Making things better? A report on reform of the NHS complaints ...

OmbudsmanThe Health Servicefor England<strong>Making</strong> <strong>things</strong> <strong>better</strong>?A <strong>report</strong> on reform of theNHS complaints procedurein EnglandHC 413

ContentsPageForeword by the Health Service Ombudsman for EnglandiiiChapter 1A brief history of proposals for reform 1The ‘old’ NHS complaints system 1Proposals for new procedure 2Inquiries 3Developments in public and patient involvement 3Developments in clinical negligence 4Chapter 2Our concerns 5Current proposals and regulations 5Fragmentation in complaints handling 5Complaints system not centred on patients’ needs 10Quality service 12Leadership, culture and governance 13Just remedies 14Problems with implementation 16Chapter 3Key elements of a new system 18Chapter 4Recommendations 20AnnexesAnnex A - Chronology of key complaints handling 23events - following the commissioning of the 1999 evaluationAnnex B - Bibliography 33iiMarch 2005 • <strong>Making</strong> <strong>things</strong> <strong>better</strong>? A <strong>report</strong> on reform of the NHS complaints procedure in England• Contents

ForewordOmbudsmanThe Health Servicefor EnglandAs Health Service Ombudsman I see hundreds of complaints from patients andcarers every year. These complaints have already been dealt with by the NHSbefore they come to me, giving my Office a unique overview of the complaintshandling process.Looking through these cases it is clear that many complainants face severeproblems in getting a satisfactory response to their complaints from health careproviders. Furthermore, the situation remains static as the NHS is not using thevaluable information contained in complaints to improve its services andcomplaint handling processes.In this <strong>report</strong> we highlight some of the problems with the current situation suchas the fragmentation of complaints systems - within the NHS, the NHS andprivate health care and between health and social care. This - combined with afailure to focus on patients' needs, poor leadership and lack of capacity andcompetence in complaint handling - has led to a system which makes it difficultfor patients to have <strong>things</strong> put right where they have gone wrong.In laying this <strong>report</strong> before Parliament - in accordance with Section 14(4)(b) ofthe Health Service Commissioners Act 1993 - my aim is to look to the future.The timing is right to consider how we can develop a truly patient-focusedcomplaints system. The Department of Health's decision to issue revisedregulations on complaint handling in 2005 - after considering the findings of theShipman Inquiry's 5th <strong>report</strong> - gives us all an opportunity to focus on how wecan achieve this.Health services that are truly responsive to patients will only come about if allhealth service leaders value feedback from patients - even when that feedbackis a complaint.In this <strong>report</strong> I call for leadership from the Department of Health andimprovements from the Healthcare Commission and others to address keyfailings in the current system. The Department of Health needs to demonstrateleadership and commitment by creating a core standard for complaints serviceshandling which meets patients' needs and by investing in trained staff who cantreat complaints positively and learn from them. The current system focuses onprocess rather than outcomes and on meeting deadlines rather than delivering aquality service.The ultimate goal must be to create a modern, responsive, patient-focusedcomplaints handling system. We would be delighted to work with theDepartment of Health, the Healthcare Commission and other providers of NHShealthcare to help achieve this.Ann AbrahamHealth Service Ombudsman for EnglandMarch 2005Foreword • <strong>Making</strong> <strong>things</strong> <strong>better</strong>? A <strong>report</strong> on reform of the NHS complaints procedure in England • March 2005iii

Chapter 1A brief history of proposals for reformThe ‘old’ NHS complaintssystem1996 Single complaints systemintroduced1. The single complaints systemintroduced in April 1996 was a radicalimprovement on a previously fragmentedand partial system. For the first time thesame complaints system covered hospital,community and primary care services(family doctors, dentists, opticians andpharmacists), and could handle concernsabout both administration and clinicaltreatment. Complaints were firstconsidered and responded to by theservice provider. This first stage wasknown as local resolution. Ifcomplainants remained dissatisfied theycould ask a convener (generally a nonexecutivemember of the organisationcomplained about) to arrange a review bya panel of lay people, with access to anynecessary clinical advice. This was knownas the second, or independent reviewstage. But there was no automatic rightto such a review. Where complainantsremained dissatisfied, or had beenrefused an independent review, theycould complain to the Health ServiceOmbudsman.1999 - 2001 Evaluation andlistening exercise2. It soon became clear that therewere major difficulties with the singlecomplaints system. The Department ofHealth had always intended to evaluatethe effectiveness of the system andcommissioned a research study, which ranfrom 1999 to 2000. The results,published in September 2001, revealedthat many complainants felt a high levelof dissatisfaction with the operation of thesystem, both at the local resolution andindependent review stages. The maincauses of dissatisfaction were unhelpful,aggressive or arrogant attitudes of staff,poor communication and a lack ofinformation and support. The mostimportant structural failure was the'perceived lack of independence in theconvening decision and in the reviewprocess generally'. The results of theevaluation resonated strongly with theexperience of the Ombudsman's office.3. The Department of Health'sevaluation <strong>report</strong>, NHS complaintsprocedure: national evaluation made 27recommendations aimed at improvementsthroughout the system, including:E.1980/03In July 2001, following her dissatisfaction with theTrust's response to her complaint about her latemother's care, Mrs A requested an independentreview. The panel was held in March 2002 and inSeptember Mrs A received a copy of the lay chair's<strong>report</strong>. She wrote to the Trust chief executivecomplaining that it was superficial, inconsistent andalmost unintelligible. Furthermore, it covered onlytwo of the four issues the panel had agreed toconsider and did not refer to the findings of theclinical assessors. It was also unclear what the finalrecommendations were. The Trust did not respond toMrs A's letter.The Ombudsman upheld the complaint. She criticised: the poor quality of the <strong>report</strong>; the failure of the lay chair to consult the otherpanel members; the convener and panel members for failing tocall the lay chair to account; the SHA for failing to ensure the lay chairadhered to complaints guidance and produced<strong>report</strong>s of the required standardThe Trust and SHA apologised for their shortcomings.a uniform national procedure, appliedequally to primary care and hospitalservices, with clear and consistenttime limits;dissemination of good practice, andmore use of conciliation to achieveresults swiftly and effectively;clear guidance on how the complaintsprocedure should be applied, andstandard targets nationally formanaging the performance of staffhandling complaints;<strong>Making</strong> <strong>things</strong> <strong>better</strong>? A <strong>report</strong> on reform of the NHS complaints procedure in England • March 2005 1

clear lines of responsibility formaking sure the complaints systemis run properly, with Chairs andChief Executives answerable to theDepartment of Health for theirperformance;a responsibility on Trust Boards toensure this work is funded properly,and staff are trained appropriately tohandle complaints and that theirclinical governance frameworkreflects complaints work as corebusiness;a system of quarterly <strong>report</strong>ing bycomplaints staff to the Trust Board,summarising the causes and trendsunderlying complaints, and makingrecommendations for action. These<strong>report</strong>s to be copied to relevantpatient representative organisations,and the Board to be responsible forimplementing recommendations;support from Primary Care Groups(PCGs) (predecessors of PrimaryCare Trusts - PCTs) for practices inmanaging the system, with a namedindividual responsible for handlingpractice complaints;regional NHS bodies, or a newindependent national complaintsauthority, to be responsible forholding panels to account andmanaging their performance;wide circulation of the panels' final<strong>report</strong>s to relevant patientrepresentative bodies and theCommission for Health Improvement(CHI), with the Trust Board beingresponsible for implementing anyrecommendations for remedialaction;new options for how panels shouldbe convened: by the HealthAuthority, neighbouringTrusts/Health Authorities, orintroducing a separate regional orsub-regional panel.2001 The Department consults onkey questions4. To coincide with the publication ofthe evaluation results, in September 2001the Department of Health issuedReforming the NHS complaints procedure -a listening document, which soughtcomments on the evaluation <strong>report</strong>'srecommendations and set out keyprinciples for an effective NHS complaintsprocedure.5. Comments on the evaluation<strong>report</strong>'s recommendations and the keyquestions were sought by 12 October2001. As well as written responses, aseries of regional events was held acrossthe country to gauge views of NHS staffand patient groups and research wascarried out with hard-to-reach groups.Proposals for the newprocedure6. The Department of Health'sresponse, in January 2002, to the Reportof the Public Inquiry into children's heartsurgery at the Bristol Royal Infirmary saidthat they intended to have a new NHScomplaints procedure in place byDecember 2002. However, no newprocedure was proposed until April 2003,when the Department published NHScomplaints reform, making <strong>things</strong> right.This described the vision of a newcomplaints procedure:open and easy to access - flexibleabout the ways people couldcomplain and with effective supportfor people wishing to do so;fair and independent -emphasising early resolution sominimising the strain and distressfor all those involved;responsive - providing appropriateand proportionate response andredress;providing an opportunity forlearning and developing -ensuring complaints are viewed as apositive opportunity to learn frompatients' views to drive continualimprovement in services.7. <strong>Making</strong> <strong>things</strong> right was notradically different from the listeningdocument, although it did attempt to takeaccount of subsequent developments inpatient and public involvement.Responsibility for independent reviewwould be placed with the new Commissionfor Healthcare Audit and Inspection (CHAI- now known as the HealthcareCommission), which was to regulatehealth services and so provide a link intothe quality improvement process.8. In November 2003 the Health andSocial Care (Community Health andStandards) Act 2003 received Royal assentpaving the way for CHAI to be set up;regulations to be made about complaintsprocedures in both health and socialservices; and for the Health ServiceOmbudsman to consider complaints aboutthe handling of NHS complaints by anyperson or NHS body.2 March 2005 • <strong>Making</strong> <strong>things</strong> <strong>better</strong>? A <strong>report</strong> on reform of the NHS complaints procedure in England

