Public Administration Select Committee - Minutes of EvidenceHC 229-iv

House of COMMONS



Public Administration Committee

Complaints: do they make a difference?

Tuesday 2 July 2013

Dr Johnny Marshall, BRENDA Hennessy and Claire Murdoch

Jonathan Senker, Ruthe Isden and Katie Shaw

Evidence heard in Public Questions 304 - 401



This is a corrected transcript of evidence taken in public and reported to the House. The transcript has been placed on the internet on the authority of the Committee, and copies have been made available by the Vote Office for the use of Members and others.


The transcript is an approved formal record of these proceedings. It will be printed in due course.

Oral Evidence

Taken before the Public Administration Committee

on Tuesday 2 July 2013

Members present:

Mr Bernard Jenkin (Chair)

Alun Cairns

Charlie Elphicke

Paul Flynn

Kelvin Hopkins

Priti Patel

Mr David Reed

Lindsay Roy


Examination of Witnesses

Witnesses: Dr Johnny Marshall, Director of Policy, NHS Confederation, Brenda Hennessy, Director of Patient and Public Experience, Addenbrooke’s Hospital, and Claire Murdoch, Chief Executive, Central and North West London NHS Foundation Trust, gave evidence.

Q304 Chair: I would be very grateful if each of our witnesses could introduce themselves for the record, please.

Brenda Hennessy: Brenda Hennessy, Director of Patient Experience at Cambridge University Hospitals, also known as Addenbrooke’s.

Chair: Addenbrooke’s, where I have not quite been a casualty.

Claire Murdoch: Claire Murdoch, Chief Executive, Central and North West London Foundation Trust. We are an organisation that provides all manner of community-facing NHS care, so physical healthcare through to learning disability and addiction.

Chair: Which hospital is that?

Claire Murdoch: We are Central and North West London Foundation Trust, which means we cover a huge geography including out to Milton Keynes.

Chair: Mental health?

Claire Murdoch: Physical, health visiting, district nursing, podiatry, dentistry, palliative care, mental health, addiction, learning disabilities. We have 1,000 inpatient beds across that geography as well and about 110,000 patients on the books, but we are a community trust, providing a spectrum of healthcare.

Dr Marshall: I am Dr Johnny Marshall. I am the Director of Policy at the NHS Confederation and practising as a GP still, two days a week. The NHS Confederation is a membership body for all providers and commissioners of NHS care. The NHS Confederation speaks on behalf of them as a system.

Chair: Welcome to this oral evidence session on complaints handling.

Q305 Priti Patel: I would like to start by exploring the whole issue of leadership and governance within trust boards around complaint handling. In particular, if we look at the recent Francis report into the failings of Mid Staffordshire and the Mid Staffs Trust, the report highlighted that there a number of very serious failures with the complaints process and the actual performance of the trust as well. Closer to home, in the eastern region, the board of our own ambulance trust failed in its leadership and governance in terms of patients, complaints and public handling of complaints. Could I therefore ask each of you for your views on what role trust boards should have in overseeing the complaints process, the complaints handling, and also the training and oversight required when it comes to ensuring the right kind of provision and resources are in place within the organisation?

Brenda Hennessy: The role of the boards is absolutely key to the success or not of a good complaints system. The board needs to take very seriously the feedback from patients, both positive and negative, from complaints and from all the other forms of feedback that we get from patients. We have to learn as an organisation from them. If that leadership is not demonstrated at the top by the board, then it is not going to filter into the culture of the organisation. Boards have to recognise, also, that complaints management needs to be well and properly resourced to provide the support that the patients and their relatives need when they are at their most vulnerable. In some organisations where the complaints process fails, it is because there is an expectation that very junior staff should be dealing with very complex issues. I do not think that is reasonable and I do not think it is helpful to patients. It does not help the board to learn, and at the end of the day the board has to recognise the importance of managing complaints properly and learning from them.

Claire Murdoch: There is no doubt in my mind: it is the job of the trust board to know very clearly what the quality of care is that you are providing. I do think that, in this hugely complex landscape of commissioning and regulators, and in our case providers, it is helpful to all if we are clear, both as boards and as the public, that the people most accountable for the quality of patient care are boards of provider organisations and the clinicians working for them. Everyone else can hold us to account and scrutinise us, but it is our job to ensure patient care is of a good standard. I would say that first. That is absolutely essential.

One has to say that, in ensuring that patient care is of a good standard, you have to set the culture in the organisation; you have to recruit the right people with the right approach and the right attitudes. You have to take every opportunity to demonstrate not only the importance of complaints, but the great effort that the board will put into identifying and acting upon other sources of information about how the quality of care is in your organisation. For example, we have about 110,000 patients on our books today; last year, 331 patients formally complained. Quite clearly, even if we were the best trust in the world, it is likely that there were more problems with care than just 331. I will just very briefly list the other sorts of things that my board does, and I think other boards do, to try and help them understand: is care safe; is it of a good quality; are we doing enough to constantly improve it?

For years, my board has had quarterly and annual complaints reports, which are published on our website, identifying themes and trends and identifying actions, and then we review those actions to see if they are making a difference. We have had for a long time a rigorous programme of board-to-ward visits. We conduct mystery shopping exercises, where staff, service users and carers are trained to go in, unannounced, to different areas of the trust and test, unannounced, the quality of service. We run a series of mock CQC inspections, which service users are part of, for example. I could go on.

My key point there is that the best of boards will recognise that you can always do better, that there will always be some failings in patient care. Some of them will be individual; some of them will be systemic. The best of boards will be endlessly creative in how they try and source feedback.

The last example I would like to give is, in the mental health elements of our service, each quarter, highly trained service users will phone 2,000 patients who have used our service in the preceding quarter to ask them a series of questions about: how was it; what could we improve on? The best of boards handle complaints well, but they do a whole lot of work upstream to avoid complaints. Complaints are part of a bigger system.

Dr Marshall: Just picking up that theme, we would recognise the value of input from patients, carers and their families as a continuum of quality improvement. Concerns and complaints are clearly an important part of that if we are genuinely going to make the NHS more accountable and address the concerns in the Francis report. That sense of it being a responsibility all the way from ward to board has to be set from the leadership at the top. The board has to make sure it is really connected with what is going on at a ward level if it is going to be able to fulfil that leadership responsibility. Some of the examples that we have heard-of boards actually discussing patients’ stories, not simply looking at the numbers; of members of the boards, on their tours around the hospital wards, talking to patients, talking to staff-are a really important part of setting the culture and the tone for the whole organisation.

How we then, as a healthcare system, take some of the great examples and ensure that they are deliverable in each of our organisations, so that it is increasingly everyone’s experience, is a really important part of training and spreading that practice. In terms of peer review, we have had chief executives from our membership saying they have learned more when other chief execs have come to visit their organisation, looked at what they are doing, and shared some of their understanding and experiences to help them improve their delivery of a whole range of services. That sort of peer review would be a really important way of trying to spread the good practice that we are hearing about throughout the NHS.

Chair: Those were very, very full answers, and a very full question too. Please can we have shorter questions and shorter answers otherwise I will have to interrupt you?

Q306 Priti Patel: I will keep this snappy. All three of you touched on a number of words: "culture", "accountability", "transparency". Were any of you at all shocked by, or what was your reaction to, some of the recent reports, such as the Francis report? I touched upon the failure of governance in the East of England Ambulance Trust, and there have been other examples since. Are you surprised by what you have heard is going on in terms of patients, lack of care, complaints handling? What is your overall reaction to that, in light of the fact that you have all been very enthusiastic, not as defensive as the culture that the public are now presented with of the NHS?

Dr Marshall: It was shocking to hear the stories of what people were experiencing, but at the same time, looking around other parts of the NHS, other people are getting a very different experience. Our members feel confident that, if they do engage with the public, listen to their stories, that has a significant impact in improving the whole patient experience and quality. The optimism lies within that, but the need to put things right is absolutely paramount.

Claire Murdoch: The experiences of those organisations were shocking, and I do not recognise that in my trust. That is not for one moment to be complacent. Things do go wrong; we are not perfect, but I do not recognise that when I look at the amount and quality of information my board scrutinises regularly, and has done for years, and the amount of presence. I have not had a Christmas Day at home for 14 years, because I consider, if you run a 365-days-of-the-year service, you should be walking the patch and visible, as well as looking at data and information. That was shocking. It is not the whole NHS. There are organisations, teams and individuals who are stunning in their practice. That was shocking. We are all ashamed and want to work hard to make sure it never happens again.

