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.
COMPLAINTS TO THE REGULATOR
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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