1.  CONSUMERS' ASSOCIATION

  1.1  Consumers'Association (CA) is an independent organisation which works on behalf of consumers to achieve improvements in the quality of goods and services. CA's key health objectives are to ensure that the public have access to information to enable them to make informed decisions about services and policy and to campaign for positive change in those areas where we have identified concern. These objectives are supported through health policy research and reports published in HealthWhich? and Which? magazines.

  1.2  CA reaches more specialists audiences through publication of Drug and Therapeutics Bulletin (DTB) and Consumer Policy Review (CPR) publishes independent and rigorous reviews of the effectiveness of drugs and treatments and is circulated monthly to over 116,000 doctors and pharmacists. CPR is published bi-monthly and aims to promote discussion and debate across a wide range of consumer policy issues.

2.  INTRODUCTION

  2.1  The National Health Service has widespread public support and is arguably the most highly valued public service in the UK. Research undertaken by CA over many years has shown that patients and clinicians agree that good communication and information processes are essential to the provision of a quality health service. However, our research has also found that both patients and clinicians believe that this is one of the key areas within the NHS which requires improvement.[3]

  2.2  It is also clear that the public interest in information about health services and their own healthcare is genuine and growing and that this interest is closely intertwined with strong patient views about the need for a more open and engaging health service and for improvements in how the health service communicates with patients and the wider public.[4] Systems for dealing with complaints quickly and appropriately are an important part of getting this communication right.

  2.3  Consumers' Association has also looked at private healthcare services and the systems which are in place in this sector for dealing with complaints and problems. Our research has found that patients who receive private treatment are significantly disadvantaged by the lack of formal and effective complaints procedures.[5] As the availability of some services on the NHS decreases, for example dentistry, we are particularly keen to ensure that that the deficiencies that we have identified in the private healthcare sector be addressed.

3.  CONSUMERS' ASSOCIATION RESEARCH

  3.1  Consumers' Association has a long history of examining how well health care services work from the patients's point of view. We believe that the experiences of people who use health services is the most important performance indicator there is and that user feedback provides valuable information in relation to how services can be improved.

  3.2  Because of our long standing commitment to ensuring that the patient experience informs the development of health care services and policy, we have worked hard to ensure that our reports and campaigns are supported by throrough and high quality research. CA has been asking patients what they think about health servies for more than 40 years and as a result we have a substantial base of information about patient experiences to draw upon. This base includes research into patient experiences with primary and acute health services both in the public and private sector. We also have investigated patient experiences with complaint procedures.

  3.3  CA is currently researching two key areas related to redress in healthcare which will be published in reports in forthcoming editions of Which? and HealthWhich? magazines. We believe that these reports, one which examines how well private healthcare provider complaint procedures work, and the other which looks at patient experiences with the General Medical Council (GMC) complaints process may be of great value to this Health Select Committee inquiry. These reports will be completed in August and October respectively and we will make this information available to the Health Select Committee at the earlierst possible opportunity. We would also be very keen to provide oral evidence to the committee in relation to this submission and the above noted reports.

4.  NHS COMPLAINTS PROCEDURES: PATIENT VIEWS

  4.1  In 1997 Consumers' Association surveyed 491 patients who had experiences with the new NHS complaints procedures.[6] We found that the most common cause for a formal complaint was unsatisfactory medical treatment, followed by poor attitude of staff and or failure or refusal to provide services. However, patients were also very clear about what they wanted to achieve by using the complaints procedure. More than half said that one of their objectives in lodging a complaint was to achieve improvements in services for other patients or to see that practical steps were taken to correct the problem. Forty-five per cent said they wanted an explanation or for the staff involved to be disciplined.

  4.2  Guidance on the NHS complaints procedures says that at the end of the process, complainants should be satisfied with the way that their complaint had been investigated, and that where appropriate they should be offered an apology and given information about steps that are being taken to deal with the problem. However, more than one third of patients who responded to our 1997 survey didn't feel that appropriate action was taken to prevent the problem from happening again and over 40 per cent were unhappy with the overall way that their complaint had been handled. Only two in 10 complaints said that they felt that practical steps had been taken to correct the problem and many were not aware of any action taken.

  4.3  In addition, nearly 60 per cent of those who responded to the survey reported that they felt that the NHS, and in particular hospital complaints managers, followed by NHS Chief Executives, did not accept responsibility for what happened. Forty per cent of respondents felt that NHS staff doubted their version of what had happened and 30 per cent said their complaint had received a hostile reception or that they felt they were treated as a nuisance. More than three-quarters of respondents said that they felt that in responding to their complaint hospital staff were trying to defend themselves.