2004 Partial implementation9. In December 2003 draftregulations for the new NHS procedurewere issued for consultation. Theintention had been to implement theregulations on 1 June 2004. Howeverabbreviated regulations, the NationalHealth Service (Complaints) Regulations2004, were eventually laid beforeParliament on 9 July 2004 and came intoforce on 30 July. Ministers had decided ona phased implementation to take accountof recommendations from the ShipmanInquiry. The Inquiry's 5th <strong>report</strong> waslikely to address complaints handling insome detail and was due to be publishedlater in 2004. Reports from otherinquiries about doctors who hadrepeatedly failed to observe properstandards of care were also expectedlater in 2004.10. The July 2004 Regulations left thelocal resolution stage of the complaintsprocedure broadly unchanged. Theyconsolidated and rationalised thestatutory requirements for local resolutionby NHS bodies and introduced a reformedindependent review stage to be carriedout by the Healthcare Commission. TheDepartment intends to issue revisedregulations in 2005 followingconsideration of the 5th Shipman <strong>report</strong>.Inquiries11. Whilst the new complaintsprocedure was in gestation there were anumber of inquiries into situations whereserious failings in systems or in standardsof clinical care continued for lengthyperiods and affected significant numbersof patients.12. The Bristol Inquiry <strong>report</strong>ed in2001, the Neale and Ayling Inquiries inSeptember 2004, the final part of theShipman Inquiry in January 2005, andthe Haslam and Kerr Inquiry <strong>report</strong>s areexpected later in 2005.13. Each of the inquiries hasconsidered why existing systems,including the complaints system, did notmean that the problems were fullyrecognised and acted upon far sooner.Each has pressed for a more patientfocusedapproach. They have alsoproduced specific recommendations oncomplaint handling.14. The Neale and Ayling inquiriescalled for:15. The Shipman inquiry <strong>report</strong>recommended key changes to handlingcomplaints about GPs including:advocacy;an independent element to thesystem;early resolution of complaints;accessible and easily-used systems;<strong>better</strong> communication;training in complaints handling for allstaff;special training in handling sensitivematters for the Patient Advice andLiasion Services (PALS) and theIndependent Complaints AdvocacyServices (ICAS) staff;the establishment of systems toensure that complaints about thesame practitioner working in differentorganisations could be linked.all complaints about GPs should be<strong>report</strong>ed to the PCT and patientscould lodge complaints direct withthe PCT; andPCTs should develop the ability toinvestigate complaints properly andrefer to the Healthcare Commissionwhere necessary.Developments in public andpatient involvement16. Between 1999 and 2004, therewere significant developments in publicand patient involvement which hadimplications for complaint handling.PALS and ICAS set up and CHCsabolished17. In 2000 the NHS plan proposedthe creation of patient advocates andpatient forums in every hospital to helpservices become more focused on patientneeds.18. Patient Advice and Liaison Serviceswere to be in place in every NHS Trustand PCT by April 2002. PALS provide onthe spot advice and information topatients, often helping to resolveconcerns before they become complaints.PALS are not intended to be directlyinvolved with formal complaints under thecomplaints procedure, but often act as agateway to another new creation - theIndependent Complaints Advocacy<strong>Making</strong> <strong>things</strong> <strong>better</strong>? A <strong>report</strong> on reform of the NHS complaints procedure in England • March 2005 3

Services, which were specifically designedto support complainants through thecomplaints procedure. Contracts wereissued to independent advice/advocacyorganisations to provide ICAS across thecountry from September 2003.19. In effect PALS and ICAS wereintended to take over the CommunityHealth Councils' (CHC) role of helpingcomplainants. CHCs were abolished inDecember 2003.2003-2004 CPPIH and patientsforums are set up then CPPIH isto be abolished20. While PALS and ICAS were beingput in place, a new national statutorybody, the Commission for Patient andPublic Involvement in Healthcare (CPPIH),was established in January 2003. Its rolewas to ensure that NHS services takeaccount of the views of the public,providing and facilitating a framework forpublic involvement and acting as achampion for patients nationally. It didthis, in the main, by setting up Patientand Public Involvement Forums whoserole was to provide direct independentinput into the day-to-day management ofhealth services. They were introduced inNHS Trusts and PCTs during 2003. Then,in July 2004, the Secretary of Stateannounced that CPPIH was to beabolished, as part of a wider review ofthe Department's 'arm's length bodies'.Patients Forums would continue but, todate, it has not been decided what otherarrangements will be provided to supportand advise them. The Department begana consultation exercise on this issue inNovember 2004.Developments in clinicalnegligence21. In June 2003 the Department ofHealth published a <strong>report</strong> by the ChiefMedical Officer, <strong>Making</strong> amends - Aconsultation paper setting out proposalsfor reforming the clinical negligencesystem. It recognised that the presentsystem is unfair, slow, costly in legal feesand encourages defensiveness. The<strong>report</strong> proposed a new NHS-based systemof redress for patients who had beenharmed by NHS care, as an alternative tolitigation. It would be run by a bodybuilding on the work of the NHS LitigationAuthority (NHSLA), which currently dealswith medical negligence litigation onbehalf of NHS Trusts. Initially it would belimited to packages of care and paymentsto families of neurologically impairedbabies and to those treated in hospital orcommunity health settings but not byprimary care services. In general,payments would be limited to £30,000,but more may be available forneurologically impaired babies. Itrecognised that those seeking financialredress should also have explanations,apologies and information about action toprevent recurrence of the problem, whichthey often did not receive when takinglegal action.22. In July 2004 the Department'sreview of arm's length bodies said thatthe NHSLA would be reconstituted tooversee the NHS redress scheme, andfurther details on the operation of thescheme would be published later in 2004.4 March 2005 • <strong>Making</strong> <strong>things</strong> <strong>better</strong>? A <strong>report</strong> on reform of the NHS complaints procedure in England •

Chapter 2Our concernsCurrent proposals andregulations23. There are five key weaknesses inthe current system and approach, whichthe interim changes introduced in 2004have not resolved:complaints systems arefragmented within the NHS,between the NHS and privatehealth care systems, andbetween health and social care;the complaints system is notcentred on the patient's needs;there is a lack of capacity andcompetence among staff todeliver a quality service;the right leadership, culture andgovernance are not in place;just remedies are not beingsecured for justified complaints.There are, in addition, a number ofproblems which arise from the waythe interim changes wereimplemented.Fragmentation in complaintshandling24. Despite the fact that NHS care isbeing delivered in an increasingly widerange of settings, it is our experience thatmost people see the NHS as essentiallyone organisation delivering one-off orongoing packages of health care. TheSecretary of State for Health is clear thatan NHS patient is an NHS patientregardless of where they are treated.However, when someone wishes tocomplain about health services, the imageof one NHS can quickly shatter if thecomplaint is about more than one NHSbody or it involves the social services.Complaints across the NHS25. A significant number of complaintscut across services provided by morethan one NHS organisation, for example,GP care followed by a hospital admission.The latest regulations, as originallydrafted, imposed a duty on NHS bodies toco-operate in such situations so as to givecomplainants a full, co-ordinated andcomprehensive response. A specificpatient-focused requirement of this sortwould have been very helpful for patientsmaking such complaints who may have tomake two or more complaints, often withdifferent timescales and stages. There isalso the issue of complaints about failuresof communication or service deliverybetween NHS providers. It is ourexperience that these are very difficult topursue and secure a satisfactoryoutcome. However, following the decisionto phase implementation (see paragraph9) Ministers decided to leave localresolution unchanged. This meant thatall new requirements, including the dutyto cooperate, were removed from theinterim regulations. The Department ofHealth has, however, said that it intendsto reintroduce the requirement whenit issues amended regulations laterthis year.E.2470/04The Ombudsman upheld Mr Q's complaint ofunreasonable delay in diagnosis and treatment of hislate wife's ovarian cancer owing to failures incommunication between the GP and two hospitalconsultants who worked in both the NHS and a privatehospital.In January 2002 Mrs Q was referred by her GP to aconsultant surgeon at a private hospital. After theconsultation, the consultant arranged for an ultrasound scan and barium enema to be carried out. Hewrote to the GP in early February but the letter wasnot entered on to the GP practice's electronic recordssystem until late April. A few days before the testswere due to take place, a second GP, who wasunaware of the surgical consultation and plannedtests, referred Mrs Q, who was by then suffering frombreathing problems, to a consultant physician inrespiratory disorders at the private hospital and shewas admitted. Later Mrs Q was transferred to a NHShospital but remained under the care of the sameconsultant physician, who also worked there for theNHS. It was not established whether or not aphotocopy of the consultant physician's notestravelled with her but the consultant surgeon's notesdid not.Mr Q informed the consultant surgeon's secretary thathis wife was in hospital and could not, therefore,cont on p6...• <strong>Making</strong> <strong>things</strong> <strong>better</strong>? A <strong>report</strong> on reform of the NHS complaints procedure in England • March 2005 5

cont...undergo the planned tests. However, the consultantphysician and the consultant surgeon did not makecontact and, a month later, it was Mr Q who contactedthe consultant surgeon to rearrange the tests. Theywere re-scheduled for 10 days later. The connectionbetween what were, apparently, two different sets ofsymptoms was not made; neither was a diagnosis ofMrs Q's illness. Eight days after that Mr and Mrs Qwere shocked to be informed that Mrs Q had ovariancancer. She died two months later.NHS foundation trusts26. Provision was made in the Healthand Social Care (Community Health andStandards) Act 2003 for theestablishment of NHS Foundation Trustsand by July 2004 the first 20 had beenauthorised. They were established tomove management of local healthservices away from the Secretary of Statefor Health to local control. NHSFoundation Trusts have to achievenational targets and standards, but havefreedom to decide how to deliver this.The Government's aim is to enable allNHS Trusts to apply for foundation statusby 2008. But NHS Foundation Trusts - anincreasing element of NHS care - aretreated differently under the NHScomplaints procedure.27. Although subject to nationaltargets and standards, the local resolutionaspects of the 2004 regulations do notapply to NHS Foundation Trusts: indeedthe regulations make specific provision forthe situation where an NHS FoundationTrust does not have a complaintsprocedure.28. An independent provider of NHSservices must ensure arrangements are inplace for the handling and considerationof complaints about any matter connectedwith its provision of services as if the NHScomplaints regulations applied. That isonly right: it would be quite wrong forNHS patients referred to independentproviders to have less opportunity to haveany concerns considered than thosehaving services provided directly bythe NHS.29. The intention is that similarprovision applies to NHS FoundationTrusts. We understand that at presentthey continue to operate local resolutionprocedures which they were required tohave prior to their change of status. TheModel Contract used when they provideNHS services requires them to maintainan NHS complaints procedure 'compliantwith all applicable Law (including any NHScomplaints Regulations in force)'.However the 2004 Regulations do notapply to them as regards local resolution,so further clarification would be helpful.30. We acknowledge that NHSFoundation Trusts are expected to providehigh quality patient services and soshould be in the vanguard of providingpatient-centred complaint handlingarrangements which enable them toimprove their services. There should beno possibility of an NHS FoundationTrust's patient receiving a poorercomplaints service than any other NHSpatient. But it is the potential forconfusion and inconsistency which is ofconcern to patients who, for example,have complaints about both a NHSFoundation Trust and other NHS bodies.It is possible for NHS Foundation Trusts torun separate systems which may, forexample, reduce the opportunity for ajoint approach to a complaint about theco-ordination of specialist care sharedbetween a regional centre and a localhospital, when one is an NHS FoundationTrust and the other is not.31. The Healthcare Commission canconsider complaints about NHSFoundation Trusts in a similar way tothose about any other NHS bodies wherea complainant is not satisfied with theoutcome of an investigation by an NHSFoundation Trust or it has no complaintsprocedure.Complaints about both health andsocial services32. At present the social servicescomplaints procedure is entirely separatefrom the NHS complaints procedure. Thiscan cause problems for users of both setsof services when <strong>things</strong> go wrong.33. Many of those who receive bothservices are elderly, frail or suffer fromlong term, disabling conditions.Complaints can arise about both healthand social services or about how theyhave worked (or not worked) togetherand it is not always clear to service userswhich organisation is responsible for theservices they receive.6 March 2005 • <strong>Making</strong> <strong>things</strong> <strong>better</strong>? A <strong>report</strong> on reform of the NHS complaints procedure in England •

