Complaints and Raising Concerns - Health Contents

2  Complaint handling

What should good complaint handling look like?

19. Most complainants do not want to become drawn into complex, formalised and adversarial systems in which the NHS adopts an overly defensive approach. Neither do they primarily complain in order to gain financial compensation but in a timely manner to have their concerns and experiences understood, failings acknowledged and apologised for, and an assurance that no one else will endure the detriment they experienced.

20. The Committee noted in its previous report that

    The existing NHS complaints system aims to resolve complaints at the local level through investigation by and resolution of complaints by the organisation being complained about (the "local resolution" stage)… The second stage of the system entails independent investigation by the Health Service Ombudsman, who investigates complaints both formally and informally if local resolution has not been achieved.[6]

21. Both parts of the system were criticised in our previous inquiry and there has been no shortage of recommendations for improvements on complaint handling. The Clwyd/Hart review made a wide range of recommendations for Government, professionals, regulators, trusts and Trust boards in this regard.[7] A number of these have been taken forward by the Department of Health through its cross-agency Complaints Programme.

22. In its written evidence, the Department said that

    The Department of Health believes it is important to join up the complaints system across the health and social care system to deal more effectively with poor care. To support this work, we have set-up a Complaints Programme Board (CPB). This was established in December 2013 to bring together a range of partners across the care system to implement actions which will lead to improvements in complaints handling as set out in Hard Truths, and assist member organisations (for example, the Care Quality Commission) to deal with poor care. Whilst the focus of the Board is on delivery of Hard Truths commitments, there is unanimous agreement within the Board that it will look more widely across health and social care to consider complaints in other health and social care settings and to bring about improvements.

    The Terms of Reference for the CPB are:

·  To implement the Government's commitments detailed in Hard Truths.

·  To deliver the bulk of the Board's Hard Truths work programme by March 2015, with organisational lead responsibility for delivery of each project to be agreed within the group.

·  To update the Secretary of State for Health on progress, as appropriate.

·  To look more widely across health and social care to consider complaints in other health and social care settings, so as to seek to align complaints handling across care services.

    The aim is to complete the work programme by March 2015, although some of the deliverables will not be realised within this time-frame.[8]

23. In evidence, witnesses indicated that a good process,[9] embedded in a supportive culture, had the following features:

·  Openness to raising issues: service users should be enabled to raise an issue or to get something put right before a formal complaint is necessary.

·  A number of ways to capture what service users are experiencing (a key issue in this regard would be the real-time capture of patient feedback data)

·  Dialogue established as soon as possible with the complainant, and a closing of the feedback loop by speaking with the patient afterwards to discuss whether all concerns had been addressed

24. The proposal for a service user-led approach to complaint handling across the health and social care sectors, published by PHSO and others in November 2014, provides a good benchmark for complaint handling. Its intention to focus the system on dealing with complaints from a service users perspective, is welcome. The objective of creating a complaints system properly responsive to service users will not be achieved, however, unless providers across the health and care sector properly embed the culture and values espoused in the report into the culture of their organisations.

25. Witnesses have pointed out that the NHS is not a single organisation, but a system of organisations which have a number of competing interests and claims. Responsibility for ensuring a properly responsive complaints system is distributed widely across the health service:

·  Trust Boards and management

·  The Care Quality Commission, through hospital inspection programmes

·  Commissioners, through e.g. meetings with providers, setting expectations of commissioned services, reviews of quality accounts and analysis of provider complaint data

·  Healthwatch England

·  Local Healthwatch, through independent scrutiny of providers and commissioners and through membership of health and wellbeing boards

·  The Health Service Ombudsman, setting standards for the health sector through her investigations of complaints and her published reports

·  The Local Government Ombudsman, operating similarly for the local authority care sector

·  Professional regulators such as the GMC and the NMC

The onus is therefore on individual providers to ensure that a rigorous focus on effective and user-focused complaint handling is maintained.