Brenda Hennessy: I would agree. I do not think one NHS organisation can hold a mirror up to itself and agree that it gets everything right all the time. The big difference in Mid Staffordshire as opposed to many other hospitals is the fact that we listen to patients, we encourage patient feedback. It is absolutely key to learning. The organisations that have failed significantly have been those in denial that have not allowed the patients a voice to be heard.

Q307 Kelvin Hopkins: Claire Murdoch said it is very important to get the right people in the Health Service. What was clear at Mid Staffs was the lack of care and compassion. How do you ensure that the people at the grassroots in the organisations have that compassion at the front of their minds?

Claire Murdoch: A few years ago-just to give you a very brief example-in my trust, we were scrutinising complaints and felt that there were too many about staff attitude, a lack of care, a lack of compassion. We looked at a range of data and decided, yes, there was a problem with, for example, our band five staff nurses. What we did then, five years ago, was change the recruitment process for staff nurses. They now go through, and have done for five years in my trust, a day long assessment centre process, where we test the numeracy and literacy before coffee. If those newly qualified nurses pass their numeracy and literacy tests, we keep them on for the rest of the day, where patients and experienced staff will test them for, even then, compassion, aptitude, attitude and motivation.

At the first assessment centre we ran, we had 240 applications; we shortlisted 40 and 30 staff turned up on the day. We failed 25 who did not pass their numeracy and literacy test. We kept the remaining five for the rest of the day and put them through their paces, and offered one job. We have run that assessment centre every month since, and we believe that over that period we have seen an improvement in front line.

Q308 Kelvin Hopkins: Is this practice general across the Health Service, or would you recommend it being general across the Health Service?

Claire Murdoch: I would absolutely recommend it to be general across the Health Service, and I think it is becoming more commonplace. Those figures were shocking. When we pooled centrally to our nursing directorate the recruitment of newly qualified nurses, to have 240 applications in one month and offer one job told us something about a wider systemic problem. I agree you have to make a big commitment, involve users and carers and bring the right people on board.

Q309 Chair: When you look at the leadership of trusts where things are going wrong, like the East Anglian ambulance service, why do you think the central leadership of the Health Service waits until things get so bad before there is intervention? It does seem to me that that is the message of Mid Staffordshire, and it is also the message of the East Anglian ambulance service. Why doesn’t the NHS Confederation see things going wrong, Dr Marshall?

Dr Marshall: From our organisation’s perspective, as a membership organisation, we are not seeing what is going on in all of those organisations on a daily basis. Taking your question, therefore, what are the signs within an organisation that can be picked up from a national level by the various different regulators or the Trust Development Authority that might see that-

Chair: I am asking you the question. What is the national leadership not doing that it does not pick these things up?

Dr Marshall: I am not sure currently that we have a process assessing, on a regular basis, what the performance is of trusts in that area.

Q310 Chair: What should that process be?

Dr Marshall: I do not have a particular answer for that. Having a standardised response to how we should be dealing with complaints, ensuring we then have some standards that people can demonstrate their delivery by, ensuring that they are open and transparent for people to see-I guess the solution lies somewhere within that territory, if we are going to be aware of picking things up in an earlier process.

Brenda Hennessy: It is about measuring what counts. When we have had a look back at the CQC visits that our trust had had, on only one occasion had the inspectors asked to look at the complaints about the service that was being monitored, or look at the compliments or the surveys. That is very rich information that needs to be used by monitoring organisations. The monitoring organisations need to be brave as well, and speak up when they see things that are wrong.

Q311 Chair: The monitoring organisation should be looking at this patient information that you are gathering.

Brenda Hennessy: Yes.

Claire Murdoch: It is my view that one has to beware of burdening provider organisations that are there to provide care for patients with too much bureaucracy and too many layers of accountability in too many different directions. It would be much better to have fewer, clearer lines of accountability up the NHS hierarchy, leaving maximum freedom to boards to determine how they deliver great patient care, safe patient care, and have a few high-level indicators of safety and very severe consequences for boards if they get it wrong. So hold our feet to the fire if we fail systemically to grip this issue of quality and improvement. I also have to say that the degree of the reorganisation in the NHS-and I am not just talking about the most recent one, so I am not being party-political at all-is never ending. For example, we now have Healthwatch, and before that we had LINks, and before that we had PPI, and before that we had the CHC. It seems to me, just as patient groups and the public find their teeth and bite to hold us to account, they are changed.

Q312 Alun Cairns: Isn’t it the nature of any modern organisation that it needs to go constantly through a reorganisation? If I point to a private sector organisation, granted where the culture would be different, it is constantly reinventing itself. Don’t you think reorganisation is often used as an excuse for failure within it?

Chair: Yes or no?

Claire Murdoch: Yes.

Dr Marshall: Yes, you have to take responsibility yourself.

Brenda Hennessy: I would say you have to be constantly learning and improving. I do not think that is the same as reorganising. One has to be open to change and embrace it for good purposes, but not for the sake of it. I think that is what Claire is referring to: that that has happened too often.

Q313 Charlie Elphicke: Claire Murdoch, we have talked a lot about complaints, but what about looking at statistics to use them as an early warning mechanism? I will give you an example. I was contesting a seat in St Albans back in the day, and I looked at statistics and found the number of elderly people dying within 28 days following a fall and breaking their hip was really through the roof. So I raised this and said, "There is a serious issue here." Suddenly, everyone was having a big investigation, changing the path of care, and realising there was a serious problem. To what extent do you do that self-checking type of work?

Claire Murdoch: I listed some of the things. My board never meets without considering a report on feedback or clinical audit or safety. We look at a whole load of information. I could list yet more examples, but rest assured they are many and numerous. If I might very briefly add this, one talks about the difference in culture between the private sector and the public sector, and it is something that is unhelpful. Within both the private and the public sectors, there is an enormous variation in how individual organisations handle themselves.

Last night, for example, I went on to the internet to look at three major private competitors of the trust, so my kind of organisation. They were major national names. I looked at my website and theirs. On my website, CNWL’s website, you can go and find all of our board papers, our performance information, our complaints information, our organisational learning information. On theirs, I can find no board papers, no information about organisational learning, no information about themes and trends.

Q314 Chair: What is the point you are making?

Claire Murdoch: The point I am making is that many of us who are working in the NHS at the moment-I am a registered nurse as well of 30 years now-are cross that there is a broad "private sector good, NHS bad; private sector open and can-do, NHS closed and defensive." We can be better and we should be. There are some appalling examples of failure but I believe there are some brilliant examples of openness and a can-do culture that would rival the best of the private sector as well. That website example is one of many.

Q315 Charlie Elphicke: Can I press you a little bit harder on this? Looking at Stafford, and indeed the Clostridium incident in West Kent, which you are probably aware of, to be blunt, when you get a body count rising, that has to throw up in the figures and someone has to say, "Oh my goodness, people should not be dying at this rate. Mortality is through the roof. What is going on? Whack." That systemically did not seem to happen. Why not? Are we all confident that it happens today?

Brenda Hennessy: We have regular morbidity and mortality reviews in the hospital and that happens in every speciality on a monthly basis. It is important that you do review your data and you drill down and look very carefully. That is something that more trusts are doing now than was the case before. We should be using clinical audit for its main purpose of helping us to be better.

Q316 Priti Patel: Can I ask you all very quickly whether you think there should be sanctions in place for those on trust boards who fail in their leadership and the way that they conduct themselves, which then brings the NHS into disrepute?

Dr Marshall: We need to take the responsibility very seriously. We need to provide people with support and clear direction but, fundamentally, if they are not demonstrating that accountability, we need to question whether that is the right role for them to be undertaking, whether they are fit to work as a director within an NHS organisation.

Q317 Priti Patel: Should they be barred from working in the NHS again?

Dr Marshall: I think we need to understand what their particular skill set is as to whether they are barred from just a particular level of accountability or all accountability. The principle has to be based on the accountability of the role that they are undertaking.

Q318 Kelvin Hopkins: Could I just say that Mid Staffs is rising up the agenda of commercial and financial pressures-

Chair: Is that a question?

Kelvin Hopkins: It is a question. Was it not the fact that it was starting to ape the private sector that caused the problem?

Claire Murdoch: No, I do not think so.

Q319 Chair: That was a no. Moving on to the trust boards, there has been some research about NHS governance of complaints handling, which was published by the PHSO, as you know. It reported that only 20% of trust boards review learning from complaints and take action as a result. Fewer than half measure patient satisfaction about complaint handling. Fewer than two thirds use a consistent approach to reviewing complaints data. About a fifth said the information they receive was ineffective in identifying and reducing risks to patients. What is your reaction to that?