34. From complaints we have seen inthe past, it is evident that cross-boundarycomplaints have often been handled verypoorly. In some cases complainants werenot told promptly of the respective rolesand responsibilities of health and socialservices organisations. Sometimes theywere not advised that they would need topursue the health and social servicesaspects of their complaint through twoseparate procedures. We have seencases where only at the conclusion of onecomplaints procedure was it clear that thefault lay with the other organisation.E.629/02Mrs H and her family were invited to a care-planningmeeting to discuss arrangements for her mother'sdischarge from hospital. Staff from the acute Trust, theCommunity Trust and Social Services were present.When Mrs H later complained about the refusal tocarry out a full continuing care assessment of hermother's needs, and the lack of information about thefinancial implications of placing her mother in a nursinghome, she faced difficulties in addressing hercomplaints to the right body.The acute Trust turned her complaints away anddirected her to the Community Trust. When Mrs Hbrought in the acute Trust's patients' representativeand asked him who was responsible for the careplanningmeeting, he directed her to Social Services.In the end the Ombudsman investigated the actions ofthe acute Trust and the PCT, which now employs a keymember of staff of the former Community Trust. TheLocal Government Ombudsman investigated theactions of the Local Authority Social ServicesDepartment.Both Ombudsmen upheld the complaints. The acuteTrust liaised with the Local Authority and a satisfactoryfinancial remedy for Mrs H was obtained.E.1324/02Mrs X, who was in her late eighties and whosebehaviour was becoming increasingly confused andaggressive, underwent a mental health assessment ata day centre. Present were: the consultant and hissenior house officer (SHO); the approved socialworker; the day centre manager; and the GP. Afterassessment, Mrs X was taken to hospital on avoluntary basis. Later she was detained under theMental Health Act. Mrs X's family had expected to bepresent when their mother's future was decided. Thatdid not happen and they later complained about theway in which she was assessed and detained, andabout aspects of her care by the Trust.Mrs X's family complained to Social Services about theactions of the social worker and their complaintculminated in the final stage of social servicesdepartments' local complaints procedure. However,some issues remained unresolved.The family also complained to the Health ServiceOmbudsman after the Trust had failed to resolveseveral issues arising from Mrs X's care andtreatment. Over time, their initial grievances becamecompounded by their dissatisfaction with the Trust'shandling of their complaint.It took 123 weeks for the Trust to deal with thefamily's complaints. It is evident that delays werecompounded by the Trust having to investigate thecomplaint in conjunction with Social Services.The Ombudsman upheld part of the complaint aboutthe Trust. However, our investigation revealed thatthe social worker's actions were a major factor in thecomplaint, which the social services' investigation hadnot uncovered. The actions of staff employed bysocial services departments were not within theHealth Service Ombudsman's jurisdiction and,therefore, she could not make findings on the partplayed by the social worker in relation to thedetention of Mrs X.E.748/05The Ombudsman received a complaint from Miss B(who was expecting a baby) that the Trust hadprovided her with an inadequate explanation of thereasons for her referral to Social Services by amidwife and had not discovered the source ofincorrect and misleading information forwarded on bythe midwife.The Ombudsman's investigation revealed informationabout social services' involvement which had not beenuncovered by the Trust.The midwife had been trying to arrange a multiagencysupport package for Miss B - as recommendedin guidance entitled Working together to safeguardchildren, which was published jointly by theDepartment of Health, the Home Office and theDepartment for Education and Employment, in 1991.The guidance describes how all agencies andprofessionals should work together to promotechildren's welfare and protect them. However, whenMiss B thought she had cause for complaint whichseemed to span both health and social services, therewas no clear way forward.Indeed, the Ombudsman found that Social Services,not the midwife, were the source of the incorrectinformation. However, the Health Service Ombudsmanhas no jurisdiction over the actions of social services'staff, and could not, therefore, comment on theiractions.• <strong>Making</strong> <strong>things</strong> <strong>better</strong>? A <strong>report</strong> on reform of the NHS complaints procedure in England • March 2005 7

2003 Provision for improvements35. We welcomed the Health and SocialCare (Community Health and Standards) Act2003 provisions for similar new health andsocial care complaints procedures, whichallowed for a complaint to be made either tothe NHS or to social services. It wasenvisaged that the two systems would'operate as far as possible in parallel so thatfor the complainant it appears as onesystem'.36. However, to date, despite some workon developing regulations and guidance onsocial care which are similar to those onhealth care, no regulation has been madeabout the joint consideration of complaints.The situation was further complicated by theneed separately to consider the adults' andchildren's parts of the social servicesprocedures.37. In October 2004 two separateconsultations, by the Department of Healthand the Department for Education andSkills, on the adults' and children's parts ofthe complaints regulations respectively,began. A month earlier the Commission forSocial Care Inspection (CSCI) had begun toconsult on the independent review stage.38. There was a widespread commitmentto joining up the health and social servicescomplaints approach. Originally it had beenhoped to launch the two new health andsocial service complaints proceduressimultaneously in 2004 but this did nothappen. Implementation of the new socialservices procedure was planned for April2005 but is now likely to be later, to allowtime for preparation.Joint working - first andsecond stage39. The draft Social Services ComplaintsRegulations do contain provision forcomplaints made under the adult socialservices procedure, but which also involvehealth matters, to be made to the localauthority. The complaints manager mustthen consult with the complaints managersof the other bodies involved and decide whoshould take the lead. Where practicable a<strong>report</strong> should be prepared dealing with allaspects of the complaint. But there is nosuch provision relating to complaints madeunder the children's procedure in the draftRepresentations (Children) Regulations.40. If provision were made for complaintsmade under the social services children'sprocedure to be dealt with in the samecollaborative way, it would be a good stepforward. Similarly, to complete the jointapproach, the NHS complaints regulationsneed to include analogous provision forcollaboration with social services.41. There are also various differences inprocedures and timescales for the localresolution stage of health and social servicescomplaints which seem likely to causeunnecessary difficulty for complainants.Perhaps, most significantly, the healthservice time limit for making a complaint issix months but draft social servicesprocedures allow 12 months.42. At the independent review stage,however, the draft regulations allow for jointhandling of complaints by the HealthcareCommission and CSCI, whether thosecomplaints are made initially under thesocial services' adults' or children'sprocedures.43. The Health and Social Care(Community Health and Standards) Act2003 also amended the existing statutorysocial services complaints procedure, andplaced a duty upon CSCI to work closelywith the Healthcare Commission in mattersof complaints concerning joint health andsocial care provision. Both the HealthcareCommission and CSCI have made generalstatements about working together butneither has yet given any real indication ofhow this will work in practice.Procedural differences between theHealthcare Commission and CSCI44. We recognise that there aredifferences in the way complaints have beendealt with in the past under the separatehealth and social services systems. Thereare also differences in the procedures whichboth the Healthcare Commission and CSCIhave said they will use. For example:the Healthcare Commission describepanels using the results of theCommission's own (stage two)preceding investigation; CSCI envisagepanels using information gathered atlocal resolution; both would allowrepresentations from both sides;the Healthcare Commission will givethe panel chair the final say in anydisagreement about the conduct of apanel; CSCI say the conduct of thepanel will be determined by themajority;8 March 2005 • <strong>Making</strong> <strong>things</strong> <strong>better</strong>? A <strong>report</strong> on reform of the NHS complaints procedure in England •

the Healthcare Commission have adetailed target system for timescalesfor handling complaints; CSCI amuch broader framework withshorter overall targets. Forexample, the former have a target offour months from request tocompletion of a panel; CSCI propose45 working days (about twomonths). The HealthcareCommission say they are nowlooking at a broader framework oftime-scales similar to CSCI tofacilitate the handling of combinedcomplaints.where differences in approach would behelpful. However, unless joint workinghas been properly considered from thestart, the needs of service users will notbe well served.Joined-up and patient-focused?46. We have grave concerns that ifcross-cutting health and social carecomplaints remain unresolved at the endof the second stage of the differentcomplaints procedures, and a third andfinal tier is needed, the difficulties for thecomplainant will multiply.45. We have experience of workingjointly with other Ombudsmen toinvestigate complaints which straddle theboundaries of health and social care. Byadopting a creative and positive approachto joint working, we manage to overcomemany of the difficulties which ourseparate legislations impose on our work.It is much more difficult to provide aseamless service under significantlydifferent procedural frameworks. Thenew parallel legislation on health andsocial services complaints provides theopportunity to co-ordinate the twosystems; it should not be missed. Clearlyit would not be helpful to straitjacket theprocedures into exactly the same format47. To illustrate this let us take ahypothetical, but not untypical, casestudy involving a 14 year old girl, Jane.Jane suffers from a mental illness andreceives care from her local mental healthtrust and social services. She alsoregularly injures herself and on thoseoccasions requires admission to the localacute trust, which now has Foundationstatus. Something goes wrong and Janetries to complain about an event in hercontinuing care and treatment whichcrosses the boundaries of the varioussystems. Local resolution fails to answerher complaint so Jane wants to ask for anindependent review. At each stage shemight need to approach three differentbodies:• <strong>Making</strong> <strong>things</strong> <strong>better</strong>? A <strong>report</strong> on reform of the NHS complaints procedure in England • March 2005 9

(The situation is no simpler if Jane wantsto involve an Ombudsman at an stage.Not only might she have to approach bothHealth and Local GovernmentOmbudsmen to cover the full range of heroriginal complaint, but if she hadconcerns about how it was handled byMonitor or CSCI she would also need toapproach the ParliamentaryOmbudsman.)48. In our view, it is quite wrong thatthere is no over-arching joined-upcomplaints framework which attempts toaddress these issues. As we have alreadynoted, those who receive services bothfrom the NHS and social services areamong the most vulnerable members ofsociety. Such a convoluted system seemsto work against the aim expressed in theNHS improvement plan 2004 to 'putpeople at the heart of public services'.Complaints system notcentred on patients’ needsInflexible processes49. Much emphasis is currently beingplaced on moves to make the NHS workin a way which <strong>better</strong> meets the needs ofpatients: and rightly so. Too often in thepast the focus was on a clinical ormanagerial perspective. That is notappropriate for a publicly funded servicein the 21st century. A real commitmentto a patient-centred service meansaccepting that it is only right for patientsto be able to express any dissatisfactionthey may have with the NHS and that thesystem which considers their concernsshould be customer-focused.50. The survey of complainants to ourOffice, carried out on our behalf by MORIin 2004, found that:by the time complainants get to us,at the end of a protracted complaintsprocedure, they feel isolated andexhausted;complainants want to talk tosomeone about their complaint andto know who will be dealing with itand how it will be dealt with. Theywant to know how their complaint isprogressing and be updated on ourwork and thinking;complainants want an appropriateoutcome to their complaint, usuallyan apology, where appropriate, achange in working practices so that itdoes not happen to someone else,and for someone to be heldaccountable for what went wrong;few complainants started out to seekfinancial recompense. But theprocess itself makes them morelikely to ask for financial redressbecause of the time and effort theyhave expended in trying to get theircomplaint resolved. Worse - whencompensation is offered, a smallamount can antagonise them evenfurther.51. We have tested these findings withcomplaint handlers in the NHS who havetold us that they reflect whatcomplainants say to them. Everycomplaint and complainant is different:one size and shape of procedure will notfit all circumstances. To be patientfocuseda complaints system needs tohave sufficient flexibility to meet thesevarying needs. Our surveys ofcomplainants who approach usdemonstrate that complainants recognisethat some complaints will take longerthan others to resolve because ofdifferences in complexity, seriousness andthe scale of investigation work required.They want a fit for purpose response tothem and their complaint with a focus onappropriate resolution, not a one size fitsall process. Complainants are preparedto wait for a comprehensive investigationand response, so long as the reasons forthis are explained and they are keptinformed of progress. The CPPIHexpressed similar views on behalf ofservice users in their comments on thedraft regulations: they would rather havea longer timescale which was adhered tothan an ambitiously short one whichproved difficult to meet.52. There can be some tensionbetween a desire to provide that flexibilityand a wish to improve performance bysetting explicit and measurable standardswhich all services must meet. Plainly, aclear basic framework needs to be givenand some standards set. However, care isneeded to avoid focusing on rigid timetargets or developing complex procedureswhich will result in the needs ofsignificant numbers of complainants notbeing met.10 March 2005 • <strong>Making</strong> <strong>things</strong> <strong>better</strong>? A <strong>report</strong> on reform of the NHS complaints procedure in England •