26. Transparency is an important element of a successful complaints process. One strand of work being undertaken through the Complaints Programme is designed to improve the collection and collation of complaints data in comparable formats by HSCIC. It is of course beneficial to have uniform datasets which can provide insight into comparative trends in complaints data, but these datasets are unlikely to be of great help to the general public in assessing how a Trust is doing on its complaint handling. Sir Robert Francis QC suggested to us that Trusts should be required to publish anonymised summaries of complaints against them, what had happened about the complaint and what the learning from it was, which would lead to greater public understanding of the nature of complaints being made against a Trust and how they were being handled:

    We need to move beyond figures in broad categories, which are pretty useless to man or beast. I think there could be an obligation—obviously anonymised—to publish in summary form what the complaint was, what happened about it and what the trust's learning from it is. If you did that in summary form…then everyone locally is going to say, "This trust is really not handling complaints very well," or, "It is doing them differently from the place down the road."[10]

27. We recommend that Trusts be required to publish at least quarterly, in anonymised summary form, details of complaints made against the Trust, how the complaints have been handled and what the Trust has learnt from them.

Complaint handling by providers

28. The handling of complaints by a provider—openness to complaints, processes for handling them, impetus in having them resolved, and sincerity of resolution—is a key factor for a well-functioning health and care system. The 'toxic cocktail' of service users reluctant to complain and providers reluctant to listen must be avoided at all costs, as it inevitably leads to a spiral of decline in service quality. Patients must be empowered to give constructive feedback on services which they believe are substandard. Anna Bradley, Chair of Healthwatch England, told us that

    One in three [patients and carers] says that they have had personal experience, or know someone who has had personal experience, of a really quite serious incident, but only half of them have done anything about it… One in four of them says they did not do anything about it because they did not think anyone would be interested. Three in five said they did not know how to do anything about it. One in two said no one would do anything about it anyway and they did not trust that they would get a decent response. As we also know, very many people…just feel too vulnerable.[11]

29. As this shows, the complaints process is seen as complex and difficult to navigate, and can prove off-putting. A great deal of evidence was received on the necessity to simplify the system and create a single route for the service user to make a complaint and be properly signposted, as Healthwatch proposed in its paper Suffering in Silence published in October 2014:

    Recommendations for wholescale reform:

·  A 'no wrong door' policy, so that wherever a complaint is raised it is the system, not the complainant, that is responsible for routing it to the appropriate agency to get it resolved.

·  The Government to explore the scope for online platforms to provide a well-publicised point of access for complaints, enable greater consumer choice, and allow anonymity where required.

·  A review of PALS and NHS Complaints Advocacy arrangements, with a view to establishing a new, easily accessible and consolidated complaints advocacy and support offer that is:

    o  Available to all users of health and social care regardless of age, condition or where they live.

    o  Independent and acts only in the interests of the individual.

    o  Well-publicised and easily recognised by everyone so that when they need help they know who to turn to.

    o  Underpinned by a set of new national standards to ensure everyone is able to access high quality support.

·  Healthwatch England to be given the power to act as a 'super-complainant' on behalf of groups of consumers on national issues.[12]

30. In its 2011 report, the Committee recommended stratifying the complaints system to, for example, separate out customer service complaints from complaints about clinical treatment. The evidence given to us in the course of this inquiry, however, from Healthwatch England, Which? and PHSO, has suggested a single system for all complaints, with proper signposting both to the access point and then from the access point to the appropriate places throughout the system. An emphasis on early identification and resolution of customer service complaints by providers would reduce the need for such complaints to enter the system: at present an issue addressed within 24 hours of being raised need not enter the formal complaints process.

31. We agree that the onus should be on the system to help a complainant. People should not be forced to search out the most appropriate way to raise concerns. We recommend that the complaints system be simplified and streamlined by establishing a single 'branded' complaints gateway across all NHS providers. This should be available online, but not exclusively so. There should be adequate resourcing to enable complaints to be examined, identified, and directed speedily to the appropriate channel.

32. Evidence from other witnesses confirms that good practice does exist, but indicates this good practice is not the norm. The Healthwatch and Public Involvement Association (HAPIA) told the Committee that

    The best hospitals value complaints, demonstrate a good sensitive inclusive investigation process; carry out the investigation quickly; meet with the complainant if appropriate and ensure that the response is provided within a reasonable time frame. In practice this is rare.[13]

In particular, HAPIA says that instances of face to face meetings with service users to discuss the outcome of complaints are few and far between.

33. The organisations that we spoke to were very clear about what constitutes good practice. We agree with Rob Webster of the NHS Confederation, who told us:

    There is a simple golden thread through complaints, which I think most people know and is good practice, which is that you always say sorry, explain what you think has happened, and describe why it is not going to happen to anybody else. [14]

34. He went on to say:

    We see in most organisations that that is widely understood and, whether it is a front­line member of staff or the chief executive who is responding, that is what they should do. The personal touch is incredibly important, and in many trusts it will be the chief executive who signs off all the formal complaints.

