerns about health professionals. One body would be the repository of complaints with responsibility for assessing cases, onward referral, and coordinating informationsharing, as well as making recommendations for improvement and potential compensatory awards. The model also promotes one disciplinary tribunal for judging charges against any health professional. By contrast, the modest remit of the UK report—to conduct a survey of users—means that it does not have the stamp of a full-blooded policy review. The report focuses on incremental improvements to the existing complaints procedure with little reference to the rest of the regulatory world and does not address the potential for duplicate and unconnected investigations. In so doing its few good suggestions, such as setting up more robust systems for monitoring complaints systems in NHS trusts and ensuring recommendations are implemented, are overshadowed by a sense of missed opportunity. An examination of the complaints procedures offered a prime opportunity to put the experiences of patients at the centre of new policy proposals for reform across the whole field. Even the evaluation’s accompanying consultation document could have seized this ground.6 Instead, it quietly concludes with a plea for new policy. Does this tame conclusion suggest that complaints reform lacks status on a crowded government agenda? The NZ report focuses on national integration but does not address issues of local resolution. The UK report, on the other hand, ignores the need for greater 1290
coordination at a national level but emphasises the importance of local systems. In the light of geographical inconsistency, the UK report suggests re-framing the local system within a tighter framework of national criteria and accountability. In the long term there would be merit in investigating a national one-stop-shop approach for the UK, to collate complaints (unresolved at the local level), concerns about health-care professionals, and adverse events. It would encompass both public and private health services, and provide a single point of entry into professional, organisational, and legal systems of redress as well as a coordinated investigative process. This system could ensure that problems are identified and lessons learned. In the short term, the key may lie in concentrating on the common needs across agencies— for example, establishing national criteria for investigations at any level and under the auspices of any agency. This measure would enable a quick and clean passing of accountability between the NHS complaints procedure and systems for professional and legal redress, as well as introduce flexibility and interconnectedness. Integrated solutions are starting to be considered in the UK. A recent Commission for Health Improvement report suggested that UK complaints data should be added to the planned national system for reporting adverse events.7 The Kennedy report into children’s heart surgery at the Bristol Royal Infirmary called for two new UK Councils, one to bring together those bodies that regulate health-care standards and institutions, and a second to oversee those bodies that regulate health-care professionals.8 However, even this attractive proposition would leave NHS complaints, the logging of adverse events, and concerns about healthcare professions in different “silos”. The problem of the chronically piecemeal approach to change in the UK is that the more the UK reforms separate parts of the system, the more it compounds its overall lack of consistency and coherence. Already in the early 1990s Margaret Stacey talked of the tendency for regulatory systems in medicine in the UK to grow “like Topsy”.9 There is no better description for the current crowded field. Rhetoric about systems thinking needs to be realised in a new approach to this policy problem—one that moves on from the particular to the wider panorama. *Belinda Finlayson, Steve Dewar Health Care Policy Programme, King’s Fund, London WIG OAN, UK (email [email protected]) 1 2 3 4
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6 7
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NHS Complaints Procedure—national evaluation. London: Department of Health, 2001. Cull H. Review of processes concerning adverse medical events. Ministry of Health: Wellington, New Zealand, 2001. Department of Health. Regulating private and voluntary healthcare: developing the way forward. London: Department of Health, 2000. Department of Health. Assuring the quality of medical practice: implementing supporting doctors protecting patients. London: Department of Health, 2001. Department of Health. Building a safer NHS for patients: implementing an organisation with a memory. Department of Health, 2001. Department of Health. Reforming the NHS complaints procedure: a listening document. London: Department of Health, 2001. Commission for Health Improvement. Investigation into issues arising from the case of Loughborough GP Peter Green. London: Stationary Office, 2001. Learning from Bristol: the report of the public inquiry into children’s heart surgery at the Bristol Royal Infirmary 1984 –1995. London: Stationery Office 2001 (Cmnd 5207). Stacey M. Regulating British medicine: General Medical Council. Chichester: John Wiley, 1992: 252.
THE LANCET • Vol 358 • October 20, 2001
For personal use. Only reproduce with permission from The Lancet Publishing Group.