Speed of response/targets andtimescales53. Complainants are interested inoutcomes, not time targets, but that isnot how complainants or, indeed,complaint handlers experience the currentsystem. The focus on process in thecurrent Regulations and the significanceof achieving the time targets for the starrating system has led to a perverseincentive for Trusts to make andcommunicate a decision, signed by theChief Executive, within 20 working days.Unfortunately, we have seen manyinstances where the pressure tocommunicate a timely decision hasoutweighed the need to consider thecomplaint properly.54. To make matters worse, there isno further target which is monitoredcentrally. We have seen many caseswhere a complainant expressinglegitimate dissatisfaction with that firstdecision has waited months for aresponse. While, therefore, one size fitsall targets are unhelpful, complainants doneed to know, at the outset, how long adecision on their complaint is likely totake and to be told of any changes tothat timescale.55. In November 2004 the HealthcareCommission undertook a consultationexercise on the approach they shouldtake in assessing whether organisationsmeet the Department of Health’sStandards for Better Health. Theconsultation is proposing that theassessment for the core standard oncomplaint handling is based on more thanthe timeliness of response and wewelcome this.56. Introducing unnecessarycomplexity to the procedures forcomplaint handling will exacerbatedifficulties in responding in a timely way.This is perhaps most apparent in thedetailed and complex procedures adoptedby the Healthcare Commission. Theregulations give them considerablediscretion on how to handle complaintsincluding the option to go direct to apanel hearing. However the Commission'sprocedures have suggested that theyintend to use panels mainly as anadditional stage: if a complainant remainsdissatisfied following an initial review andinvestigation. The Commission say thatthey are motivated by a desire to givethe patient 'the strongest sense ofindependent resolution', Given the abilityof the complainant to appeal to theOmbudsman as a final recourse, used inthis way the panel would appear only tolengthen and complicate matters for thecomplainant rather than speeding up andsimplifying them. The process wouldthen have 15 separate actions listed, eachwith a separate time target, leading to atotal time target for cases going to apanel hearing of over a year from thepoint of first contact with theCommission: though their overall target isto resolve complaints in six months.Deterring primary care complaints57. Another important aspect ofcomplaints handling in the NHS which isnot meeting patients' needs concernscomplaints about primary care contractors(GPs, dentists, pharmacists andopticians). Currently patients can findthemselves having to complain directly tothe very person about whom they have acomplaint. That person may also be theone who responds to them, without anyinput from a third party. For the patient,dealing directly with a practitioner withwhom they have a continuing relationshipcan be very difficult.E.1152/03Mrs R asked Dr G to make a home visit to her motherand subsequently made a complaint about hisbehaviour. Dr G asked Mrs R's mother to find anotherdoctor.The Ombudsman investigated his action and upheldthe complaint. She found that Dr G had actedunreasonably by ending his professional relationshipwith Mrs R's mother as a result of Mrs R's complaint.It was inappropriate for a GP to try to remove apatient from his list because of difficulties withanother member of the family.Dr G agreed to familiarise himself with GMC, RCGPand BMA guidelines relating to removals from lists.He also agreed to familiarise himself with thestatutory position from April 2004 whereby a GPnormally needs to warn a patient before they can beremoved. He also agreed to discuss his approach tocomplaint handling with the PCT.58. For some time it was intended toresolve this problem through the newcomplaints procedure. <strong>Making</strong> <strong>things</strong> rightproposed that patients, if they wished,should be able to complain direct to the• <strong>Making</strong> <strong>things</strong> <strong>better</strong>? A <strong>report</strong> on reform of the NHS complaints procedure in England • March 2005 11

PCT about a primary care contractorrather than to the practitioner. Theoriginal draft of the 2004 regulationsmade such provision and we supportedthat change. However no such provisionwas retained in the final version, thoughthe Department of Health say that will beincluded in revised regulations in 2005. Apatient-centred complaints system wouldrecognise the difficulty for some patientsin this situation and make provision forcomplaints to be made to the PCT. The5th Shipman <strong>report</strong> recommended amuch enhanced role for PCTs in handlingcomplaints about GPs - including suchdirect access for complainants.Need for support and advice59. We recognise that access tospecial support can often help acomplainant present their complainteffectively. Complainants may need helpin writing their complaint, translation andthe intervention of interpreters, or to talkto someone who can explain and helpthem through the present, complicatedprocess. PALS and ICAS do provide suchhelp and we have received complaintswhich are comprehensive, clear, thoroughand well argued because of theirinvolvement. Our knowledge ofcomplaints supports the recommendationsmade by recent Inquiry <strong>report</strong>s about theneed for competent and sensitiveadvocates.Quality serviceInadequate investigation60. Rigorous and evidence-basedinvestigations by competent staff areessential. But, in our experience, boththe quality of the complaint investigationand the competence of staff handlingcomplaints vary significantly and areoften inadequate for the task. We havereceived many complaints where the localresolution:had had no clinical input althoughthe complaint was about diagnosisand treatment;was based on inadequate oruncorroborated evidence;was flawed because of the partialityor perceived partiality of thereviewer;accepted the views of Trust staffwithout question;did not cover all aspects of thecomplaint;was based on poor analysis andjudgment;was poorly documented and failed togive reasons for the decision.Such concerns have been highlighted in anumber of recent Inquiry <strong>report</strong>s.Different perceptions of the quality oflocal investigation in health and socialservices, (ie that in the past it has beenless robust in the NHS), have alsocontributed to the differences in approachbetween CSCI and the HealthcareCommission, though the HealthcareCommission are anxious to use theirpowers to help ensure that localinvestigation and resolution in the NHS ismore effective. However, we do seeexamples of good complaints handlingtoo:E.2146/03Mr S complained about his diagnosis and the careprovided to him within a Trust's general mental healthand psychotherapy services. Mr S sent numerousletters to Trust personnel which all sought to expandhis original complaint.The Trust investigated his complaints speedily and aresponse from the Chief Executive was sent to Mr S amonth after he submitted a formal complaint. Asubsequent letter offered a further attempt at localresolution but once that had again failed, thecomplaint was referred to the convener for possibleindependent review. The convener took appropriateclinical advice and rejected the request for a review.Mr S complained to the Ombudsman.The Ombudsman decided not to investigate Mr S'scomplaint. She had no concerns about the standardof care given to Mr S and commended the Trust formaking significant and strenuous efforts to addressall Mr S's complaints with considerable patience,understanding and sensitivity, and in a timely way.Lack of capacity and competence61. Often the shortcomings in theinvestigation relate directly to the lack ofcompetence of the staff handling thecomplaint. Local complaint handlers areoften junior staff, selected for theirinterpersonal skills, but not necessarilytheir analytical skills. For example, it isstill not uncommon for the formersecretary to the Chief Executive to leadon complaints. Certainly it is rare to findthat all front line staff have receivedtraining in handling complaints.12 March 2005 • <strong>Making</strong> <strong>things</strong> <strong>better</strong>? A <strong>report</strong> on reform of the NHS complaints procedure in England •

62. One of the recommendations ofthe evaluation of the old complaintsprocedure 1 was that Boards of NHSbodies should ensure that:all staff are adequately trained todeal with complaints and aresupported in the event of acomplaint being made against them.Training in handling complaintsshould be a compulsory part ofinduction and continuing education;staff managing complaints areappropriately trained, have adequateadministrative resource and accessto senior managerial supervision andsupport.63. An early draft of the currentregulations contained a requirement 2 thatNHS bodies must ensure staff wereappropriately trained in the operation ofthe complaints arrangements. There isno mention of training in the final versionor in the guidance. The Department saysthat this requirement will be reintroducedin revised regulations to be issued thisyear.64. We welcome the fact that traininginitiatives in complaint handling areunderway. The NHS and MiddlesexUniversities are developing an accreditedqualification in complaint management,which will be relevant to those withspecific responsibilities for complaints.The present good practice toolkit for localresolution (developed under the oldcomplaints system) includes a list ofcompetencies for complaints managers.However this has not been revised andstrengthened to match the new systemand there is no evidence, of which we areaware, that these competencies havebeen widely embraced at the local level.A crucial point in complaint managementis the time that concerns are first raisedand this means that all staff need to havea basic understanding of how to deal withcomplaints and concerns and thecommunication skills to do so effectively.65. Whilst developments in trainingand guidance are to be encouraged, thegeneral pace of progress in this area andthe emphasis placed upon it isdisappointingly limited in an NHS whichaims to be more patient-centred. As theDepartment's evaluation and subsequentinquiries have recognised, there has notbeen sufficient emphasis on developing agroup of appropriately influential andcompetent staff to undertake thoroughand open complaint investigations.Leadership, culture andgovernanceStrong leadership and a learningculture66. In our experience, clear, positiveleadership is essential for thedevelopment of an open, learning culturein which complaints are welcomed andresolved and lessons learned. Certainlywe have direct experience of clusters ofcomplaints against specific trusts or otherbodies which reflect a defensive approachto complainants, and indeed us, by theChief Executive. Those organisations,despite ostensibly accepting ourrecommendations, have failed to addresssystemic issues and created a context forrepeated mistakes….and complaints. ChiefExecutives who welcome complaints andsupport a learning rather than a blameculture by their own example, rarely havecomplaints upheld by this office.Governance and accountability67. The Department’s 2001 evaluation<strong>report</strong> recommended that the Board ofevery NHS organisation should be heldaccountable for the performance of theorganisation in handling complaints. Wewholeheartedly endorse that. It is theBoard and Chief Executive who can createa culture of openness and learning,monitor performance on complaintshandling, and make effective connectionswith clinical governance.68. The 2004 regulations require aBoard member to take responsibility forensuring compliance with thearrangements and that action is taken inthe light of the outcome of anyinvestigation. While that goes some waytowards building a framework ofaccountability, it is not sufficient. Thereis nothing to prevent the Board levelsponsor from being an executive directorwho is already managerially accountablefor complaint handling, and who mayhave a vested interest in convincing theBoard that all is well.69. The evaluation also recommendedthat Boards had to ensure that agreed1 6.12 2 29• <strong>Making</strong> <strong>things</strong> <strong>better</strong>? A <strong>report</strong> on reform of the NHS complaints procedure in England • March 2005 13