Brenda Hennessy: I would say that our organisation actually undertakes all of those.

Q320 Chair: I am not asking about your organisation. I know your organisation does. What is your reaction to that data?

Brenda Hennessy: It is absolutely key that that data is used and should be reviewed. It should be the responsibility of every board to look at the information and ensure that action is taken.

Q321 Chair: Would you say this is a good thing or bad thing? What do those figures reflect about the culture of the NHS?

Brenda Hennessy: They reflect that we need to be better and boards need to be better at looking at what has in the past been considered some of the softer aspects of care. Some trust boards will concentrate on finances and targets, and the care of the patients, the way complaints are managed, is not always seen as important.

Dr Marshall: That clearly reflects the current position and, in a recent survey of our members, 90% were already taking action even before the second Francis report was published in recognition of the fact that we all need to do better. That is a very accurate self-assessment. It is not acceptable fro, our members’ point of view, and they are already taking action to try and address those concerns and improve those figures.

Q322 Chair: What should national NHS leadership do about this? In our evidence last week, Sir David Nicholson seemed very keen to improve complaints handling at trust level, but was less clear about the responsibility of national leadership for ensuring this is happening. What is the national leadership’s responsibility for ensuring that those figures that I have just referred to improve?

Claire Murdoch: I am shocked that trusts do not routinely look at complaints, themes, trends, actions and follow up. It has to be a board responsibility.

Q323 Chair: So it is not the national leadership’s responsibility?

Claire Murdoch: I think first and foremost it is the boards’. We need to account and be checked on. Public scrutiny is right, and I am delighted at the recent discussions about the CQC and the change in its inspection regime. We have yet to see whether it will change the waiting way it inspects. I would typify the previous inspection regime as being a sort of computer-generated algorithm that tried to judge trusts.

Q324 Chair: What are the pressures on trust boards? Do you get pressures from national leadership about improving complaint handling? Historically, it does not seem that that was the case.

Brenda Hennessy: I would still say that is the case. I do not think individual trusts are particularly monitored on their complaints management. We have NHS regulations that are of a high standard and fit for purpose. What we do not have is best practice standards to monitor boards and organisations by. That would help the national bodies to provide a better monitoring regime.

Dr Marshall: Having consistent national standards would be a very good place to start, partly because some of the regulation and oversight of the providers is now separated between NHS England from a national perspective, CCGs, and regulators, such as CQC. To have a set of national standards that everyone is working to would be a really good idea. To ensure we are then joining up the intelligence and the information-one of the problems with Mid Staffs was that we were not putting all the information in the same place-is going to be an important national function. Having the right sort of information technology to support that will be a national role.

Q325 Chair: One of the recommendations arising from Francis was to set up an NHS national leadership academy. What do you hope will come out of that? What is the objective of that, in your view?

Brenda Hennessy: My preference would be to see individual organisations being required to invest more money in training and development of leaders at all levels within their organisations. The NHS spends a lot of money training doctors and nurses. In comparison to private industry, we spend a pittance on teaching our leaders, both junior leaders and more senior leaders, to be good at developing teams, to performance manage staff. I would rather see the investment locally, and trusts and boards required to invest more in the training and developing of people, who are our most important resource.

Dr Marshall: There is an NHS Leadership Academy already in existence and its role in terms of ensuring that we have the necessary education and training across the board and to a certain level is important.

Q326 Chair: Have you each attended the academy, or attended leadership courses?

Dr Marshall: I have been on the NHS Top Leaders course.

Q327 Chair: What did it teach you about complaint handling?

Dr Marshall: It is designed very much to support you as an individual, understanding your role, your self-reflection, your leadership skills. For me, from an individual perspective, it did make sure I looked across the whole range of leadership skills, not just the pacesetting style, which is perhaps the natural style within the NHS, but something that is much more engaging and facilitating with people. It is an individual support that I had, and that is true of all the leaders.

Q328 Chair: What assessment do you think the national Leadership Academy has made of what kind of leadership the NHS needs?

Dr Marshall: It has a good idea that some of the natural style of leadership within the NHS has been what is described as a pacesetting style, and that tends to respond to the targetdriven approach, if you are looking to try and determine things at a local level nationally. What it understands is that you need something that is much more facilitative, much more engaging with people at a local level. Within a complaints perspective, that means you really need to be ensuring that it is the firsttouch ward staff on the ground dealing with patients’ concerns who are really picking up and dealing with those. The leadership style is ensuring that you are setting that for your staff on the front line.

Q329 Chair: What values do you feel the national Leadership Academy should be inculcating into the leaders of the NHS?

Dr Marshall: The values of openness and transparency, and the values of partnership. If I look at my own profession over the 20-25 years I have been in it, there is a sense of moving away from what has traditionally been quite a paternalistic sense of consulting to one that is much more around partnership, recognising people as being an integral part of their care and central to it. Those are the sorts of values that we are trying to distil into the NHS.

Q330 Chair: To all three of you: how confident are you that the national Leadership Academy is going to address the deficiencies in NHS leadership, throughout the entire leadership, about complaints handling and the values that the organisation needs in order to successfully address the needs of patients?

Brenda Hennessy: I have to say I do not know enough yet about its intended work programme. I have significant doubt, though, that it will reach down to, and enable a flow of support for, a ward manager who will typically manage about 60 or 70 nurses delivering front line care. More emphasis needs to be put on helping those people at an early stage of their career.

Q331 Chair: Is that not a trust responsibility? Is that not your responsibility as a trust director?

Brenda Hennessy: It is, but it is about investment. We invest a lot nationally, but very little at local level, for leadership development.

Q332 Chair: Would it be fair to say that none of you have really got a very clear idea about what the strategic objectives of leadership education at the top of the NHS should be about; that that has not come down to you yet?

Claire Murdoch: I am a board member of our local education and training board-LETB-in North West London. I put myself on that board because you do need to take a sectorwide view of issues such as leadership and standards of training. This is a very personal view, but I think anything that requires big national solutions to enable providers such as my own to deliver great patient care needs very careful thinking about. I do not know enough about the approach yet. I would prefer to work locally in London and in my patch to think about the leadership issues.

Q333 Chair: What about your peer group and the training your peer group is getting across the NHS? On a scale of one to 10, bluntly, do you think the Leadership Academy is going to deliver 100% of what is needed-10-or zero? Where on the scale is your confidence?

Dr Marshall: We are going through a transition, and therefore confidence in that transition-

Chair: That is not answering my question. Where is your confidence?

Dr Marshall: My confidence is the NHS Leadership Academy understands the task in hand.

Q334 Chair: So it is 10.

Dr Marshall: It understands the task in hand. In terms of understanding its role at the national level versus what we were describing as needing to occur at a local level, I do not think we have bottomed that out. I am confident that we understand the problem, but not the solution.

Q335 Chair: I will put you at a five

Dr Marshall: Maybe a six.

Q336 Chair: Claire Murdoch?

Claire Murdoch: Am I allowed to be agnostic at this stage?

Q337 Chair: That is candid. It means you do not know and that tells us something.

Brenda Hennessy: I would say I do not know yet. Time has yet to show it.

Q338 Chair: Does that not in itself say something about the profile and the respect a Leadership Academy is meant to have in an organisation, which it does not have?

Claire Murdoch: With respect, it could equally mean that somebody like me, 30 years at it, with a trust board that has been in post for a long time and is growing great leaders for the future in my organisation, the job is being done, and I am not looking more widely. I don’t know.

Chair: But if your trust is such a success, and indeed your leadership is such a success, why are you not involved in the education of others?

Kelvin Hopkins: Spreading the kind of practice that you obviously indulge in across the whole NHS would make a difference.

Q339 Chair: Can I have an answer to my question? Would we not expect you to be one of the people helping the Leadership Academy to spread good practice and good experience?

Claire Murdoch: I would be happy to help them if I were asked.

Q340 Chair: Have you been asked?

Claire Murdoch: No.

Q341 Chair: My own trust chairman is an excellent leader, and he has not been asked.

Claire Murdoch: I think there is an issue about who is asked.

Q342 Chair: Dr Marshall, is this something that you will take up?

Dr Marshall: The NHS Confederation is taking it up. The NHS Leadership Academy has an important role, but that sense of us at a local level taking responsibility for our organisations is really, really important. From an NHS Confederation perspective, we are showcasing some of the examples that you have heard today to our members. We are trying to promote a sense of peer review, so we have an openness where organisations are going into other organisations and learning from each other. The providers need to take responsibility, not leave it all with the Leadership Academy.