Information

  4.4  This study also found that patients may be experiencing problems getting information about formal NHS complaints procedures and how they work. Over 300 people answered questions about accessing information about the complaints procedure and almost half said that they were not told what the procedures were, or given any written information. Over half said that they were not told that they could seek assistance from a Community Health Council or that they could direct their complaints to a complaint manager. In addition, although NHS guidelines are clear that complainants have a right to request that their complaint be considered by an independent review panel, more than half of the respondents in the survey said that they were not told this could be requested.

Local Resolution

  4.5  The emphasis of the new NHS Complaints Procedure is on resolving problems quickly and at the local level. However, many patients who responded to CA's survey were not happy about the idea of having to take up their grievance with the individual who had caused the problem. Many patients said that they were concerned about the impact that their complaint would have on their relationship with the practitioner concerned or felt that they would not get a fair hearing. Seventy per cent said that they would have preferred to take the complaint up with someone completely independent.

  4.6  At the end of local resolution more than seven out of 10 people received a written response outlining the outcome of their complaint. However, nearly six out of 10 did not get an explanation of how their complaint had been investigated and only three out of 10 got an explanation about what had gone wrong. Nearly three quarters of complainants who responded to the survey said that they were not satisfied with the way their complaint had been handled by the end of local resolution and nearly six in 10 respondents decided to pursue their complaint beyond this stage.

Time Limits

  4.7  The survey also found that time limits for responding to complaints were not being met. Seven out of 10 initial complaints were not acknowledged within two working days as required by NHS guidelines, and following the investigation, nearly six out of 10 complainants did not get a full reply within the 20 day working deadline. However, those who responded to the survey who did receive a full response within the set time frame were more likely to report higher levels of satisfaction with the local resolution stage, the final outcome and the overall handling of the complaint.

Independent Review Panel

  4.8  Only one in five of the complainants who responded to the survey who had requested that an Independent Review Panel hear their complaint had their request approved. While the most common reason for refusing the request for a review was referral back to the local resolution stage for further work, most complainants felt that their request had not been fairly considered.

  4.9  Most of the 11 respondents who had their complaint considered by an Independent Review Panel felt that their complaint had been fairly investigated and that their complaint had been taken seriously. Most felt that they'd been given an adequate opportunity to present their concerns and that the Panel did not question the credibility of their concerns. In six of the 11 cases, the complainant was satisfied with the outcome of the investigation. However, some complainants did not perceive the Independent Review Panel members as independent particularly where doctors and non-executive of health authorities were involved.

  4.10  Complainants should receive a written letter from the Chief Executive of the Trust or Health Authority outlining the outcome of the Independent Review Panel investigation and informing the complainant of action which would be taken as a result of the Panel's report. Two of the complainants who had gone through the Independent Review Panel process did not receive a copy of the final report. Seven complainants received reports which outlined the Independent Review Panel's investigations. However, only four complainants had an explanation of what went wrong and only two received an apology. Two complainants were not advised that they could ask the Ombudsman to consider their case if they were not satisfied with the outcome of the investigation.

Areas for Improvement

  4.11  CA's investigation into patient experiences with the NHS complaints procedures show that there are key areas where improvements are required. In particular, there is a need to ensure that more complete and accurate information is made available to patients in relation to complaint procedures, what can be expected in terms of time-frames for responses, and about where to get support in putting forward a complaint. Our investigation found that this information is still not getting to patients on a consistent basis and we are very concerned that many patients are being denied the opportunity to have their concerns formally addressed.

  4.12  It is evident that most patients who complain are motivated by a genuine desire to correct problems and improve services. Patients want to see evidence that their concern has been properly addressed and to be given a full explanation of what went wrong and an apology if appropriate. Unfortunately, the NHS complaint procedures do not ensure that complainants will receive information about how the investigation was undertaken and details about what was found. Even in those instances where complainants have their case considered by an Independent Review Panel there is no guarantee that they will receive a complete report on the outcome of the investigation.

  4.13  While the principle of local resolution is sound, in practice patients may feel reluctant to raise their concern directly with the individual responsible for the problem. We are especially concerned about this issue in the primary care setting as the relationship between patients and their GP practice is more complex than relationships at the secondary care level. If complaints are poorly received or not managed sensitively there is a possibility that the relationship between the patient and GP practice will be irrevocably damaged. In the worst case scenario the patient and their family may be removed from the GP's list. We understand that the Health Service Ombudsman has reported a similar concern in his annual report.

  4.14  CA strongly recommends that measures be put in place to ensure that patients are fully aware of complaint procedures, including their right to ask the Health Service Ombudsman to look at their case.

  4.15  We also recommend that complainants should be entitled to receive a formal report from the Independent Review Panel. Where complaints have been upheld, the appropriate NHS manager should be required to provide complainants with a report outlining actions which will be taken to address the problem.