actions were implemented. But the 2004regulations are weaker, requiring onlythat the designated Board member mustensure that action is taken in the light ofthe outcome of an investigation. Thatleaves scope for the wider Board not toaccept accountability and for partialimplementation of agreed actions. Ourown experience has shown us that someNHS bodies lose interest in the outcomeof complaints once a response promisingaction has been sent and implementationmay be poorly monitored. It is importantin a patient-centred service that actionsare delivered and that implementation ismonitored from outside the departmentconcerned.70. The 2001 evaluation <strong>report</strong> alsorecommended that complaints handlingshould be an explicit part of theperformance management of Chairs andChief Executives of NHS bodies. No suchprovision has been made.Integration of complaintsprocedure with other NHS systems71. Clearly the NHS complaints systemshould not operate in isolation. Theoriginal evaluation recognised this andrecommended that Boards should ensurethat 'the complaints procedure isintegrated into the clinicalgovernance/quality framework of theorganisation.' That is not fully reflected inthe regulations or guidance. The guidancesays only that the designated Boardmember for complaints 'may' wish to linkthe complaints procedure with clinicalgovernance processes and riskmanagement strategies.72. It is essential that connections aremade which facilitate learning fromcomplaints. At national level theintegration of the second stage of theprocedure into the HealthcareCommission's work should provide thatconnection. But matters should not haveto reach the Healthcare Commissionbefore such a connection can be madeand lessons can be learned.73. Since the evaluation there havebeen many relevant developments atnational and local level, particularly inpatient and public involvement, and linksbetween these and complaints systemswill also be important, especially inimproving patient focus. However it isless clear how and whether links will bemade with other work, especially at locallevel. In particular, there is no referencein the present complaints regulations andguidance to establishing links withPatients Forums despite there being realpotential in involving them (and ICAS andPALS) in reviewing plans for, performanceand outcomes of complaints procedures.Indeed, in commenting on the role ofPatient Forums, we have supported thesuggestion that such forums couldusefully check whether recommendationshave been followed up.Just remediesLong standing concerns74. The existing NHS complaintssystem says nothing about financialredress, and it is rarely, if ever,recommended or paid. Financialregulations governing the NHS havesometimes been quoted as preventingthis. But NHS bodies may make specialpayments where there has been afinancial loss as a result of the actions oromissions of the NHS body. Otherpayments may be made in exceptionalcircumstances. We have increasinglybeen recommending, and securing,financial redress for complainants fromNHS bodies in appropriate circumstances.But, in effect, other than by submitting acomplaint to the Ombudsman, financialredress has generally only been availablethrough legal action for medicalnegligence. Complainants who have givenany indication that they intended to takelegal action have been excluded from thecomplaints procedure.75. We have been raising our concernsabout this situation for several years. Inour Annual Report for 1998-1999, wepointed out that:'It is relatively easy to decide the appropriate way ofdealing with the extremes: for example, clinicalnegligence causing serious damage is appropriatefor the courts; relatively minor shortcomings withoutserious consequences can be dealt with by aneffective and responsive complaints procedure. It isthe middle group of cases, lying between theextremes, which is more difficult to deal with. Thoseare cases in which the complainant has sufferedsignificant loss or damage through what he or sheperceives - sometimes rightly - as shortcomings inthe standard of care which do not amount tonegligence as that term is understood by the courts.As <strong>things</strong> now stand, complainants in suchcircumstances have no means of pursing their case14 March 2005 • <strong>Making</strong> <strong>things</strong> <strong>better</strong>? A <strong>report</strong> on reform of the NHS complaints procedure in England •

except through the courts. Their case will probablyfail; so that they will be left with an unremediedgrievance, which on some occasions may bejustified, and legal costs to pay as well. In thisrespect the NHS treats complainants worse thaneither central or local government. Both central andlocal government are willing, if they consider acomplaint justified, even if there is no legal liability,not only to give financial compensation for anyascertainable loss due to their failings, but also tomake payment for distress-including any distressoccasioned by difficulty in having the complaintaccepted.'76. The issue was again raised in ourAnnual Report for 2003-04:'It is … important that injustice is fully andappropriately remedied. Most complainants want tounderstand what went wrong and to receive anapology for the distress caused. The concept offinancial redress has gained ground in central andlocal government, but there is a marked reluctanceto accept it in the NHS. It is gratifying to note,therefore, that there are several examples of trustsagreeing to offer a financial remedy to complainantsas recompense for the severe difficulties they hadexperienced in trying to make their complaints. Forexample, a trust which had consistently failed to dealwith a request for an independent review agreed toour recommendation that the complainant shouldreceive an ex gratia payment in recognition of theinconvenience he had suffered. We aim to see theNHS aligning itself with other parts of the publicsector in this regard and we will continue to promotediscussion within the NHS about this significantissue for complainants.'Limited scope of the proposedNHS redress scheme77. None of the recent documentsabout the reform of the complaintsprocedure says how, if at all, it is plannedto relate to the NHS redress schemeproposed in <strong>Making</strong> amends.78. The NHS redress scheme, asdescribed in <strong>Making</strong> amends, would belimited to cases where there were seriousshortcomings in the standards of care andwhere the adverse outcome is not theresult of natural progress of a disease.But there are situations where significant,but perhaps not in themselves serious,lapses in standards of care can havedetrimental consequences which arehighly significant for the patient.79. The proposed redress schemerightly emphasises the responsibility ofthe NHS to deliver a package of care andremedial treatment by way of redress.But such NHS care and treatment, ifrequired, should be provided in anyevent. There are also a number ofsituations where the NHS is at fault butno such remedial care and treatment isneeded or possible and where,nevertheless, natural justice suggeststhat financial redress would beappropriate. That includes the mostserious cases where the patient dies, andsituations where the patient incurssignificant unnecessary costs because of anon-clinical failing. The current proposalsare too narrow to accommodate thesesituations.Lack of clarity in current system80. It is unclear what is intended to bedone about financial redress under thenew NHS complaints procedure. The2003 Act 3 says regulations may includeprovision for recommendations about acomplaint and the action to be taken as aresult. However, the regulations referonly to a 'response' to the complaint andsay nothing about any recommendationsor action at local resolution 4 . Nor is theguidance significantly more helpful,saying only that 'An outcome, orexplanation of planned action, should beincluded where the investigation findsthat something could/should have beendone differently, or if there is anything tobe done as a result of the complaint' 5 andthat 'it is good practice for replies to beas conciliatory as possible, includingappropriate apologies' 6 .81. The Healthcare Commission'sprocedures allow an investigation <strong>report</strong>to explore 'any options for resolution'. Itwill include any recommendations forimproving services or actions to rectifythe situation. The procedures also statethat panels will make two sets ofrecommendations when called for: onerelating to redress for the individual andthe other relating to improvements toservices. However, their leaflet forcomplainants says that they cannot awardcompensation: and the Commission saythat they have had legal advice to thateffect.82. It cannot be acceptable that thosewho have had their complaints upheldlocally or by the Healthcare Commissioncan receive redress only by complainingto the Ombudsman's Office. There needs3 Section 115(2)(h) and (i)4 (13) 5 (3.55) 6 (3.54)• <strong>Making</strong> <strong>things</strong> <strong>better</strong>? A <strong>report</strong> on reform of the NHS complaints procedure in England • March 2005 15

to be provision for a full range ofremedies at all levels of the complaintssystem, including explanations, apologies,specific actions or treatment, and, whereappropriate, financial compensation.Problems withimplementationDelay83. It has taken more than three yearsfrom the evaluation of the previousprocedure, which indicated majorproblems, to the first changes beingmade. The changes are still far fromcomplete.84. The pattern in moving towards anew procedure seems to have been oneof 'slippage and scramble'. The slippage isexemplified both by the time between theend of the listening exercise in October2001 and the issue of <strong>Making</strong> <strong>things</strong> rightover 18 months later in April 2003, andby the delay from intended fullimplementation in April 2004 to partialimplementation at the end of July 2004.More changes are promised in 2005. Thescramble is exemplified by the six weeklistening exercise in 2001 (rather than theusual three month consultation period)and the rushed finalisation of regulationsfor the Healthcare Commission's new rolein July 2004. Such a pattern of longperiods of comparative inactivity,interspersed with much shorter periods offrantic activity to unrealistic deadlines, isnot conducive to well-planned andthought-through change.Lack of preparedness andconfusion85. The result of the scrambles forchange was often confusion. Theimplementation of the 2004 regulationsand the transfer of responsibility for thesecond stage of the procedure to theHealthcare Commission exemplify this.The Healthcare Commission formallycame into existence in April 2004,although it had operated in shadow formfor some time before that. Its complaintshandling role was entirely new. At onepoint it had been hoped it could take oncomplaints from April 2004. Howeverconsultation on new draft regulations didnot begin until December 2003 and thisdelayed their planned implementationuntil 1 June 2004. The original draftregulations included detailed changesrelating to local resolution as well asdefining the Healthcare Commission's newrole. In March 2004 we raised concernsthat it would be difficult, if not impossible,for the Healthcare Commission to deliveran effective complaints handling processfrom 1 June 2004 and that this riskedbringing the new arrangements intodisrepute from the outset.86. The Department of Health gavelittle extra time to the HealthcareCommission to prepare for their new role,even though major changes to localresolution were postponed to 2005. ByMay 2004 it had been decided tointroduce the changes affecting theHealthcare Commission on 1 July. In factthe relevant regulations were not laiduntil 9 July and came into force on 30July.87. The rushed introduction, andconsequent lack of preparedness,impacted on both complainants and thosetrying to operate the procedure at alllevels. Although the delay in theimplementation of the original plansfurther weakened the effectiveness of theold system, this difficulty needed to bebalanced with the confusion surroundinga rushed implementation. Implementingregulations three weeks after they werelaid in Parliament gave inadequate timefor the public, NHS staff, advisers andvoluntary agencies to understand themand use them effectively. Guidance onthe application of the regulations for NHSbodies other than the HealthcareCommission was not issued until 19August, nearly three weeks after theregulations came into force.88. Given that public confidence in thesystem was already low, as shown by theevaluation <strong>report</strong> published in 2001, weexpressed our concern at the time that abad start to the new system was likely tocreate a further loss in public confidencewhich would be difficult to overcome.89. The Healthcare Commission had tobuild up their capacity to handle thesecond stage from scratch: an enormoustask. By May 2004 they had developedtheir communications strategy, had filled41 of the 70 posts they forecast theyneeded to handle complaints, and wererecruiting lay people to sit onindependent panels. They had beentesting an IT system. Despite thoseachievements there was much to do. Forexample:16 March 2005 • <strong>Making</strong> <strong>things</strong> <strong>better</strong>? A <strong>report</strong> on reform of the NHS complaints procedure in England •