    As part of the good practice, certain things should happen almost immediately. In my own trust I used to have a standard, which was that you get an acknowledgment within 72 hours and we will ask you personally, "What do you want to get out of this complaint? How long do you want it to take? What do you want to happen with it?" You will have personal contact, and then you will get a response from the chief executive, which will not be a standard format: it will be about you and those three things—the apology, explaining what has happened and why it will not happen to somebody else.

35. Professor Sir Mike Richards, the Chief Inspector of Hospitals, told us about CQC's experience of complaints handling through inspection:

    Some places are doing this well, some are doing it less well, and most have room for improvement in how they are managing complaints. I do not think you will be surprised about that, but that is certainly what we are finding. But through that we will also be able to say, "This is what we see as good practice," and there will hopefully be some places that we will be able to say are outstanding in how they manage complaints…

    Sometimes it is about the care and treatment [people] have received. Quite often it is about staff attitudes. Sometimes it is about administrative failings. Very often it is about car parking…But one of the things that I think is also important is to be able to ask a trust, "Is it the same now as it was a year ago?", seeing if they have moved on. In one trust I remember a lot of complaints had been about ward 12, and, actually, those complaints had now ceased. Why? It was because they had really taken them on board and had sorted out the problems that there were on ward 12.[15]

36. Witnesses were generally agreed that it is the Trust Board and management which have the lead responsibility for setting an open culture in which complaints can be received and dealt with constructively. The Department of Health has set out several expectations, such as prominent displays of information on the ward about how to complain, but it cannot in the normal course of events intervene in the system to force a Trust to change its practices: it could not, for example, force a Board to appoint a senior non-executive director to review complaints made to the Trust.

37. Day to day responsibility for assuring the public about the quality of services in providers, including the handling of complaints, appears to rest with the CQC. Professor Sir Mike Richards described[16] the range of tools (including information gathering, listening exercises and the use of intelligence) which the CQC can use to assure itself that a provider has good systems for handling complaints, supported by an open and responsive culture. He told us

    I can confirm that it is very high on our priority list. There is absolutely no doubt about that. As we have been doing our initial inspections, we have been trying to build our concerns handling, if you like—how we look at concerns, whether they are staff concerns or patient and public concerns—into every step of our process.[17]

38. The knowledge that the CQC takes the adequacy of complaint handling seriously ought to encourage Boards to review their arrangements, consider the openness of their culture to complaints and raise their game: there should be no room for complacency even in trusts which consider themselves to be high performers.

39. The CQC exercises 'soft power' through its well-publicised standards, which should encourage all Trusts to prioritise complaint handling and related issues of governance as they know they will be held to account on these issues at inspection. It also exercises 'hard power' through its power to put Trusts into special measures, whereupon the Trust Development Authority or Monitor can take steps to change or remove the Board if they consider it necessary to improve performance.

40. The CQC is unable to investigate individual cases raised with it, though it has in the past undertaken to this Committee to use such material as 'free intelligence'. There is though a risk of the CQC, through its inspection activity, being seen as the body which can examine a provider in respect of an individual complaint raised. As the reformed health and care system joins up, and services and complaints systems become, we hope, more integrated, the risk of inappropriate signposting to the CQC is clearly increased. The CQC should therefore continue to make it clear that it cannot in general investigate complaints made to it about NHS or social services. Its report Complaints Matter, published in December and which we discuss later, in paragraph 60, is a potential helpful step in that direction.

41. It is clear that the Chief Inspector of Hospitals takes complaint handling in Trusts seriously and he has taken up the challenge given to him by Ann Clwyd to make complaint handling standards a priority. We welcome the efforts of the CQC in this area.

42. The relationship between the provider and the commissioner is, in our view, key to determining the day-to-day quality of services provided under NHS contracts. It is the commissioner which is best placed to work constructively with the provider on delivering improvements. We do, however, expect the CQC to examine the culture of complaints handling by providers.

Role of commissioners in complaints, and handling of complaints by commissioners

43. In this inquiry we have found little if any evidence of an active role for commissioners in handling complaints from service users or holding providers to account for the complaints systems they use.