Q343 Chair: But if the Leadership Academy is simply buying in some courses from outside to put people on, it does not really deserve the title Leadership Academy, does it?

Dr Marshall: The Leadership Academy has a role that is greater than that, but I would agree that currently it remains unclear during this transition period. How that fits in with the local education and training boards, how it fits in with the end provider, the trust, is a really important part of getting this right.

Q344 Kelvin Hopkins: What Claire Murdoch has done is very impressive. Why is that not done across the whole of the Health Service? How can we make sure it is done across the whole of the Health Service?

Chair: Good question.

Claire Murdoch: Good question. It was partly my point about the private sector and the public sector. It was not to pit one against the other; it was simply to say that I think one best understands quality when you look at it organisation by organisation. Then you do think very hard about how you promulgate and spread best practice. One thing I have to say is that it is right we look at leadership. I love my job, I have considered myself incredibly fortunate, but the average life span-and I am sure you have heard it here-of a chief executive in the NHS is two years. I have been a chief exec for seven years, so I feel I am ticking, about to explode.

One can grow leaders, but if they are quickly rubbished or put on the scrap heap then some of the best people who you want to step into these roles, who perhaps have got careers they are proud of and they have invested in heavily over the years, simply will not make that step. Thinking about how one supports leaders in terms of training and how we support each other is absolutely right, but I also think there is something about the broader culture that does not invest 30 years in growing someone and scrap them at the first hurdle. It is different with Mid Staffs and systemic failure.

Chair: We must press on, but thank you for that answer.

Q345 Mr Reed: From the patients’ perspective, the new commissioning arrangements are more complex than what went before. What are the problems that will cause in relation to complaints handling?

Dr Marshall: The division between NHS England and clinical commissioning groups, which previously sat under a PCT responsibility, does make it more difficult, particularly when we are increasingly looking at services being more integrated. Identifying the division and which particular provider the commissioner is responsible for will be much more difficult. So we will need to make sure that the local area teams around NHS England are working closely with the clinical commissioning groups to share information so they can really ensure that we are learning from that. We need to make it really clear, signposting to patients so they know where they can go to be able to raise their complaint. It is less important where they go than the fact it is raised, it is heard and it is fed into the right person. There are concerns that is not in there at the moment

Q346 Mr Reed: How do we make that happen? That is a great aspiration, but how do we, in this complex environment, make sure that happens. What do we need in terms of tools or requirements from the centre?

Dr Marshall: At a local level, it will be clinical commissioning groups talking to the NHS England local area teams.

Q347 Chair: Talking?

Dr Marshall: In terms of trying to establish the right processes. Currently, it will involve them discussing with each other what information they have and how they can share it. Fundamentally, it comes down to the sharing of information. We need new systems in place that do not exist at the moment to allow that sharing of information. There are quality surveillance groups that will meet across clinical commissioning groups, NHS England, Public Health England, Healthwatch and a few other regulators. They will be looking at things at quite a high level around quality. If we are going to learn from the softer intelligence and the stories, it is really important that we can share that information.

Brenda Hennessy: We regularly manage and co-ordinate crossorganisation complaints, some of which will include issues about commissioning. In addition, we meet on a monthly basis with our clinical commissioning group, specifically to look at quality, so aspects of that agenda are about our patient experience surveys, our complaints, any serious incidents, our general patient safety measures, infection control etc. There is good opportunity for dialogue with our commissioners at those meetings on a very regular basis. We look at complaints, trends and work with them to see if there is any contribution that they can make.

Q348 Mr Reed: What more do we need to do to ensure that the patient voice is heard, within the design of these new systems? You have been talking about the CCGs in NHS England, but I wonder how we might build the user voice into that more strongly?

Brenda Hennessy: I am very passionate about engaging with patients. If we just concentrate on looking at complaints, that is already too late. We need to be making sure that patients feel they can talk to staff, question them, find out about the hospital. We should be working to use the rich information that we get from patients from so many different avenues to improve our services. We should be aiming to get it right first time. When we deal with a complaint, it is too late. We need to be working more to help our nurses deal with issues on the ward as soon as they arise and nip them in the bud; make sure we are getting it right, and putting it right, for the patient and their relatives. It is taking that step backwards and looking at how we can be very open in everything that we do with our patients.

Claire Murdoch: In the current climate, health has never been more fragmented. We have got public health, the huge swathes of money going to the local authorities for, say, sexual health services for the first time, CCGs, and then specialist commissioning. I do think the one place that could effectively join up the overview, as yet untested and finding their feet, would be the health and wellbeing boards. If I were a committee sitting centrally, I might be tempted to charge them to answer that question locally with users, and to be able to demonstrate how they have talked to the public and users about how you hold a very fragmented broader health system to account. In that, if I might, I would include all of those private providers on whom vast amounts of NHS money are spent, because that is still a public service. It is not easy, but I would ask the health and wellbeing boards to demonstrate that system leadership.

Q349 Mr Reed: That is an interesting idea. Can you expand on that slightly further? How will a patient know whom to complain to?

Claire Murdoch: Firstly, all providers should make it really easy and clear for patients to complain. If I get a complaint that is about a GP, the local acute trust or public health, I think I should undertake to say I will help the patient, or my complaints handlers-as you have just said-should help the patient get answers to that complaint. We should all show some system leadership at provider level. At provider level, we should have an agreement between us that wherever a complaint lands from a patient, we deal with it. We, on their behalf, navigate the system with and for them, if it involves many agencies. On commissioning-and there will be some complaints and concerns about commissioning-maybe the health and wellbeing boards should get somebody in the commissioning system within each borough or county to take the lead similarly. It would be something like that-really easy and clear.

Q350 Mr Reed: The point that it should be tackled at the point where it is received is good. How do you ensure learning across the system, not just within the borough or county but more widely?

Dr Marshall: Learning across the system is a real challenge around integrated care, and it really means you need to be sitting down as a team, with all the different parts of the team who are responsible around an individual’s care, and looking at that together to understand the learning. In my own practice, we are very good at doing that for particular complaints that come in around the practice, but often if they involve an interface with the hospital, with community services, it is more difficult to get everyone around the table literally to be able to really understand that. We are going to have to work out how we work across providers to come up with models of learning on that basis.

Q351 Chair: How would you expect commissioning authorities to include, in their contractual arrangements with providers like you, ensuring that complaint handling is properly addressed and properly managed in the provider units?

Brenda Hennessy: We do that through our regular monthly quality meeting.

Q352 Chair: With the commissioner?

Brenda Hennessy: Yes.

Claire Murdoch: We have something similar.

Q353 Chair: But is it actually in the contractual arrangements?

Brenda Hennessy: Yes. It is part of our requirements, looking at the quality measures in our contract, that we do that.

Q354 Chair: Do you feel that commissioners are concentrating on the right aspects of complaints handling in those conversations? What are they missing? If you were a failing trust, what would they not be picking up from these conversations?

Brenda Hennessy: If they are in a failing trust, I think the trust is possibly hoodwinking them, but I find that difficult to say. I just know that we try to be very honest with our CCG.

Q355 Chair: In a trust that may be not failing but that was not really addressing complaints as proactively and as positively as it should, do you think the commissioning groups would pick it up?

Claire Murdoch: It will depend on the commissioning group. Just as you can have failing providers, you can have failing commissioners.

Q356 Chair: Dr Marshall, what advice would you give commissioning authorities about how to promote good complaint handling?

Dr Marshall: There are lots of demands on clinical commissioning groups, which have been stripped down. One of the concerns that we have from NHS England Confederation is that it may be a very large demand to place on them. It is really important that we try to get to the point that there is real time information that they can see. It is through having that conversation with your provider around your quality, but also talking to the other regulators so you are sharing information, so you are getting a broader picture. Do not just look at one piece of the information.

Q357 Chair: By the time the regulator is picking it up, it is going wrong. The point is, how should it be embedded in the commissioning process so it does not go wrong?

Dr Marshall: So I think it is embedding all of those things. They will all give you a different perspective. The other opportunity, and I have seen this within a clinical commissioning group, is actually using the fact that the GPs are part of that clinical commissioning group: they have regular contact with their patients and feeding information and concerns, and holding the clinical commissioning group to account for addressing some of the safety issues they are picking up.

Q358 Chair: What I am hearing is how it should work in theory, but I am not really clear of the practical measures that a clinical commissioning group should implement in their commissioning in order to make sure it is happening. How much thought has been given to this, do you think?