they were not able to issueinformation on how they wouldoperate the second stage until July,and there was subsequent furtherreview after that;by May 2004 they had not developeda policy on access to expert advice(an important area, which had beena difficulty with the previousarrangements).90. The Healthcare Commission saythe IT system was fully operational by thelaunch of their complaints role and thatthey have been able to obtain expertadvice for the cases they haveconsidered. However they have receivedsignificantly more complaints thanoriginally forecast. The overall effect forcomplainants has been a severe delay inhaving their complaints addressed. Wehave been in active dialogue with theHealthcare Commission and we areassured that they now have action inhand to address the backlog ofcomplaints.Transitional arrangements91. Transitional arrangements (forcomplaints part way through the oldprocedure) have also suffered in thescramble to introduce the new procedure.The 2004 regulations say that, wherelocal resolution has already beencompleted and the complainant hasrequested an independent review underthe old procedures, 'the independentreview panel must be established inaccordance with the former complaintsprovisions, conduct its investigation andmake a <strong>report</strong> in accordance with thoseprovisions.' This takes no account of thefact that under the old procedureconveners rejected a significantproportion of requests for independentreview. Taken literally the regulationsappear to suggest that a panel should beheld in every case where the complainantrequests it.92. There is evidence that in practicethere was considerable uncertainty aboutwhat could or should happen whencomplainants expressed dissatisfactionwith the outcome of local resolution inJune/July 2004, when there wasconfusion across the health service aboutwhen the new arrangements were to beintroduced. The Department of Healthclarified that, strictly, anyone who hadmade a panel request locally before 30July 2004 should be allowed to proceedby that route if they wished. However,there also seems have been anunderstanding by the HealthcareCommission that the second stage forsuch complaints could be handled bythem, from earlier in the summer. SomeNHS bodies were referring requests forpanels to the Healthcare Commissionduring July. This may have been apragmatic approach, as local systems forarranging independent reviews werewinding down, but given the confusionabout what approach should be taken andthe lack of publicity around the transitionand new arrangements, complainantswere unable to make an informed choice.We have seen a number of cases wherecomplainants were given inaccurateinformation about the options forprogressing their complaints - no doubt ingood faith, by conveners or Trust staffwho were unaware of the most recentchanges to the proposed arrangements ortimetable. It is essential that lessons arelearned from this before new regulationsare introduced in 2005.Our commitment to collaborationand comment93. Throughout the development ofpolicy and regulations on complainthandling in the NHS we have been indialogue with the Department of Health,either directly with officials or in formalresponses to consultations. There havebeen many <strong>things</strong> to welcome, includingthe stated aims of making the systemmore accessible, responsive, independentand <strong>better</strong> linked to improving services.However, we have clearly expressed ourconcerns to the Department and indeedto the Public Administration SelectCommittee throughout this period. TheDepartment's intention to issue furtherregulations in 2005, taking account of theShipman and other Inquiries, presents afresh opportunity to reflect on theshortcomings that still exist and whatmust be done to address them.• <strong>Making</strong> <strong>things</strong> <strong>better</strong>? A <strong>report</strong> on reform of the NHS complaints procedure in England • March 2005 17

Chapter 3Key elements of a new system94. It is only right that, if we are toexpress such significant concerns aboutpresent system, we should also makeclear what we believe needs to be done.The essential elements in the new systemshould be those that ensure:coherent and comprehensivecoverage;customer focus, accessibility,flexibility and transparency;a quality service;leadership, culture andgovernance;the provision of just remedies;improvements in service as aresult of learning fromcomplaints.To be effective such newarrangements must be introduced ina planned and project managed way.95. It is not for us to set out howthese outcomes should be achieved, thatis a matter for the Department of Health,working with others such as theHealthcare Commission and local NHSbodies. We would certainly want to workwith the Department to share ourknowledge and learning and expand theprinciples which we propose mustunderpin the system.Coherent and comprehensivecoverage96. So that complainants can complaineasily about a single provider, two ormore NHS providers, or organisationswhich provide social care as well ashealth care, there must be a consistentapproach to the handling of complaintsacross all providers of NHS services,irrespective of where those services aredelivered, including primary care, NHSFoundation Trusts and independentproviders of NHS services, as well as insocial care. But that is not enough. Thereneeds also to be a clear commitment thatall these organisations will collaborate toaddress complaints in a joined up wayand arrangements must be built into thesystem to achieve this.Customer focus, accessibility,flexibility and transparency97. All users of health and social careservices should know how to complainand access to the complaints processmust be equally available to all groups inour community. Complainants need tofeel confident that a properly madecomplaint will not have an adverse effecton their future relationships with theservice providers, particularly where s/heis their GP. Complainants who do not wishto complain direct to family healthpractitioners, should be able to complainto PCTs. Complainants must know howthey can pursue their complaint wherethey are dissatisfied with the resultachieved locally, or at the HealthcareCommission. The new approach should bebased on listening to complainants andoffering support and advocacy toenable them to pursue their concerns inthe best possible way.98. The system should allow for aflexible approach to complaintresolution tailored to differentcomplaints and complainants' needs.It should encourage skilled staff to adaptthe investigation and outcome to theirvaried circumstances. Key issues raisedby the complainant must be addressed inany response and explanations givenorally or in writing in terms which thecomplainant can understand. Responsesshould be timely, and any targets mustbe carefully constructed to avoidintroducing perverse incentives.Targets should cover both timescales andthe quality of the service and outcome.Quality service99. Those working throughout the NHSshould be open about mistakes andfailures by individuals or systems.Acknowledging and addressing mistakesshould be encouraged not punished.Complainants and staff need to feelconfident that they will be treated fairly,given an opportunity to contribute to the18 March 2005 • <strong>Making</strong> <strong>things</strong> <strong>better</strong>? A <strong>report</strong> on reform of the NHS complaints procedure in England •

process and provided with support andfeedback.100. The initial investigation must beadequate to enable a full, carefullyconsidered response to thecomplainant, and opportunities for earlyresolution should be taken.Investigations must be evidence-basedand sufficiently rigorous to be used asan initial investigation for subsequentparts of the complaints system and theredress scheme, or in deciding whetherthe body needs to consider other action inthe interests of patient safety orimproving performance. Those handlingthe complaint need to have the authorityand skills to decide how detailed aninvestigation is required for eachcomplaint and to carry out theinvestigation: in some cases this willinvolve seeing records, interviewing staffand taking clinical advice. Arrangementsto obtain appropriate advice are required,as is access to mediation, whereappropriate.101. Delivery of a new high quality localcomplaints service will require a newfocus on the training and competenceof complaints staff, for an enhancedrole and responsibility in complaintsinvestigation. Managers and front-linestaff should also be well-motivated andtrained in customer service and complainthandling.Leadership, culture andgovernance102. This will involve the Boards andChief Executives of NHS bodies creating aculture of openness and learning.There should be clear standards ofbehaviour set and followed by theleadership of each local organisation, andthe monitoring of performance oncomplaints by managers and by theBoard. Managers need to ensure thatarrangements for complaint handling arewell connected with clinicalgovernance and quality improvementactivity.where appropriate, financialcompensation. Redress should bedesigned to put the complainant back inthe position they would have been in hadthe service failure or maladministrationnot occurred; or, if that is not possible, tocompensate them appropriately.Improvements in service104. Recommendations arising fromcomplaints should lead to practicalimprovements in service, and progresson implementation and effectivenessshould be monitored. As well as<strong>report</strong>ing to the Board, NHS bodies needto build in systems locally to feed backlearning from complaints todirectorates/teams. Inquiries havehighlighted the need for systems to be inplace to ensure that those (fortunatelyrare) clinicians who repeatedly harm orpose a risk to patients are identified,wherever they are working.105. The Healthcare Commission is in astrong position, in collaboration withothers, to identify and drive forwardlearning from complaints nationally.106. And our Office is committed tomaking an active contribution to theimprovement of services from theevidence we gather.Implementation107. Implementation needs to beplanned in more detail and withsufficient time for NHS and otherorganisations to be informed about whatis expected of them. Patients,complainants and those supporting themneed to be given clear information aboutthe changes and the implications forthem, well in advance of the changetaking effect. Detailed guidance should bein place well before implementation ofnew procedures, together with training forstaff. Transitional arrangements shouldbe well thought through and clearlypublicised.Just remedies103. All levels of the complaints systemshould include provision for a full range ofremedies for justified complaints,including explanations, apologies, specificactions or treatment for the patient,changes to prevent recurrence and,• <strong>Making</strong> <strong>things</strong> <strong>better</strong>? A <strong>report</strong> on reform of the NHS complaints procedure in England • March 2005 19

Chapter 4Recommendations108. The outcomes we seek to achievefrom the complaints system are clear.The pause in the implementation of arevised complaints process, prompted, inparticular, by the Shipman Inquiry,presents the opportunity for theDepartment of Health to take a lead andensure that these outcomes are finallysecured for complainants in a new healthand social care complaints system.109. The history of proposals forreform, described in Chapter 1 of this<strong>report</strong>, shows that there is remarkableconsensus about what an effectivecomplaints system should look like andwhat it needs to deliver. The Departmentof Health's publication, <strong>Making</strong> <strong>things</strong>right, echoed the recommendations thatemerged from the 'listening exercise' andthe Bristol Inquiry, and has beenreinforced by the recommendations of theAyling, Neale and Shipman Inquiries. Wedo not dissent from that vision - indeedwe have positively welcomed it.110. The challenge, therefore, is not indetermining the vision of an effectivecomplaints system, but in avoiding themistakes of the past and turning theaspirations of <strong>Making</strong> <strong>things</strong> right into areality for patients and their families andNHS staff. Our recommendations areframed to that end.111. A number of bodies need to worktogether to ensure that we now createthe modern, responsive, patient-focusedsystem to which we all aspire. Inparticular we see clear roles for theDepartment of Health, the HealthcareCommission and all providers of NHShealthcare.Setting the national framework112. The Department should set theframework and principles for the newcomplaints system. The core standardsset by the Department of Health for allNHS bodies should set out the qualitystandards to which they should adhere.The standards should focus on outcomesand approach, not process.113. We recommend that theDepartment of Health set core standardsfor the complaints system. This willensure that the key outcomes, clearlydescribed in our principles, are secured.The outcomes we seek are:a simple, consistent approach acrossall health and appropriate social careproviders, so that a complainant canuse the same approach whencomplaining about any NHS care andis enabled to pursue a complaintwhich crosses organisationalboundaries easily and to similartimescales;a complaints service accessible to allmembers of our diverse community,tailored to the needs of thecomplainant and the particularcomplaint and providing support forthose who need it to pursue theircomplaint. Those handling thecomplaint should understand whatthe complaint is about and what thecomplainant would like to happen asa result of the complaint. Thecomplainant should be clear how andto what timescales his/her complaintwill be dealt with and be kept intouch with progress;fit for purpose, thorough, rigorousand evidence based investigations ofcomplaints with clear, well explaineddecisions. An approach which is fair tocomplainants and NHS staff and earnstheir confidence. Complaints handledby motivated, competent staff withthe authority to secure the activeparticipation of all relevant staff;a culture of openness and nondefensivenesswhich welcomescomplaints as a way of remedyingmistakes and improving service.Leadership by senior managers wholive out this commitment and have inplace systems to incorporate thislearning through clinical governanceand quality improvement;provision for a full range of remediesfor justified complaints at all levels ofthe complaints system to includeexplanations, apologies, specificactions or treatment and, whereappropriate, financial compensationfor loss, distress or inconvenience.20 March 2005 • <strong>Making</strong> <strong>things</strong> <strong>better</strong>? A <strong>report</strong> on reform of the NHS complaints procedure in England •