44. In previous reports on commissioning the Committee has recommended that commissioners take an active role in driving up standards in complaints handling.[18] This could be done through active monitoring of the services delivered under contract, examination of provider board policies, quality accounts and reports on complaint handling, collaboration with local Healthwatch and CQC on complaint intelligence, and the use of qualitative and quantitative provider complaints data to analyse trends and indicate areas for improvement.

45. The lack of evidence of commissioner engagement in complaints processes is of some concern. CCGs, or commissioning support units (where these functions have been outsourced), must ensure that they have the capacity and the capability to monitor how the providers from whom they commission services deal with complaints, and must use the commissioning process to require high standards in complaint handling. Commissioners themselves have a role in the complaints process, and are required to handle complaints not only about the services that they commission on behalf of their populations from providers but also about the exercise of any of their own functions.

46. We have to assume that levels of public awareness of CCGs, and of their function in relation to complaints, is low: it is to a provider that a service user is most likely to complain. Since complaining to a commissioner is apparently not often done, it is difficult to assess the impact on the system which complaints by this route have. The commissioner route may well be inadequately signposted within most health economies. While it is difficult to see why a provider would encourage a complainant to take a complaint to a commissioner, rather than handling it directly, there is a case for better publicity and better signposting for complaints which are best made to commissioners.

47. We recommend that the system for service users to make complaints to commissioners about NHS services should be integrated into a single complaints system. Commissioners need to take a far greater role in holding providers to account for delivering a well-functioning complaints system.

Complaints handling in primary care

48. NHS England is the commissioner of primary care and is the body to which complaints about GP practices and other primary care services are directed. There has been concern about the use by NHS England of out of area services to handle GP complaints raised locally. In written evidence we were told about the example of primary care complaints from Devon, Cornwall and the Isles of Scilly which are now passed to a call centre in Leeds and dealt with by a commissioning support unit in NW London. This illustrates the opportunity for confusion, dissatisfaction of service users, unacceptable delays and breakdowns in working relationships.

49. Dr Sam Barrell, who told us about these problems, wrote that

    Because this arrangement had a "soft launch" it fell to local CCGs to communicate the change in the service to providers, practice managers and other parties. This did create confusion and effectively created a two-flow process, because complaints about the majority of services could be handled locally by the CCG, but complaints about primary care had to be handled at a national level in London. This led to dissatisfaction for patients and those using services, but also for NHS staff who had been unaware of the changes to their roles. Some relationships were undermined, and the abrupt change of thinking compromised some of the solid foundations laid by PCTs on which CCGs had planned to build.

    The confusion was compounded when it came to multiagency complaints that included a primary care element. In these types of complaints, input was required from NHS England; however, we had no knowledge of any process or timeframes that NHS England was adhering to. Locally in Devon we had some 20 complaints severely delayed by this new system. This had a clear impact on clients and, as a result, referrals to the Parliamentary and Health Service Ombudsman increased from on average one complaint a month to three complaints for each of the months of May, June and July 2013. They were referred because of the unacceptable delay. Additionally, the Ombudsman service did not appear to be aware of the changes to the handling of primary care complaints, which led to further confusion and lack of clarity in terms of the responsible organisation. [19]

50. In the light of that evidence, it is not surprising that in its submission HAPIA describes primary care complaints as a 'complete and utter mess' and 'a perverse way of running a system'.[20]

51. NHS England accepts that it initially did not have adequate capacity to handle complaints, and that there was higher than expected demand: it says it service has now improved.[21] It maintains that its centralised approach to complaint handling is appropriate in certain circumstances and brings benefits, but it has the arrangements under review.[22] Neil Churchill, NHS England's Director for Improving patient Experience, told us in correspondence:

    Your challenge about whether our approach is sufficiently local to optimise patient satisfaction and learning from complaints is nevertheless well made. We are certainly open to ideas about how we can organise our complaints handling differently if this will benefit patients. However, this will need to be in the context of the further 15% cut in our running costs from next April, which will inevitably mean reductions in the number of staff in our local teams. It may be the case, for example, that the greater involvement of Clinical Commissioning Groups (CCG(s)) in complaints will help drive improvements in clinical practice or the administrative systems used by GPs, dentists and optometrists. As you know, NHS England is currently exploring co-commissioning of primary care with CCGs and as part of that we are certainly prepared to design, pilot and evaluate a different approach to complaints management in partnership with a CCG, or a cluster of CCGs. This will enable us to measure levels of patient satisfaction, learning from complaints and value for money against our existing models of delivery. We will be delighted to talk to Dr Barrell about how we might design such a pilot and would be happy to inform you and the Committee about the results.[23]

52. The Committee is concerned about the effects of centralising complaint handling in primary care by NHS England. We do not believe that primary care complaints should be investigated in a different region. This has led to fragmentation and disconnection from local knowledge and impaired the ability to deliver a timely response and learn from complaints. We recommend NHS England reports on progress on providing a primary care complaints system that is responsive to patients in a timely manner and which results in local learning and improvement.