  4.16  CA strongly recommends that procedures for managing complaints in primary care be reviewed to establish the extent to which patients who complain are being removed from GP lists and to consider whether there are better ways of enabling patients and GPs to resolve complaints in a non-confrontational manner—for example, through the use of lay conciliators.

  4.17  We also recommend that measures be introduced which make it a disciplinary offence for practitioners to remove, without suitable justification, patients from their list because they have made a formal complaint.

  4.18  Consumers' Association also recommends that the new NHS patient survey initiative be used to assess, on an ongoing basis, how well redress system work from the user perspective.

5.  COMPLEXITY OF REDRESS SYSTEMS

  5.1  Consumers' Association is concerned that patients may not be given full and complete information about complaints systems. We are also concerned that people who wish to complain may not have access to information to enable them to make an informed decision about which complaint or disciplinary process is most appropriate for their case.

  5.2  At the outset most complainants will not be familiar with the purpose and remit of all of the existing redress systems—these include the NHS procedures, the Health Service Ombudsman, professional body disciplinary procedures (eg General Medical Council) and the recently introduced Pre-action Protocol for the resolution of Clinical Disputes. While many of these systems have similar features, for example, all may result in an investigation of a complaint, the purpose and outcome of each is very different.

  5.3  In our view, a satisfactory complaint outcome is closely linked to the ability of complainants to use the appropriate system—if a complainant is seeking an explanation or an apology, the NHS complaints procedure is a far more appropriate than the General Medical Council disciplinary procedures which cannot assure that an apology will be provided even if a complaint is upheld. However, we are not confident that there are systems in place to ensure that complainants have access to information about the various redress systems and the differences between them.

  5.4  Consumers' Association recommends that sign-posting measures be put in place to ensure that complainants have knowledge—at the outset of their complaint— of all of the available redress systems. All agencies and organisations which are involved in either administering complaint systems, or supporting complainants to use these systems, should provide complainants with standardised information which clearly states how each redress system works and provides detailed information about their specific purpose and what can be achieved by using them.

  5.5  Information should also be provided about where complainants can seek independent advice, for example, from a Community Health Council, about how to best pursue their complaint.

6.  HEALTH SERVICE OMBUDSMAN

  6.1  Consumers' Association has a number of specific concerns about the Health Service Ombudsman scheme. Our concern about the lack of authority of the Ombudsman to investigate private health care sector complaints is outlined in the following section. (Section 7)

  6.2  However, we are also concerned about the inability of the Ombudsman to investigate complaints about GPs once they retire from NHS practice. CA has recently reported on a case where the Health Service Ombudsman, on legal advice, had to discontinue an investigation when the GP in question retired from the NHS.[7] Our report found that although a complaint cannot be pursued after a GP retires from the NHS, GPs can continue to work as an NHS locum or in private practice as long as they are registered with the General Medical Council. In our view, regulations must be changed to enable investigations of complaints to continue as long as a GP is practising and registered with the General Medical Council.

  6.3  CA recommends that the Health Service Ombudsman be given the authority to continue investigations of cases involving GPs as they are registered with the GMC.

7.  COMPLAINTS ABOUT PRIVATE HEALTHCARE PROVIDERS

  7.1  As previously reported to the Health Select Committee those who use private health care services can only access formal redress through professional bodies, such as the General Medical Council, or by taking legal action. In the majority of cases where patients experience problems with services neither of these options is suitable. Patients can complain to the hospital or clinic where they received treatment, however, there is no guarantee that their grievance will be considered or responded to.

  7.2  It is our view that regardless of whether people use NHS or private health care services they should have access to adequate redress systems. We are particularly concerned that in areas where private services are becoming more and more common, such as dentistry, where one in four adults are now registered privately, patients are being denied the opportunity to have their concerns and problems formally addressed.

  7.3  In our previous submission to the Health Select Committee inquiry into regulation of private healthcare CA recommended that there be a statutory requirement for formal complaints systems in this sector. We also recommended that the remit of the Health Service Ombudsman be extended to the private health care sector. We urge the Committee to consider these recommendations as part of its inquiry into procedures related to adverse clinical incidents and outcomes in medical care.

8.  INFORMATION AND COMMUNICATION

  8.1  In considering how well formal complaint and disciplinary procedures work it is important to consider patient experiences in relation to day-to-day communication with healthcare professionals. We believe that these experiences provide insight into why many patients may feel that formal action is the only option available to them.