This would need to include provisionfor the Healthcare Commission torecommend financial redress.Redress should be designed to putthe complainant back in the positionthey would have been in had theservice failure or maladministrationnot occurred; or, if that is notpossible, to compensate themappropriately;recommendations arising from theinvestigation of complaints should beimplemented to ensure the mistakesdo not recur. Systemic faults shouldbe identified and addressed both inrelation to individuals, organisationsand across organisations to bringabout continuous improvements inpatient service;114. We recommend that theDepartment of Health require thesestandards to be met by all providers ofNHS care irrespective of whether thatcare is provided in an NHS Trust hospital,an NHS Foundation Trust, by independentcontractors to the NHS such as familydoctors and dentists, by contractors inthe private sector or by any other serviceproviders.115. We recommend that theDepartment of Health take the lead inensuring that the core standards andcommon approach to complaints areadopted across health and social care byco-ordinating discussions involving all theinterested parties: specifically theDepartment for Education and Skills, theHealthcare Commission, the Commissionfor Social Care Inspection, the LocalGovernment Ombudsmen and the HealthService Ombudsman.116. We recommend that theDepartment of Health ensure thatpatients are able to complain direct totheir Primary Care Trust about primarycare providers such as their GP or dentistand be supported by the PCT in pursuingthe complaint.The Healthcare Commission117. The Healthcare Commission playstwo distinct roles in delivering thecomplaints system: the provider of theindependent stage of the process and theRegulator and Inspector of healthcare.118. As the deliverer of theindependent second stage werecommend that the HealthcareCommission should ensure that both thelocal resolution stage and their owndelivery meet the core standards setdown by the Department of Health. Indoing so they should review their owncomplaints process.119. As Regulator and Inspector, werecommend that the HealthcareCommission:review their assessment proposalsfor complaint handling in the light ofthe adoption of a new core standardto ensure that local NHS bodies takereal responsibility for handling theirown complaints;develop best practice guidance incomplaint handling as adevelopmental standard for NHSproviders;capture and share learning fromcomplaints and best practice acrossthe health service.Delivery by all NHS providers120. NHS bodies will be at the forefrontof delivering the core standards of thenew NHS complaints system. To achievethis we recommend that each NHS body(including PCTs):develops and documents its own fitfor purpose local procedure;ensures that its complaints system isaccessible to all members of theirlocal communities;provides appropriate support toenable patients or theirrepresentatives to make a complainteffectively;ensures that it has sufficientcompetent and influential staff toinvestigate and deal with complaintseffectively;provides training in handlingcomplaints to all staff to ensure thepatient receives a quality servicewherever they make their complaint;provides clear leadership so thatcomplaints are welcomed andlearning is secured;works collaboratively with allmembers of their local health andsocial care economy to enable acomplainant to make a singlecomplaint about cross organisationalissues.• <strong>Making</strong> <strong>things</strong> <strong>better</strong>? A <strong>report</strong> on reform of the NHS complaints procedure in England • March 2005 21

Introducing the new system121. The new NHS complaints systemwhich will follow from these corestandards will only work in practice if it isimplemented effectively.122. We recommend that theDepartment of Health draw up andpublish a clear project plan for theintroduction of the new system which:provides comprehensive publicity forthe new scheme for complainantsand NHS staff;sets clear timescales for the deliveryof each step of the implementationprocess;provides for the development anddissemination of clear guidance tosupport the new system;provides for the necessary trainingof staff.22 March 2005 • <strong>Making</strong> <strong>things</strong> <strong>better</strong>? A <strong>report</strong> on reform of the NHS complaints procedure in England •

Annex AChronology of key complaints handlingevents - following the commissioningof the 1999 evaluation1. An independent evaluation of the existing NHS complaints procedure wascommissioned by the Department of Health in 1999. Between 1999 and publication ofthe evaluation, in September 2001, a number of other NHS developments (detailedbelow) took place.2. The NHS Plan: a plan for investment, a plan for reform was issued in July 2000detailing the Government's plans for investment, reform and 'a health service designedaround the patient'. The Plan said that patient advocates would be set up in everyhospital, along with patients' forums, to help services become more patient centred.(With the independent evaluation of complaints procedures continuing during 1999-2000, the NHS Plan committed Ministers to acting on the results of the evaluation.)3. The <strong>report</strong> of the inquiry into children's heart surgery at the Bristol RoyalInfirmary was issued in June 2001. That recommended in chapter 23:' 36. Complaints should be dealt with swiftly and thoroughly, keeping the patient and carer informed. Thereshould be a strong independent element, not part of the trust's management or board, in any body consideringserious complaints which require formal investigation. An independent advocacy service should be set up.'37. There should be an urgent review of the system for providing compensation to those who suffer harmarising out of medical care. The review should be concerned with the introduction of an administrative systemfor responding promptly to patients' needs in place of the current system of clinical negligence and should takeaccount of other administrative systems for meeting the financial needs of the public. …'55. There also needs to be an open and easily accessible system for the patient or carer to [complain].Currently, the complaints system operated in trusts is widely acknowledged to be cumbersome andbureaucratic. Despite efforts to reform it in the mid-1990s the system has too many layers and lacks a sufficientelement of independence. … The decision to establish Patient Advocacy and Liaison Services within trusts is afirst and important component of a broader system to identify and respond to problems as early as possible. …'57. Patients, for the most part … do not want to complain. Often they feel forced to because their concern hasbeen ignored or not properly addressed. The message is clear: improve communication generally, be more openwith patients, and complaints will go down. For the complaints which remain, the system in place must be open,minimally bureaucratic, receptive, and appropriately independent.'Parallel policy developments on patient/public involvement inhealthcare and clinical negligence4. In July 2001 the Secretary of State for Health announced plans to produce,early in 2002, a White Paper setting out reforms to the system for dealing with clinicalnegligence claims.5. In September 2001 the Department of Health issued a discussion documentoutlining proposals for involving patients and the public in healthcare. Proposeddevelopments included:introducing Patient Advocacy and Liaison Services (PALS) - providinginformation and on the spot help - in every Trust;providing locally based Independent Complaints Advocacy Services (ICAS) inEngland, operating to core standards;• <strong>Making</strong> <strong>things</strong> <strong>better</strong>? A <strong>report</strong> on reform of the NHS complaints procedure in England • March 2005 23

introducing Patients' Forums in every Trust, to bring the patient's perspective toTrust management decision-making. These Forums would also be able to elect oneof their members to sit on the Trust Board as a Non-Executive Director;setting up a ‘Voice’ in every Strategic Health Authority area, a professional groupacting as a local resource for helping communities;setting up a new national patients' body to set standards and provide training, andto monitor the new arrangements.6. Details of the final arrangements were published in November 2001. PALS werenow to be Patient Advice (rather than Advocacy) and Liaison Services. Rather than boththe local 'voice' and a national patients' body, a national Commission for Patient andPublic Involvement in Health (CPPIH) was to be established with local networks andcommunity outreach workers. It was envisaged that PALS would be available in all Trustsfrom April 2002, CPPIH and Patients Forums would be established at the beginning of2003, and Community Health Councils would cease to operate in April 2003. (Provisionfor these changes was subsequently made in the National Health Service and HealthCare Professionals Act 2002.)Progress on complaints systems7. In September 2001 the Department of Health published the evaluation of theold procedure (commissioned in 1999) as two documents, an evaluation <strong>report</strong>, NHScomplaints procedure: national evaluation, and Reforming the NHS complaints procedure- a listening document. The evaluation <strong>report</strong> found a high level of dissatisfactionamongst complainants about the operation of both the local resolution and independentreview stages. Most found both stages stressful, unfair and biased and they weredissatisfied with the outcome. Amongst Community Health Councils (which often advisedand supported complainants) only a small minority thought the systems of localresolution and independent review worked well.8. The summary of the evaluation <strong>report</strong> said (paragraphs 6 and 10):'The main causes of dissatisfaction among complainants are operational failures: unhelpful, aggressive orarrogant attitudes of staff, poor communication and a lack of information and support. The most importantstructural failure is the perceived lack of independence in the convening decision and in the review processgenerally'.'Among those operating the procedure there is a broad consensus about the elements which need to beimproved:There is a wide measure of agreement that independent review should be more independent and should beseen to be so. Irrespective of the impartiality of a convenor, it is accepted that complainants do notperceive the current procedure to be independent.There is a perception that current procedures, particularly those involving independent review, are timeconsumingand costly to operate.Performance targets relating to the convening decision, the appointment of panel members and drafting a<strong>report</strong> of a panel are all perceived to be difficult to meet.There is agreement that procedures need to be improved to ensure that services improve following acomplaint…'9. The <strong>report</strong> went on to identify a range of policy implications and made 27recommendations for change. These recommendations were summarised in the listeningdocument as follows:'a uniform national procedure, applied equally to primary care and hospital services, and with clear andconsistent time limits;dissemination of good practice, and more use of conciliation to achieve results swiftly and effectively;clear guidance to clarify how the complaints procedure should be applied, and standard targetsnationally for managing the performance of staff handling complaints;standardised administrative and financial support, and standard expenses and retainers for chairs and laymembers;clear lines of responsibility for making sure the complaints system is run properly, with Chairs and ChiefExecutives answerable to the Department of Health for their performance in this area.24 March 2005 • <strong>Making</strong> <strong>things</strong> <strong>better</strong>? A <strong>report</strong> on reform of the NHS complaints procedure in England •