Complaint handling in social care

53. The complaints system in social care is functionally separate from the complaints system in health care, though each is governed by the same set of regulations: complaints about care homes arising from the social services function of a local authority follow a different route from complaints about NHS providers. HAPIA call for a 'consistent easily-understood system across the country'[24] which uses common terminology and clear and unambiguous approaches to complaint handling. In written evidence, Which? sets out some of the anomalies of the current position, with separate systems for local health and care complaints. At the second tier, the situation becomes more complicated:

    At the second tier, there are several ombudsmen and other bodies operating in the same space, with overlapping coverage that varies depending on how the service is funded and which part of government has oversight. As well as making the system more complex for the user to navigate, this also increases the risk that systemic problems are overlooked or fall through the gaps.

    For example, an individual with a complaint about a nursing home could potentially take their complaint to two or three different ombudsmen depending on who the responsible department is and how their place at the home is funded. If it were a social care issue they would need to go to the Local Government Ombudsman (LGO), but if it related to a health matter they would need to approach the Parliamentary and Health Services Ombudsman (PHSO). If the complaint straddled both of these issues, it would fall under the remit of both ombudsmen, and the user would need to decide which to go to. If it was regarding a health matter that was privately-funded, they would not have any access to PHSO.[25]

54. The solution that Which? and others propose is, as we have discussed earlier, a single access point:

    The Government should establish a 'one-stop' telephone and web complaints portal for public services along the lines of the Complaints Wales service, run up by the Welsh Public Services Ombudsman. Its functions would include signposting people to the right body for first-tier complaints, directly sending their complaint to providers and commissioners if they wish, and acting as a gateway for second-tier complaints, directly sending people's complaints to the relevant ombudsman service.

    Behind this one-stop portal there should sit a rationalised set of public services ombudsmen with consistent powers and processes that would mirror the regulatory landscape…[26]

55. On the evidence we have heard there is a strong case for working towards the integration of social care complaints into a single complaints system. As a first step we consider there should be a single health and social care ombudsman.


56. The Relatives and Residents Association[27] are critical of CQC's approach to issues raised with them by individuals. They note that CQC seeks feedback and yet says that it cannot address individual complaints. The RRA are also concerned that the information that is provided is not being used to pick up on poor care generally:

    This continuing misguided policy means that a great deal of important intelligence, often needing urgent investigation and, sometimes enforcement, is missed or lost. This also means a further loss of trust by relatives and the general public in CQC's efficacy.[28]

57. The CQC itself insists that this information is used;

    Information from people who use care services about the quality and safety of their care, including their concerns and complaints, is a vital source of information for our new surveillance model. We will make systematic use of people's views and experiences, including complaints and views of staff, along with information from local and national data and intelligence sources, previous inspections, and from local authority overview and scrutiny committees. We will place more emphasis on the content and trends in complaints made and will consider how complaints are handled and responded to by providers when we carry out inspections. We will also make sure we understand the reality of people's individual experiences of care, including working closely with local Healthwatch and local voluntary groups.[29]

58. David Behan emphasised this point in oral evidence:

    …we do not have the ability to adjudicate complaints and work towards resolving them. But…the intelligence that we gather from people who raise concerns is absolutely essential to us so that we can assess whether their complaint is something that has affected just them or whether there is a pattern of complaints coming from, say, maternity care, and if there was that would then inform our inspection plans.[30]

59. There has now been a further development, with the CQC publishing its report Complaints Matter. This reiterates many of the points made in the CQC written and oral evidence about its use of complaints as intelligent monitoring of the system, but also sets out how it will from now on look at the way an organisation deals with complaints as part of its inspection process:

    In October 2014 we introduced a mandatory key line of enquiry for inspections of hospitals, mental health services, community healthcare services, GP practices, out-of-hours services and adult social care services. This looks at how well complaints and concerns are handled. This assessment forms part of our judgement and rating of an organisation's responsiveness. For consistency in all inspections, this will apply to dentists, independent hospitals and ambulance services from April 2015.