Reforming complaints systems: UK and New Zealand The long-awaited report into the UK’s National Health Service complaints system1 published early this month describes high levels of dissatisfaction among users. An inquiry into New Zealand’s (NZ) procedures, the Cull report, described a similar picture.2 Despite this similarity, two different policy responses emerged. Both reports follow high-profile public scandals about errant doctors. The reports come in a climate of increasing public concern and concomitant demands for more effective and transparent systems of scrutiny and assurance. The attempts from both countries to address these expectations take different forms. The UK report follows a trend towards insular but detailed consideration of one aspect of the overall system of public protection.3–5 By contrast, the NZ report looks at complaints procedures as part of an examination of the bigger picture. The regulatory landscapes in the UK and NZ are populated with multiple agencies set up to act on concerns about standards of care. The Cull report notes: “Currently, fourteen organisations potentially can each undertake an investigation into the same adverse medical event, contemporaneously or cumulatively without reference to the other”. The regulatory landscape in the UK looks similar with new organisations such as the National Clinical Assessment Authority, to address concerns about doctors’ performance; the Commission for Health Improvement, to address issues of organisations’ competence; and the National Patient Safety Agency, to act as a watchdog for adverse events. In view of this crowded landscape the Cull report was given a radical remit, which is reflected in the proposal for one investigative process for all health-service-related complaints. This system would incorporate a “one-stop shop” for complaints, adverse events, and concerns about health professionals. One body would be the repository of complaints with responsibility for assessing cases, onward referral, and coordinating informationsharing, as well as making recommendations for improvement and potential compensatory awards. The model also promotes one disciplinary tribunal for judging charges against any health professional. By contrast, the modest remit of the UK report—to conduct a survey of users—means that it does not have the stamp of a full-blooded policy review. The report focuses on incremental improvements to the existing complaints procedure with little reference to the rest of the regulatory world and does not address the potential for duplicate and unconnected investigations. In so doing its few good suggestions, such as setting up more robust systems for monitoring complaints systems in NHS trusts and ensuring recommendations are implemented, are overshadowed by a sense of missed opportunity. An examination of the complaints procedures offered a prime opportunity to put the experiences of patients at the centre of new policy proposals for reform across the whole field. Even the evaluation’s accompanying consultation document could have seized this ground.6 Instead, it quietly concludes with a plea for new policy. Does this tame conclusion suggest that complaints reform lacks status on a crowded government agenda? The NZ report focuses on national integration but does not address issues of local resolution. The UK report, on the other hand, ignores the need for greater 1290
coordination at a national level but emphasises the importance of local systems. In the light of geographical inconsistency, the UK report suggests re-framing the local system within a tighter framework of national criteria and accountability. In the long term there would be merit in investigating a national one-stop-shop approach for the UK, to collate complaints (unresolved at the local level), concerns about health-care professionals, and adverse events. It would encompass both public and private health services, and provide a single point of entry into professional, organisational, and legal systems of redress as well as a coordinated investigative process. This system could ensure that problems are identified and lessons learned. In the short term, the key may lie in concentrating on the common needs across agencies— for example, establishing national criteria for investigations at any level and under the auspices of any agency. This measure would enable a quick and clean passing of accountability between the NHS complaints procedure and systems for professional and legal redress, as well as introduce flexibility and interconnectedness. Integrated solutions are starting to be considered in the UK. A recent Commission for Health Improvement report suggested that UK complaints data should be added to the planned national system for reporting adverse events.7 The Kennedy report into children’s heart surgery at the Bristol Royal Infirmary called for two new UK Councils, one to bring together those bodies that regulate health-care standards and institutions, and a second to oversee those bodies that regulate health-care professionals.8 However, even this attractive proposition would leave NHS complaints, the logging of adverse events, and concerns about healthcare professions in different “silos”. The problem of the chronically piecemeal approach to change in the UK is that the more the UK reforms separate parts of the system, the more it compounds its overall lack of consistency and coherence. Already in the early 1990s Margaret Stacey talked of the tendency for regulatory systems in medicine in the UK to grow “like Topsy”.9 There is no better description for the current crowded field. Rhetoric about systems thinking needs to be realised in a new approach to this policy problem—one that moves on from the particular to the wider panorama. *Belinda Finlayson, Steve Dewar Health Care Policy Programme, King’s Fund, London WIG OAN, UK (email [email protected]) 1 2 3 4
5
6 7
8
9
NHS Complaints Procedure—national evaluation. London: Department of Health, 2001. Cull H. Review of processes concerning adverse medical events. Ministry of Health: Wellington, New Zealand, 2001. Department of Health. Regulating private and voluntary healthcare: developing the way forward. London: Department of Health, 2000. Department of Health. Assuring the quality of medical practice: implementing supporting doctors protecting patients. London: Department of Health, 2001. Department of Health. Building a safer NHS for patients: implementing an organisation with a memory. Department of Health, 2001. Department of Health. Reforming the NHS complaints procedure: a listening document. London: Department of Health, 2001. Commission for Health Improvement. Investigation into issues arising from the case of Loughborough GP Peter Green. London: Stationary Office, 2001. Learning from Bristol: the report of the public inquiry into children’s heart surgery at the Bristol Royal Infirmary 1984 –1995. London: Stationery Office 2001 (Cmnd 5207). Stacey M. Regulating British medicine: General Medical Council. Chichester: John Wiley, 1992: 252.
THE LANCET • Vol 358 • October 20, 2001
For personal use. Only reproduce with permission from The Lancet Publishing Group.