Dr Marshall: I think a lot of thought has been given to it by the clinical commissioning groups. We are in this transition period, which is not designed to be an excuse, but there is the sense of people wishing to put together all those things that we have talked about in piecemeal. I am not sure that they exist in one particular health system at the moment, but there is no reason that through development this could not happen. If you put all those bits together, you will have a much more robust system.

Q359 Lindsay Roy: We have heard about leadership, about culture, about accountability, about learning and listening. Can I ask what the hallmarks of an effective complaints handling procedure are, from the patient point of view, in a nutshell?

Dr Marshall: Patients want to feel that they have been heard. They want to feel that people are taking them seriously and ensure that people are taking action and responding on the back of that complaint.

Brenda Hennessy: It is important to do everything you can to give the patient or their relative the confidence that you will be truthful with them, you will be honest with them and you will support them. I encourage all of my patient advice and complaints team to act very objectively. I do not expect them to defend the organisation if we have done anything wrong, and we have to win the confidence of the patient that we will do that. Patients want an apology, they want to know what happened and that we are going to do something to make a difference in the future. We will fail those patients if we do not learn, as an organisation, to be better. Sadly, the one thing that you cannot do is turn the clock back. Some patients and their relatives go through dreadful experiences, and you can make all the promises in the world about making things better in the future, but the sad thing is you cannot turn the clock back. It is important to recognise that when we are looking after patients who are using our services and counting on us to give them the answers they need to their questions.

Q360 Lindsay Roy: What are the main barriers to patients making complaints? How can the process be simplified?

Brenda Hennessy: For an acute hospital, the majority of patients that are in beds today, any day, will probably be over 65 or 70. A lot of those patients feel vulnerable. They feel that they cannot speak up because it might impact on the care that they get, that people might be difficult or unpleasant with them. That is why we have to educate our staff at the front line to be very open, and to be proactively asking patients, "Are you happy with the care that you are getting? Do you have any concerns?" We do not want a patient to be unhappy, feel that they have not been cared for or dealt with kindly and wait until they go out of hospital. That is too late for the patient and it is too late for the organisation. We want them to feel that they can speak up, so it is about some of the education and training that my team deliver to our front line staff to give them the confidence to ask those questions and to act on it quickly.

Claire Murdoch: The only thing I would like to add to that is that, if one looks at a trust like mine-but I am sure it is true of others-there are so many different patient groups that you do need quite a detailed understanding of how you enable people to complain. If I go to a sexual health clinic, you can put your views about the treatment you received in at the touch screens yourself. We run learning disability services, and it is really important that we have users and advocates working alongside people with learning disability to make it easy for them to express views. For the 2,000 patients a quarter we phone with mental health problems, it is about that very proactive reaching out and making it easy.

In my experience, most of us do not want to complain. What we want is to know our views are heard right up front, as you say, and are dealt with and taken seriously. Often, by the time it gets to me, we have failed and that person has had a poor experience. It requires huge investment in front line and attitude culture training, and being endlessly creative about how you help patients have a voice. If they have got dementia, it is their carers; if they are children, it is their parents; palliative care is different again.

Q361 Chair: Brenda Hennessy, you asked two questions. Are you happy? Are you satisfied? They are closed questions. Don’t you ask yourself to ask open questions? How happy are you? What concerns do you have? They are far more likely to give you information than if you just say, "Is everything alright?"

Brenda Hennessy: Absolutely. We do that on a regular basis. We ask our staff to say to our patients, "I am the senior nurse on the ward. We hope you have good care, but if you have any concerns please let us know, because we want to do something about it." We should not look at complaints in isolation. The more that we encourage proactively patients to give us feedback through focus groups, through surveys, they will know that we are an organisation that wants to hear their views and hopefully that will give them the confidence to speak up when things go wrong.

Q362 Lindsay Roy: In effect, what you are saying is leadership and training at the front line to resolve things at the front line is absolutely crucial. Are you aware of models of good practice in terms of removing barriers to complaints, and can these be shared?

Brenda Hennessy: It is about having a very accessible service. We run a service that is open seven days a week. It is available to relatives when they come in at the weekend. It is right next to the main reception. We have Hospedia in the hospital and a free phone line for patients or relatives to phone up our service. It is important to make sure that people are aware of all the points of access to get to speak to people.

Q363 Lindsay Roy: It seems very complex. Is there scope for a single portal, as they have in Wales and Ireland?

Brenda Hennessy: As Claire said, different people would like to use different mechanisms to get in touch with us. We try and be as flexible as possible.

Q364 Lindsay Roy: It does need to be clear what those portals are.

Dr Marshall: The portals need to be very clearly signposted, but if we are going to have this continuum of trying to deal with the concern before it escalates, that has got to be dealt with as locally as possible. When that is not resolved, you then need to have a very clear portal. If you go into the wrong one, that should not matter. You should be directed to the right one. It should not be someone’s responsibility to know how to do that.

Q365 Lindsay Roy: A cross referencing?

Dr Marshall: Yes, there should be that sort of cross reference, as Claire was alluding to.

Q366 Chair: I have a technical question. When a Minister gets correspondence via an MP about something that has gone wrong in a trust or a complaint in a trust, what is your expectation of how the Minister should handle that?

Brenda Hennessy: In a very open way.

Q367 Chair: In terms of relationship with your trust.

Brenda Hennessy: I deal with Ministers’ briefings when they come through the regional office. If they raise concerns, we will look to investigate. Very often they are already going through a process.

Q368 Chair: Do you think it is right that a Minister should refer a complaint about your trust straight back to you without the consent of the constituent? Should the constituent’s consent be sought before the information is given to you? Very often I think people complain to the MP and we take the complaint to the Minister; they do not want to complain directly to the trust because they are worried about the consequences of complaining to the trust. Do you think there is an issue of sensitivity around this?

Claire Murdoch: I do not think you can investigate a complaint unless you are open with all parties. I would be open with the complainant that, in order to get to the bottom of their complaint, we have to speak to the trust.

Q369 Chair: How much would you expect the Minister and the MP to have cleared it with the constituent before the name of the complainant and the nature of the complaint are handed to the trust? Do you assume that, when you get this complaint, the constituent is happy to have given that information?

Claire Murdoch: Yes. I have always assumed that.

Q370 Chair: So you would you expect the Minister and his private office to have cleared with the MP and the constituent, before you receive the information, that you are going to get that information.

Brenda Hennessy: My understanding is that it is actually embedded in the NHS regulations that, if a constituent raises a complaint with an MP, then it will be dealt with and the trust will be open with the MP in proving information to enable the MP to respond, which we would do directly anyway to the complainant.

Q371 Chair: Have you ever had experience of receiving a complaint in this way where presumably you then make contact with the person who has complained, and they say, "Oh, I only wrote to my MP." Has that ever happened to you?

Brenda Hennessy: I have never had that happen.

Q372 Chair: They expect you to get in touch, do they?

Brenda Hennessy: Yes, because they are expecting their parliamentary representative to take that up on their behalf.

Q373 Paul Flynn: Are there alternatives to litigation? What the evidence that we have seen says is that, overwhelmingly, the complainants say that they want, first of all, an admission that something went wrong, an explanation of why it went wrong, an apology, and some indication that, because they complained the situation, is less likely to happen in the future. What they tend to get is confrontational, defensive; it leads to apologies, possibly after litigation, but often grudging apologies.

Chair: Can we have a question?

Paul Flynn: What do you think we should be doing? Is this really the situation? Is there a possibility of an alternative culture that would lead to that first set of requirements they are asking for, which would cost very little, rather than going into the expense and upset of litigation?

Dr Marshall: We have been doing some work in the NHS Confederation to support Patient Opinion, a patient group, and Numbers4Good, a social investment fund, to look at what lessons we might be able to learn from the criminal justice system about restorative address, very much addressing just those things that you described. We have been trying to put a proposal together to support them and to get some funding to run that in a health setting to see if it would deliver just what you are describing.

Q374 Paul Flynn: How would you train staff or try to alter staff attitude? Without a doubt, after what has happened on very recent occasions, they are very defensive. Can we get a new attitude there to make them more open and less concerned that they are going to appear in some dreadful report?

Claire Murdoch: I do think that it is about recruiting the right people. Every month I speak to our 50 to 70 new staff and address them on induction. I always make a point of telling them stories about when I have got stuff wrong and had to say sorry. I urge them, if they make mistakes or human error, to say sorry quickly, to fess up, as it were, and deal with it. I give them my pledge that we will back and support them in doing that. I do also say, "If you make the same mistake every week, you might expect a different treatment at our hands." It starts at the top. You set a culture where it is alright to say sorry. It is alright to say sorry even if, at the same time, a complainant is pursing litigation. My advice to anyone would be do not be overly advised by your lawyers. If you have done something wrong and there is litigation running, say sorry anyway. If it makes it worse for you when the case comes to court, if that happens, so be it; deal with it then. Do not let that inhibit you from saying sorry.