  8.2  CA research as far back as 1974 has found that information provision and communication within the NHS to be particularly poor, even when it comes to basics.[8] However, it isn't just access to information about how services are organised which is problematic. In study after study CA has highlighted lack of information coupled with concerns about poor communication, insufficient consultation times and lack of opportunities to participate in decisions, as the greatest source of dissatisfaction for patients. These concerns are shared by patients across all sectors of the service—inpatients, outpatients, patients in general practice and day surgery patients.[9]

  8.3  In our view this research highlights important messages which must be considered in relation to formal systems for complaints. Firstly, patients do want to be involved in decisions about their healthcare and fully understand treatment options and implications. We believe that these principles may not be fully understood within the health service and pressures are such that instead of implementing measures to improve communication, patients and their doctors have fewer and fewer opportunities to properly engage.

  8.4  Consumers' Association studies have consistently found that patients want more information than they are provided with. A 1991 study found that of 262 recent outpatients, 74 per cent wanted as much information as possible, 18 per cent wanted some information and only 8 per cent wanted to leave things to the doctor[10]. In a 1995 study we found that of the 1,618 patients surveyed, 46 per cent were not satisfied with the amount of involvement they had in their choice of treatment or in the decision taken during their consultation. Of 323 hospital based patients surveyed, more than one in three wanted more say in treatment decisions affecting their care.[11]

  8.5  Patients closely associate good information and communication processes with quality services. Two of the three criteria selected as characteristics of a good GP practice in a 1986 CA survey were concerned with information. In a 1991 survey, 63 per cent of patients reported that in their view a doctor "who takes time to listen and explain things clearly" is important for a quality health service.[12]

  8.6  Our research has found that clinicians also recognise the value of communicating with their patients. In a 1995 survey of 1,705 GPs about factors important for the provision of a good service, most selected "a doctor who listens and explains clearly" as their first priority followed by "involvement of patients in treatment decisions".[13]

  8.7  Feedback from hospital based doctors also surveyed in 1995 was similar. When asked about inpatient services 74 per cent of doctors rated good doctor/patient communication as the most important factor to the provision of a good quality service. Fifty one per cent rated the involvement of patients in decisions as the second most important factor and 47 per cent rated patient understanding of risks and benefits of treatment as third.[14]

  8.8  Patients and clinicians clearly see that good communication is essential to the provision of high quality care. However, it is also clear that in today's health service opportunities to improve communication between patients and clinicians may not be a priority. When CA asked 118 trust senior managers in 1995 about criteria for the provision of a quality service, only 4 per cent rated patient centred factors such as "attention to patient's needs as an individual" and "communication between staff and patients" as important. Understandably, the availability of highly motivated staff was ranked by over 80 per cent as the most important criteria for a good service. However, with regard to issues where services could be improved managers said that staff and organisational issues were more pressing than patient centred care.[15]

  8.9  We believe that poor communication between patients and healthcare professionals inevitably leads to higher levels of patient dissatisfaction and concern about services and treatment. Increases in formal patient complaints about health services may in large part be due to the decline in day-to-day opportunities for patients and healthcare professionals to communicate effectively.

  8.10  When CA looked at patient experiences of hospital care in 1997 we reported that patients found surgical pre-assessment clinics provided a good opportunity to meet clinical staff, ask questions and to find out more about the procedure they were booked to have.[16] In our view this kind of measure, which gives patients an opportunity to learn more about their treatment before it happens, is good practice and should be encouraged. We also believe that healthcare professionals should receive more formal training in communication skills and that more emphasis be placed on ensuring that patients can access information.

  8.11  CA recommends that measures be taken to ensure that the health services places a high priority on achieving meaningful improvements in the way that healthcare professionals communicate with patients. It is recognised that the health service faces considerable pressure in relation to resources and that this means that many professionals have less time to properly listen to and communicate with patients. However, it must be accepted that responding to formal complaints can be far more time consuming that an effective but informal patient/healthcare professional exchange.

June 1999

4   Consumers' Association Briefing, The NHS and the Consumer Perspective, June 1998. Back

5   Consumers' Association, Submission to Health Select Committee inquiry into Regulation of Private Healthcare providers, January 1999. Back

6   Consumers' Association, Which? NHS Complaints, September 1997. Back

7   Consumers' Association, Which? How GPs duck investigations, June 1999. Back

8   Consumers' Association Briefing, The NHS and the Consumer Perspective, June 1998. Back

9   Consumers' Association Briefing, The NHS and the Consumer Perspective, June 1998. Back

10   Consumers' Association, Which? What's Up Doc, February 1991. Back

11   Consumers' Association, HealthWhich?, The NHS What's the Verdict, June 1995. Back

12   Consumers' Association, HealthWhich?, Patient Information, August 1991. Back

13   Consumers' Assocciation, HealthWhich?, The NHS What's the Verdict, June 1995. Back

14   Consumers' Association, HealthWhich?, The NHS What's the Verdict, June 1995. Back

15   Consumers' Association, HealthWhich?, The NHS What's the Verdict, June 1995. Back

16   Consumers' Association, Which? NHS Complaints, September 1997. Back