    New and robust methods help inspection teams to understand how well providers listen to people's concerns and learn from them to improve quality.

    Before a CQC inspection, we gather information relating to complaints and concerns, including details from partners such as the health and social care ombudsmen, local authorities, Healthwatch England and complaints advocacy services.

    We request a range of information from providers before we inspect, such as a summary of complaints from the last 12 months and how these were resolved.

    We ask what people who use services think about the way complaints and concerns are handled, using surveys, comment cards, and conversations during inspections, often led by CQC's Experts by Experience.

    During site visits, our inspectors review a sample of complaints files to understand if these have been handled in a way that matches the good practice we expect to see.

    On large inspections (in hospitals, mental health services and community healthcare services), we are introducing a lead inspector for complaints and staff concerns to draw evidence together.

    Our inspection reports now include a description of the provider's handling of complaints. And the new fundamental standards include requirements around complaints handling as well as the new duty of candour. Where we find breaches of these standards, we will use our range of enforcement powers: warning notices, suspending or cancelling registration and ultimately prosecution. We will work with partners to encourage improvement.[31]

60. This move by CQC to make examination of complaints processes part of its inspection model is very welcome. In time, this should lead to a significant increase in the attention that organisations pay to the way in which they handle complaints and therefore to an improvement in quality. It does not resolve the problem of how individual complaints raised with CQC can be addressed, but it may provide the impetus for the degree of system-wide improvement that the Committee and many others wish to see.

61. The Complaints Matter report also addresses the issue of concerns raised by staff. It says that

    We expect complaints and concerns to be used to improve the quality of care, and that employees who raise concern are valued, respected and protected. Reprisals such as victimisation or bullying are unacceptable.

    In every inspection and as part of assessing an organisation's leadership, CQC will look at processes in place to handle staff concerns.[32]

    We look at issues connected with staff raising concerns in the final section of this report.

Complaint advocacy services

62. Advocacy services can play a significant role in helping people to raise complaints and concerns about care and related issues. The problem that has been expressed to us is that those services are fragmented and difficult to find. Robert Francis told us:

    I am concerned at what is or is not happening with advocacy services and the support network. It does seem to be more fragmented even than it was at the time I looked at it. I am concerned about how that is funded and what is happening with the money around that, but most importantly I think it is becoming more difficult than it was for people to find what is the advocacy service. I recently had an experience where a letter arrived and I thought the answer to it would be to put the individual in touch with the advocacy service appropriate for the particular hospital that the complaint was about. I am afraid I spent 20 minutes on the internet and was none the wiser. If I could not find it, then I don't know how a member of the public was expected to, so I think there is work to be done there. [33]

63. One arm of the advocacy arrangements is the Patient Advice and Liaison Service. As we noted in our previous report:

    Patient Advice and Liaison Services (PALS) were established across the NHS between 2000 and 2002 and aim to ensure that the NHS:

    […] listens to patients, their relatives, carers and friends, and answer their questions and resolves their concerns as quickly as possible.

    PALS staff will routinely:

·  provide information about the NHS, the complaints procedures and complaints advocacy,

·  help resolve concerns or problems about NHS services, and

·  provide information about agencies and support groups outside the NHS.

    Additionally, PALS aims to provide an early warning system for NHS organisations and regulatory bodies by identifying problems or gaps in services and reporting them.

    Although PALS are not formally seen as part of the two stage complaints process, they do aim to resolve concerns and problems before they become formal complaints. The National PALS Network told us that:

    […] we do not believe that PALS is simply a "gateway to the complaints system" but an integral part of it. If organisations only categorise issues as complaints because a 'formal' investigation has been carried out by an investigating officer or complaints manager they are seriously under-counting complaints and undervaluing other means of resolving complaints.[34]

64. The picture on PALS services in NHS Trusts is very mixed. They can work well, but are not equipped to deal with complex cases and are seen by many as lacking independence as in some places they are part of the complaints system as well as acting as advocates. As Healthwatch England told us:

    Some people have told us that they are very happy with advocacy services, specifically mentioning that PALS helped to sort out their problem and gave them confidence in the complaints system. However, other people have told us that advocacy can be hard to access and of poor quality, and told us about bad experiences they had with PALS.[35]

At the time of our earlier inquiry, advocacy was provided through the Independent Complaints Advocacy Service (ICAS). Although the experience of the service was good for many patients, the service was found to be inconsistent and some patients were not aware that it existed. As part of the changes brought about by the Health and Social Care Act 2012, ICAS ceased to exist on 31 March 2013. From 1 April 2013, commissioning of NHS complaints advocacy services transferred to individual Local Authorities.