Q375 Paul Flynn: You said, in recruiting staff, you measure compassion. How do you do that?

Claire Murdoch: We do. When we introduced our compassion test four or five years ago, it sparked a whole load of blogs and opinion nationally and internationally because, if one takes a pure science approach to it, there is no reliable test for compassion. What we do during the remainder of that day is use carers and users; we give applicants hypothetical situations and ask them to discuss in a group what they would do and how they would approach it. We do the one-to-one interviews as well. We, with the users and carers, judge whether that person has the right motivation and so on and so forth; whether they can think empathically and creatively about the situations we have given them. At the end of the day, I think it was Einstein who said, "Not everything that counts can be counted." We allow ourselves licence to feel and make our judgments about whether this looks like a compassionate person before us.

Q376 Paul Flynn: One of our witnesses said that the way to improve the interface between the organisation and the public was to make sure that within the organisation there is empathy, there is consideration, they are treated in a way that they hope that they will treat the public outside. Is there room for improvement in the Health Service in this area?

Claire Murdoch: Yes, always.

Q377 Paul Flynn: Are you hopeful for the future? Can there be an alternative to litigation that can work?

Claire Murdoch: Litigation, in my trust, is very low, I am told by the NHSLA. We pay more than we cost, if that is the right word. I like to think that it is the slow accumulation of, and build-up of, a culture that tries to deal with things and get it right first time. We still do not; we have such a long journey to go on, but I like to think there is a relationship between the two, and that litigation reduces as you build a more compassionate, confident, proud workforce. This relationship is very difficult to measure.

Q378 Paul Flynn: Should the politicians be helping in this? We get operatic performances when these reports come out, and the politicians tend to grandstand, I am afraid, and they are fairly unhelpful in this, I would have thought. What would you expect of the politicians to improve the relationship between the NHS and its patients?

Claire Murdoch: When you look at MORI polls, which have been questioning patients for years about whether they have good levels of confidence in their NHS provider, the levels of confidence are very high. When those same patients are asked, in MORI polls, "Do you have confidence in national leadership?", or the politics and that kind of higher level, levels of confidence are very low. We must resist the notion that the NHS is broken and we need to fix it. Patient confidence in the NHS still rides incredibly high. The thing is that those of us engaged in providing health services have to redouble our efforts each year to be better than we were the year before, and to help those organisations that struggle. Politicians have a different job to do, but I would not be the expert on that.

Q379 Paul Flynn: Thank you very much. I am grateful for your answer.

Claire Murdoch: I think that is a big ask for politicians.

Brenda Hennessy: With regards to litigation, it is my experience over a number of years that the vast majority of people who raise complaints do not want money, do not want to sue organisations; they want answers and they are entitled to them. I do not think we are defensive. We are very open to the extent that I will commission independent clinical assessments if I think there is some impasse that we have got to, and the complainant will get a copy of that independent clinical assessment completely unabridged. We ask that they are written in a way that patients would understand.

In addition, if we feel that a patient has suffered real harm from something that we have done or we have failed to do, we will give them advice. We will suggest that they should consider taking action against the trust, and we will advise them that they should go to AvMA to make sure that they get advice about reputable solicitors. Sometimes, people say, "I do not feel that I should do that." I say, "That is up to you, but you are not going to have the same working life that you did, and you have to think about your future and your entitlement." We do try to be very honest, and we support patients through the process. As Claire said, we will deal with complaints and respond to them openly and fully, irrespective of any claim that might be going through the system at the same time. That is absolutely key to success in responding to patients’ concerns

Q380 Chair: It has been a very interesting and helpful session. Thank you very much indeed. Can I ask one final question? Do you get any support or outside help with preparing for an evidence session of this nature as trust leaders?

Claire Murdoch: No. My team have been brilliant. I was asked on-I don’t know about you-Wednesday morning of last week, and said yes, because it seemed an invitation you do not say no to. No, but my team at the trust have been terrifically helpful.

Brenda Hennessy: No. We were offered a phone number to contact the Select Committee support if we wanted to discuss the questions. We got a list of the questions and I think the people that are here are here because they might not know the whole of the NHS but they know their areas and their organisations.

Chair: Thank you very much indeed for your evidence. We will move on to the next session.

Examination of Witnesses

Witnesses: Jonathan Senker, Chief Executive, Voiceability, Ruthe Isden, Services Programme Manager, Age UK, and Katie Shaw, Head of Welfare Policy, Citizens Advice Bureau, gave evidence.

Q381 Chair: Welcome, to our second panel. I do not quite know how to describe you, except that we think you are advocates of complainants; you must tell me whether I have described that correctly. I would like to invite each of you to introduce yourself.

Jonathan Senker: Thank you, and thank you for the invitation. Yes, it is an accurate description. I work with Voiceability. We work with people who face disadvantage and discrimination, particularly people with disabilities, older people, people with mental health needs, people who use health and social care services. We work with people to enable them to have a voice and full rights and equality in their lives. We have been working for over 30 years, but since 1 April 2013 we have also been providing the NHS Complaints Advocacy Service: independent advocacy to support people to take forward complaints. We provide that service in 29 London boroughs, and in six other local authority areas across the country.

Ruthe Isden: I am Ruthe Isden. I am from Age UK. We work at local, national and international level to support and advocate on behalf of older people. As part of that work, we offer services directly to older people, including information and advice services, and we touch about six million older people and their families every year through that provision.

Chair: I am very fond of Age UK Colchester.

Katie Shaw: Hi, I am Katie Shaw. I am head of the welfare policy team at Citizens Advice. The CAB service provides advice to around two million clients a year with around six million different problems and from around 3,000 different outreach settings, including health settings. We cover a range of issues. The top issues are benefits, debt, housing and employment, but health after that. A disproportionate number of our clients have long-term health issues or disabilities, and are more disadvantaged generally in society than the larger population.

Q382 Chair: Mr Senker, you must feel free to stand and stretch your back. I understand you are in some discomfort, and we will understand that. What do you think most people expect to get out of a complaint?

Jonathan Senker: I think, as described earlier, it is very much about an explanation, an apology if things have gone wrong and steps to rectify the situation. That is what most people who approach us are looking for from the complaints service.

Ruthe Isden: I would absolutely agree with that. It falls into four broad categories. First and foremost, particularly with health and social care services, where it is often not very clear to somebody what has gone wrong, they want to understand what has happened and they want to get that information. People want an apology. They want a genuine apology, and they want to really understand that they will actually have an impact for the future. They want to know that, by complaining, by feeding back, things will change and this will not happen to someone else. The fourth and very important category is often -we have touched on this-people do not necessarily want to complain per se, but they have an issue and they just want to get it sorted out so that they can access the service or get the help they need.

Q383 Chair: So you think quite a lot of people are put into a complaints system who just want to have their concern dealt with and are not really complaining.

Ruthe Isden: That is some of our experience working through our own information and advice networks. What people come to us with is they have an issue; in some way a service has perhaps let them down or has not provided or come up with the goods, and they want that sorted out, particularly perhaps when it is a time-sensitive issue so people are not getting care help that they need; they are not getting a benefit that they really need. They want it sorted.

Katie Shaw: That would be our experience. In some ways, why people do not complain is because the most important thing they want is the issue resolved. Sometimes that can be such a long process, by the time that is sorted, they are just in a sense weary of dealing with the issue. They often need quite a lot of encouragement to complain. What they do want from a complaint is that acknowledgement, that being heard and someone having understood what the problem is. They often feel that is where things fall down, because standard letters and that kind of thing suggest that no one is really interested in what their issue is in the first place. People do want that sense of "I have been heard, I have been understood and it will not happen that way next time."

Q384 Chair: How much do you think complainants understand the difference between a complaint and an appeal process?

Katie Shaw: People do not necessarily. We often see things do not get dealt with because they use the wrong language. The departments should certainly understand what the language should mean. For example, they might use the words, "I want to appeal", and I am in particular thinking of HMRC issues in tax credits. What they mean is there is something they are unhappy with here, but they might get a response back that there is not a legal right to appeal against that decision; it is not necessarily forwarded on to the complaints department. They need to be heard much more. I like the words used earlier about "proactive". We need to help someone direct their query and their unhappiness in the right place, regardless of the language that is used.

We often see issues that are not accepted as complaints when they really are complaints, just because it has perhaps got several things going on in that letter. The person might be telling their story; the issue might not yet be resolved, so the letter is passed to the department. The person opening the post might think they can best deal with that issue. Even if it has a complaint sometimes clearly written there, it will not be dealt with as a complaint at all. That is really disappointing. It should be possible to deal with two things at the same time. You should be able to appeal and complain about a situation.

Ruthe Isden: I would say that is symptomatic of having, in some cases, processes that are very driven by systems. Those systems are devised by the services themselves rather than a more outcomes based approach, which starts with: "This person is telling us a story about something that has not gone well for them and we need to respond to that." It may be that fewer complaints processes are appropriate, or other ways are appropriate, rather than putting the onus back on to the individual, often in very distressing circumstances, to figure out what all of these different corporate systems and processes mean.

Q385 Chair: Why do people come to advocacy support services like yours? Is that something that is increasing and something that complaint handlers need to recognise more?

Jonathan Senker: People come to us at each stage of the process. What is quite interesting for us is the different stages at which people come to us within health and within social care. Within social care and also within mental health services, often we have a prior involvement, we are involved with that person to enable them to have a voice proactively in what is going on in their lives, to think about what they really want, to make sure that is taken account of. Within most NHS services, people can only approach us, or we can only provide effective support, in relation to complaints. That is a severe limitation. While we can talk through the situation with them, we can help them explore whether they wish to make a complaint or not, we can only provide effective support to them to pursue that complaint. What that really misses out on is, as we have been talking about, the main thing that people often want, which is resolution to the issue-a change in a treatment decision, for example-rather than an answer and adjudication as to whether that was the correct decision later on. That is something that the PALS service is designed to do, and does in some areas quite well, in some areas very poorly. It is a really critical gap if we want to hear the voice of people using health services. It is enabling people to have that proactive support, quite often independent support if people have lost faith in their NHS provider, to seek a resolution and work things out to get it right, rather than a complaint response, which is often quite delayed; the events have passed and cannot be changed at that time.

Ruthe Isden: I would agree. There is a huge need for information advice and advocacy services to support people to make complaints and to have their voices heard. That is partly because there are many circumstances in which people will, on a very practical level, require that support. They might be suffering with dementia; they might have learning disabilities and they might be-thinking about our own cohort-particularly frail. There is a need to provide that independent support in order to get through the process, but I think, equally, it is very important to invest in information and advice services to help people to understand what they are entitled to, what their rights are because often people do not know if they have a legitimate complaint. They just have a sense that they have been treated not very well in a particular situation, or they are not very happy with the outcome, and they do not really know what to do about it. It is about signposting support and options to make their voices heard to make their complaint, wherever it is appropriate.

Katie Shaw: The main thing is that some of the clients that we see are most likely to have bad experience of public services more generally, because their vulnerability might mean that they have been unable to access it and the services have not been adaptable: for example, problems around getting a benefit claim sorted. Sometimes you have to have a lot of determination and express your needs really well in order to get it delivered in a way that is appropriate to your needs. Often the people that are most vulnerable are least able to express how they need that service to be delivered. I am thinking particularly about the growth of digital services and telephone services, when some people still need those services delivered face to face.

Chair: We must press on as quickly as possible because I think colleagues will want to go to questions, which is in only 15 minutes. Mr Hopkins: short question, short answer.

Q386 Kelvin Hopkins: The Health Service Ombudsman has recently produced a report and data about people’s attitudes to the complaints systems in the public sector, particularly the Health Service. It says that the attitude and competence of staff, the requirement to provide a complaint in writing when a high proportion of people cannot actually do that, and the feeling that complaints are not being used to improve services are issues. How do you respond to that?

Jonathan Senker: It is sadly accurate. Some of it is particularly shocking: for example, the inability to provide complaints orally. It is very clear in the 2009 regulations that that ought to be accepted. There are very significant barriers to people making complaints, and those barriers are especially high for people, for example, with learning disabilities, with severe and enduring mental health needs and with advanced dementia. There are other barriers in terms of a lack of information available, particularly with over five million households in Britain that do not have internet access, yet there is an increasing reliance on internet availability to get good information about pursuing complaints. There are also additional barriers in the lack of transparent information about the support that is available to make a complaint. Going into hospitals, there is a lot of information available; there is very little information about independent support to make complaints. That is something we need to work with the NHS to help to change. There are some key things that need to be done. One of the really important ways of doing that is integrating complaints within other feedback mechanisms, so people are signposted to complaints as another option, another way of taking things forward, if they are concerned when they are being asked, "How good was your treatment? How good was your GP?" and so on.

Q387 Kelvin Hopkins: Would it be a good idea to reintroduce Community Health Councils, where you can get face-to-face consideration immediately, revamp them, upgrade them-a one-stop shop for everybody? Would that not be a better way of proceeding?

Jonathan Senker: There have been very many iterations of attempts to get a body that provides public support to individual people using the NHS. Our focus has been very much about how we work within the current systems. There is certainly a great deal more that we can be doing, together with Healthwatch and together with the wider NHS, to make sure that the message gets out there about the importance of feedback and complaints as one part of that.

Ruthe Isden: A one-stop shop is a very useful idea, not least of all because it enables people to collect complaints, information, feedback and collate it in a way and use trends, which is not always possible when you are dealing with things, not even just on a providerbyprovider basis; you see organisations that are dealing with things on a departmentbydepartment basis and those wider trends are not being recognised or learnt from. This comes back to a wider issue here, which is about how we deal with complaints as a range of things. There are organisations within our services whose attitude is, "You come to us; you come on to our territory and speak our language and engage with our processes that are designed to meet our needs, rather than us going to you, to where you are, to talk your language and hear about your story." Whether you are talking about engagement in its broader sense, through to how you actually receive complaints, there is a wider issue there that needs to be dealt with.

Q388 Kelvin Hopkins: Just following that point precisely, isn’t it important for them to have independence from the organisations about which complaints are being made? The Community Health Councils I know were regarded as an irritant by many people in the Health Service, and the private sector in particular would not like an independent service of that kind.

Ruthe Isden: There have been strengths and weaknesses in all the different iterations, and we have heard about some of those already this morning. What is really critical in terms of Healthwatch, which is the most recent, is that it is given sufficient resources and sufficient time to actually learn to undertake that work in a really effective way. I suppose what I am cautioning against as well is saying that, if we have a one-stop shop, that will solve all of our problems. It is very important as a backstop and as that place of last resort and perhaps first entry, but we also need to be looking at how a range of other organisations and other routes also ensure that we are getting that breadth and depth of information that we need.

Q389 Mr Reed: Can a complaints system help to address a more profound loss of confidence by some sections of the community, in particular in public services? I am thinking of the view of sections of the black community about mental health services for instance, because of the treatment of black people within those settings, particularly young black men. How can a complaints system help to address that loss of trust?

Katie Shaw: I would say, more broadly, complaints systems and general collection of feedback is really important in getting that confidence back. One of the biggest things that CAB advisors see, where they lose confidence, is where they have dealt with a complaint or they have fed back to some services, and yet you see the same thing happen again and again and again. Whichever service provider it is, they have to be proactively getting that information and demonstrating they have taken that learning on board in the way their systems have changed or the way their direct contact with service users has changed. It has to be really proactive and it has to be really demonstrating that to people.

Q390 Mr Reed: Is there a further role within that for information sharing, so it is not just one organisation that hears and acts on the learning? How do we make that happen?

Katie Shaw: That is the challenge, because good practice can be shared, and that is true of all complaints systems. There is a greater place there for shared learnings on feedback systems, from what we have heard today, particularly around health, but it is true whether it be HMRC complaints, Jobcentre Plus or DWP complaints, and it is true about what is good practice in getting access to services and making the service really tailored to the need of the person. In those sorts of areas, there must be good practice that can be shared, rather than necessarily on specifics around client issues and where they have been failing.

Jonathan Senker: I do not think the complaints system of itself can necessarily resolve those issues. It can make them better or make them worse. At its best, we see complaints handling that is personal, really addresses the individual, looks with them at what resolution they want, and is prepared to show them that, if they are looking for change in the system, that change actually has been made. We have had NHS organisations taking people onto the ward to show how practice is different, to allow them to interview senior staff and junior staff. At its worst, we see procedural, mechanistic responses that fail to do that, and actually further alienate people. Some of the real clues that people are looking for is evidence that change is made. It is very easy at the end of a complaint response to write "and we will do x, y and z." There is a degree of cynicism, and justified cynicism sometimes, that those things actually are done.