65. While the Committee supported proposals for local commissioning of advocacy services in its 2011 report, it appears from the evidence that this commissioning has not had the desired effect. NHS Advocacy services are now commissioned locally, and there is a patchwork of different types of provision. Some services are provided by local Healthwatch, others by third party services, and these can be difficult to identify and locate. Healthwatch England told us that:

    We have heard that many of the NHS Complaints Advocacy Services are asked to work under tight budget constraints, and that they sometimes have to limit the number of people they meet with to provide assistance. In some areas, the same organisation that runs Local Healthwatch also runs the complaints advocacy service, which helps to join-up different complaints advocacy and support. However, there is inconsistent access to complaints advocacy across areas based on the appetite of councils and availability of resource.[36]

66. We recommend that there should be clear commissioning and consistent branding of PALS and NHS Advocacy services to make them as visible and effective as possible to any patient seeking assistance through the complaints process. Current arrangements are variable and too often unsatisfactory.

67. In its written evidence the Department of Health said that it would begin a review of PALS services in 2014 and would also review the commissioning arrangements for independent advocacy services. In responding to this report, we ask the Department to set out what progress has been made in reviewing the commissioning arrangements for advocacy services.

68. HAPIA[37] raise concerns about the role of local Healthwatch following changes legislated for in the Health and Social Care Act 2012. It argues that they are not public facing, and they have no role in complaints advocacy unless commissioned to provide a specific service.

69. HAPIA also allege that local Healthwatch have little information on the performance of providers on complaints issues, since they are not routinely provided with qualitative data from complaints (either by providers or commissioners).

70. There is general concern over the effectiveness of operation of local Healthwatch. While we were quoted examples in evidence of local Healthwatch organisations (e.g. Peterborough)[38] making a difference to local complaint handling, the picture which emerges is of a patchwork of local accountability with worrying potential for gaps.

71. Since funding provided to local authorities for Healthwatch has not been ring fenced, there are suggestions that it has not all been spent on Healthwatch activities and that as a consequence some local Healthwatch organisations are under-resourced. Lisa O'Dwyer, of Action against Medical Accidents, told us:

    I think there are difficulties with local Healthwatch. Certainly from what we have seen, the service is not consistent. I don't know if that is because of funding. There seem to be differences in funding. There are problems with that. I don't know how accurate the reports are, but apparently the funding that was allocated is £10 million short, and I think there are further complications because the funding has not been ring­fenced specifically for complaints. It goes to the local authority, and it is for the local authority to decide how best the complaints need to be served, so I think there are real difficulties. If you are going to look at strong complaints, you need uniformity and consistency. That is not going to happen unless it is properly funded.[39]

72. We recommend that the Government provide a progress report on the functioning, funding and budgets of local Healthwatch organisations, in order that the information be available to our successor Committee.

6   Health Committee, Complaints and Litigation, summary. Back

7   A Review of the NHS Hospitals Complaints System Putting Patients Back in the Picture, October 2013, chapter 6. Back

8   CRC 74 Back

9   Eg Q 408 Back

10   Q 39 Back

11   Q22 Back

12   Suffering in silence, Healthwatch England, October 2014 Back

13   CRC 109 Back

14   Q 408 Back

15   Qs 283, 286 Back

16   Qs 271-78 Back

17   Q 278 Back

18   Health Committee, Complaints and Litigation, para 90 Back

19   CRC 111 Back

20   CRC 109 Back

21   CRC 115 Back

22   ibid Back

23   CRC 115 Back

24   CRC 109 Back

25   CRC 85, paras 19 and 20. Back

26   Ibid para 28 Back

27   CRC 105 Back

28   CRC 105, para 9. Back

29   CRC 95 para 15 Back

30   Q 318 Back

31   Complaints Matter, CQC, 8 December 2014, summary Back

32   ibid Back

33   Q 25 Back

34   Health Committee, Complaints and Litigation, paras 51 to 53 Back

35   CRC 69 para 22. Back

36   CRC 69, para 23 Back

37   CRC 109 Back

38   Q 47 Back

39   Q 218 Back

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Prepared 23 January 2015