What that comes down to is not additional regulation, additional processes; it is moving that action into the mainstream of management of those services so that change does happen and is seen to happen. I think then we begin to build a body of evidence that we can provide back to people and say, "You said; we did; it happened". Those things begin to build confidence, in a way that mechanistic complaint handling at the moment fails to do all too often, I am afraid.

Q391 Lindsay Roy: Is there a significant role for Government in facilitating the complaints process? Can they or should they do more?

Katie Shaw: It is worth taking a look at the new Government website I know it is still in development, but in preparation, and in particular looking at different complaints procedures, I put in complaints into the system. Let’s say it needs a lot of further development, but it is very hard to actually see each Government Department’s complaints process and they are not pooled together. Interestingly, if you put in complaints without any further details, you will get tax credit appeals and complaints as the first thing. Whether that is because it is the most commonly searched for item, I am not quite sure how it works. Put in hospital complaints and you will get a report on Broadmoor. It is not necessarily leading you to where you expect to go, so there is a lot more support and central information that the Government can do to get things really clear.

On minimum standards, obviously the Parliamentary and Health Service Ombudsman have got quite clear guidance, and it tells you what you need to go through first before they can deal with your complaint. We see good practice from the Financial Ombudsman Service; they are following the British standard around inclusive service provision pushed by a lot of private services, getting customer input into the design of services to make them inclusive and then following that through into complaints procedures as well. There is a greater role for Government to tie those things together, help people and direct them to where they need to go.

Chair: Very interesting.

Q392 Lindsay Roy: Is complexity a major issue?

Katie Shaw: Yes, I think it is. Also, in terms of process, to get your complaint looked at by an independent person or organisation, whether it be the Ombudsman or the step before that for some services, it has to be dealt with thoroughly first by usually two stages within the department. People often do not know where it has got to. They do not know whether they are at the first stage or the second stage and so how you deal with that, in terms of your correspondence, making it really clear where someone is and what their next step is, is really, really important. People are put off by that complexity. Too many people give up at the first stage, not because they are satisfied, but because they are not sure they can really put up with going through the next stages. There is a lot more people can do to make it easier.

That is sometimes maybe making a phone call to the complainant, checking they have fully understood what their issue is and resolving where possible. We are a bit nervous about that, because we do not want people to be encouraged to settle by a persuasive caller early on, but to get the information properly at that early stage is really important, and that can be a helpful way of ensuring the issues are addressed.

Q393 Lindsay Roy: Are there any other ways that complainants can be supported through the complaints process?

Katie Shaw: Through resources and advice, and advocacy organisations are really important, as is recognising that actually it is a really big deal for people. Certainly, on complex issues around health and social care and also on tax credits, people do not really know quite what has gone wrong, so they feel unable to put it in their letter or over the phone. Resources for advice and advocacy services are really important ways to help ensure that those facts are put down, and sometimes that the emotion is taken out of it to make sure those facts are clearly there, and that the responding organisation can pick them up and deal with them.

Q394 Lindsay Roy: At present, for example, CAB feels overburdened.

Katie Shaw: We are stretched, and there are capacity issues with cuts to local Government services and cuts to the legal aid budget. This means that we are tightly constrained, but we do see that complaints could be a way to resolve some of the problems at source. We have put on a new training course for advisers on complaints systems, because too often we see the same things coming over and over again. If they were dealt with better and learning was made from those issues, we would perhaps see fewer people coming through the door. It is being proactive, and trying to get that learning embedded into the departments and stop people coming in with the same problems over and over.

Jonathan Senker: I would make three points. Firstly, monitoring matters, and if we were to monitor one thing, I would like it to be people’s satisfaction with the complaints process, and for that to be really, really effectively used. The second thing is about setting an overall culture that welcomes complaints. The notion of a chief executive of an NHS organisation or a director of social services getting dismissed for not getting enough complaints is almost laughable, but perhaps that is the kind of cultural expectation that we want to start to expect. Thirdly, your point about resources is a correct point. Certainly, the decisions that we are taking within our support for people complaining about the NHS are to really focus that on people who have the greatest barriers, who face the greatest difficulty in having their voice heard.

We are also acutely aware of just how effectively, inadvertently, health and social care systems are making even the most able amongst us feel tremendously fearful; we find it tremendously difficult. At the moment, we recognise that we have to support those people by supporting them to help themselves with self-help packs, with brief information. We know it is not enough. However, those kinds of balances are the balances that are made within limited resources to equip the people that need the support the most.

Ruthe Isden: Can I just add two things in terms of minimum standards? Time limits are incredible important. These things can go on for incredibly long periods of time, not just because they are complicated, but because people are chasing and chasing and chasing. There should be standards about response times etc.

There is a lot that Government could do around increasing awareness of consumer-for want of a better word-rights in this space, making it easier to access that information. We have raised the issue about having a one-stop shop at local level for, say, health and social care, perhaps with Healthwatch, but also thinking about what opportunities there might be to create a broader platform at national level as well to help people get to where they need to be when they want to make a complaint.

Q395 Lindsay Roy: That is the portal issue again.

Ruthe Isden: It is both online and also telephone based, having a number of different outlets. It is also through working with organisations like ours, helping us to deliver better services through training and professional helplines, but also giving us perhaps routes to feed in some of the wider trends that we are observing so that they can be dealt with at source, because we do not want people to get to the point of complaints.

Q396 Chair: If there was, at central Government level, a single point of contact, where somebody could go to start a complaints process, that needn’t necessarily stop people complaining at local level or at service level elsewhere, but is that not the missing link-a single place where people can go and say, "How do I complain about this?"

Ruthe Isden: Certainly. There should be a single place that people can go to get basic information and advice about how to complain, who to complain to and what type of information they should be including with that, and also support to get to the right place. For example, in health, people often phone CQC when it is an Ombudsman issue, and they are not supported to get to the right point in the system.

Q397 Chair: Helping resolve the complexity of the complaints system with that complainant, monitoring the complaints system, setting standards and increasing awareness: these are all your suggestions. Would the PHSO, the Parliamentary and Health Service Ombudsman, be the obvious organisation to take on those responsibilities?

Ruthe Isden: They are an organisation that we hold in high esteem. They would be an obvious partner. It should be something that needs to engage properly a number of bodies. If you just look at, for example, the health and social care space, you would also want to ensure that CQC were involved, so that they were learning and could use that information in their own processes as well. Healthwatch, on the other hand-

Q398 Chair: When anybody contacts the Ombudsman, the first thing they always say is, "Have you complained to the service involved?" We can talk about the MP filter, perhaps not today. If the Cabinet Office tried to set up a one-stop shop for complaints, it would get lost in other bits of Government, wouldn’t it? Isn’t the Parliamentary and Health Service Ombudsman the obvious first point of contact, because it is an organisation that already has the right profile with the public?

Katie Shaw: They do. We have a consumer education function within Citizens Advice now, and there is a big issue there about whether people know where to go, and would people automatically go to the Parliamentary and Health Service Ombudsman? They know where to direct people, but I still think there is a learning amongst the public about them being a consumer and complaints advocate.

Q399 Chair: It does not resolve your role at all; you still have a huge role to play. I am not suggesting that the PHSO should put you out of business-on the contrary.

Ruthe Isden: It is a question of recognition and brand. They are an organisation that we hold in esteem and that have a number of the right elements, but they would probably themselves acknowledge that they would need to build a wider public recognition of their brand, and build the infrastructure and capacity to deliver that sort of a service.

Q400 Chair: And, to make sense of it, you would have to get rid of the MP filter.

Ruthe Isden: Certainly on one level, in the route into the first port of call, absolutely.

Q401 Chair: But you would have no objection if the PHSO was developed in that role, or an aspect of that role, as a single point of contact, to help people navigate through complaints systems wherever they are.

Ruthe Isden: It would be helpful and certainly, if they were open to developing strong links with wider organisations as well, as we said, so they could feed in trends and also understand professional training, there is a lot of scope to make some real improvements.

Chair: We have overrun time already. It will seem a perilously short time to you, but we have really appreciated your evidence today. May I also thank you on behalf of the Committee for what you do? Each of us, as constituency MPs, depends upon Citizens Advice, Age UK and other organisations. Voiceability does not have such a high profile, but obviously provides a great deal of valuable support, helps MPs do their job. Sometimes, with the CAB, you say to your constituent, "Have you been for advice from your CAB", and the constituent says, "They told me to come and see you." We sometimes play pass the parcel. Thank you for what you do, and thank you for your evidence today.

Prepared 30th July 2013