Trust Boards responsible for ensuring this work is funded properly and staff are trained appropriately tohandle complaints.Trust Boards also responsible for ensuring their clinical governance framework reflects complaints workas core business.A system of quarterly <strong>report</strong>ing by complaints staff to the Trust Board, summarising the causes and trendsunderlying complaints, and making recommendations for action. These <strong>report</strong>s to be copied to relevantpatient representative organisations, and the Board to be responsible for implementing recommendations.As this would apply equally in primary care services, support from Trust Boards and PCGs [PrimaryCare groups - the predecessors of the current Primary Care Trusts - PCTs] would be needed forindividual practices in managing the system, with a named individual responsible for handling practicecomplaints.'10. The <strong>report</strong> also recommended the following reforms for the second levelIndependent Review stage:'consistently applied criteria for convening Independent Review Panels.Regional NHS bodies, or a new independent national complaints authority to be responsible for holdingthe panels to account and managing their performance to minimum standards.Possible wider powers for panels to summon witnesses and hear evidence, supported by an up to datedatabase of clinical assessors, and also the potential to handle some cases on a "fast-track".Wide circulation of the Panel's final <strong>report</strong>s to relevant patient representative bodies and the Commissionfor Health Improvement, with the Trust Board being responsible for implementing any recommendationsfor remedial action.new options for how Panels should be convened: by the Health Authority, neighbouring Trusts/HealthAuthorities, or introducing a separate regional or sub-regional panel.'11. The listening document said that the Department of Health believed that to beeffective and to work for the people it affects, the NHS complaints procedure needed to:be easy for patients to access;resolve complaints quickly;be an open process, which is independent where appropriate;be responsive to the outcome of complaints so effective improvements are made asa result.12. Comments on the evaluation <strong>report</strong>'s recommendations and certain key questionswere sought by 12 October 2001. As well as seeking written responses, a series ofregional events was held across the country to gauge views from NHS staff and patientgroups and research was carried out with hard-to-reach groups.13. When in January 2002 the Department of Health published its formal responseto the Bristol Royal Infirmary Inquiry, it said (para 13) that its programme of reformincluded 'a reformed NHS complaints procedure by December 2002'. However it was notuntil 28 March 2003 that the Department published, NHS complaints reform - making<strong>things</strong> right, outlining the Government's plans for improving the complaints procedure.NHS Complaints reform - making <strong>things</strong> right - March 200314. This Department of Health publication described the vision of a new complaintsprocedure as being:'open and easy to access - by being flexible about the ways people could complain and with effectivesupport for people wishing to do so,fair and independent - with the emphasis on early resolution so minimising the strain and distress for allthose involved,responsive - providing appropriate and proportionate response and redress,learning and developing - ensuring complaints are viewed as a positive opportunity to learn frompatients' views to drive continual improvement in services.'15. This would involve:changing attitudes and forming positive relationships, through <strong>better</strong> access to• <strong>Making</strong> <strong>things</strong> <strong>better</strong>? A <strong>report</strong> on reform of the NHS complaints procedure in England • March 2005 25

information; developing customer awareness; improving communication skills; andthrough the demonstrable use of patient feedback to improve services;acting on concerns and getting the response right. This would involve PatientAdvice and Liaison Services; modern matrons (who would make sure standardswere met); promoting good practice in local resolution (e.g. by producing a goodpractice toolkit). Access to the complaints procedure would also need to be madeeasier, for example by enabling complaints to be made direct to a Primary CareTrust (PCT) where there are concerns about a Family Health Service practitioner;providing remedies, responses and support which people want. This would involvetailoring responses, delivering explanations and apologies as well as practicalmeasures, quickly and directly and broadening the options for resolving complaints- including promoting the use of methods of alternative dispute resolution such asconciliation. It would also include reviewing existing guidance in relation to financialredress and the relationship between the systems for dealing with complaints andclinical negligence claims; and providing easy access to ICAS (ICAS performancestandards would be set by CPPIH, and commissioned by Patients' Forums);introducing 'Truly Independent Review'. Responsibility for this stage would beplaced with the new Commission for Healthcare Audit and Inspection (eventuallyknown as the Healthcare Commission). This would provide a direct link into thequality improvement process and enable robust assessment of cases and moreoptions, as cases could be investigated in detail as an individual complaint orconsidered as part of an inspection or enquiry about failures in an organisation.This would also provide harmonisation with social care complaints, as theequivalent body for social care - the Commission for Social Care Inspection (CSCI)- would have similar powers for social services complaints and the twoorganisations would be under a duty to co-operate with each other;integrating complaints into wider systems, for example, individuals at Board levelwould be required to take overall responsibility for the investigation of and learningfrom adverse events, complaints and negligence claims. Quality and the patient'sexperience would also be improved by promoting the use of complaint materialwithin wider initiatives such as clinical governance, a new adverse incident<strong>report</strong>ing system, reform to professional regulation and development, and riskmanagement. In addition, the skills and competencies needed to deal withcomplaints effectively would need to have a high profile within education, trainingand professional development.16. Because of the need for primary legislation to establish CHAI and CSCI, thosebodies could not be established before April 2004.Reforming the approach to clinical negligence in the NHS - June 200317. In the interim, in June 2003, the Department of Health published a <strong>report</strong> bythe Chief Medical Officer - <strong>Making</strong> amends. A consultation paper setting out proposalsfor reforming the clinical negligence system. The <strong>report</strong> recognised that the system iscomplex, unfair, slow, costly in legal fees, and that it encourages defensiveness. It alsofound that patients were dissatisfied with the lack of explanations and apologies orreassurance that action has been taken to prevent repetition.18. This <strong>report</strong> proposed a new NHS-based system of redress for patients who havebeen harmed as a result of NHS hospital care. The system would be administered by abody 'building on the work' of the current NHS Litigation Authority (NHSLA). Paymentwould only be made if there were serious shortcomings in the standards of care, theharm could have been avoided or if the adverse outcome was not the result of thenatural progression of the illness.19. Initially this system of redress would be limited to payments to families ofneurological impaired babies, payments under £30,000 and those treated in hospital orcommunity health settings (e.g. not in primary care). Consideration would be given toextending it later. The new arrangements would have four main elements:investigating the incident;providing an explanation to the patient and action to prevent repetition;26 March 2005 • <strong>Making</strong> <strong>things</strong> <strong>better</strong>? A <strong>report</strong> on reform of the NHS complaints procedure in England •

developing and delivering a package of care;providing payment for pain and suffering, out of pocket expenses and care ortreatment which the NHS could not provide.20. Access to the scheme would be available following local investigation of theadverse event or complaint; investigation of a complaint by CHAI; delivery of arecommendation by the Health Service Ombudsman; or following the investigation of aclaim made directly by a patient or relatives to the NHS Litigation Authority.21. Other recommendations included:setting a new standard for after-event/complaint management by local NHSproviders with CHAI assessing compliance through its inspections;removing the current NHS complaint procedure rule requiring a complaint to behalted pending resolution of a claim (this was seen as providing a potential benefitin reducing the number of people who pursue litigation and reducing thedissatisfaction complainants and claimants currently feel);providing communication training for NHS staff within the context of complainthandling;introducing a duty of candour, together with exemption from disciplinary actionwhen <strong>report</strong>ing incidents, with a view to improving patient safety.Response of the Health Service Ombudsman to <strong>Making</strong> amends22. In October 2003 the Ombudsman wrote to the Chief Medical Officer commentingon the paper and welcoming the review. Issues raised included the lack of clarity in theinterface between the proposed scheme and the work of the Health ServiceOmbudsman's Office, and the narrow approach taken on the question of financialredress. (When the Ombudsman upholds a complaint about the NHS, an appropriateremedy is recommended, which may include an element of financial redress. If theoperation of the scheme fell outside the Office's jurisdiction, complainants wouldpotentially lose a right of access to an independent Ombudsman.) <strong>Making</strong> amends onlyrecognised harm as a result of sub-standard care as eligible for possible financialredress, whilst <strong>Making</strong> <strong>things</strong> right referred only to apologies, explanations and practicalmeasures. The Ombudsman expressed the view that the NHS needed to considerredress in a much wider sense if it wished to make amends for poor service and servicefailures as well as addressing clinical negligence.Health and Social Care (Community Health and Standards) Act 200323. This Act received Royal assent in November 2003 and contained several elementsrelevant to reform of the NHS complaints procedure, most notably:providing for NHS Foundation Trusts to be established, and for an IndependentRegulator (now known as Monitor) to be established for them;enabling the Commission for Healthcare Audit and Inspection (CHAI) and theCommission for Social Care Inspection (CSCI) to be set up, along with a duty forthem to work together when appropriate;abolishing the National Care Standards Commission (only set up in April 2002) andthe Commission for Health Improvement (CHI);making some provision on complaints about the NHS, e.g. giving the Secretary ofState power to make relevant regulations and to give CHAI and independent panelsthe powers to consider them:making similar provision about complaints about social services and CSCI;imposing a duty on NHS bodies to have arrangements for monitoring and improvingthe quality of health care;providing for the Health Service Ombudsman to consider complaints about thehandling of complaints by any person or body under the regulations.Consultation on new draft regulations and guidance on the NHScomplaints procedure24. Draft regulations went out for consultation in December 2003, with responsesdue by March 2004, with a view to introduction of the regulations on 1 June 2004. The• <strong>Making</strong> <strong>things</strong> <strong>better</strong>? A <strong>report</strong> on reform of the NHS complaints procedure in England • March 2005 27

Healthcare Commission also consulted on their proposals for the independent stage ofthe procedure. (The Health Service Ombudsman responded to both consultations on 30March 2004, copying letters to each of the other consulting organisations.)25. The Ombudsman's main concern about the regulations was that the timescale foreffective introduction of the arrangements was too tight. As expected, CHAI was beinggiven responsibility for the second stage of the NHS complaints procedure, and theOmbudsman expressed concern that it would be difficult, if not impossible, for them todeliver an effective complaints handling process from 1 June 2004. The Ombudsmansuggested a three way discussion with the Department and CHAI.26. The Ombudsman also had a range of other concerns. These included concern thatfocusing on process and timescales might provide a perverse incentive in terms ofquality of response and that unrealistic timescales might jeopardise the credibility of theprocedure. Other issues included the failure to include any specific mention of redressand the degree of ambiguity about the role of panels. The relevant Act and regulationsseemed to suggest CHAI could investigate or set up a panel, whereas CHAI seemed tobe proposing an investigation, followed by a panel if the complainant asked for one.27. The Ombudsman raised a number of similar issues with CHAI, including thepoints about timescales, panels and redress, as well as raising additional issues around:delivering secure mechanisms for obtaining clinical advice;considering the proposal that complainants could pursue a complaint whilst takinglegal action;ensuring sufficient patient focus;ensuring some of the detailed time targets were realistic.28. The Health Service Ombudsman was given another opportunity to comment onfurther revisions to the regulations and did so in May 2004 raising a number offurther points.29. During the consultation period the Public Administration Select Committee tookevidence on NHS complaints reform and associated matters (including <strong>Making</strong> amends)at a session on 29 January 2004. The Health Service Ombudsman also expressedconcerns about the proposals in a memorandum to the Committee, as did theConsumer's Association (CA) and Action against Medical Accidents (AvMA), from whomevidence was taken. The two bodies suggested that:an opportunity to address adverse events in a joined-up way had not been grasped(AvMA) and that the proposals did not represent a comprehensive framework ofpatient-focused redress (CA);the NHS should offer compensation in straightforward cases where an internalinvestigation has identified a clear case for this;PCTs should see all complaints about primary care in their area (rather than justreceiving retrospective <strong>report</strong>s) to enable them to manage clinical governance andprotect patient safety;bodies have a duty to implement recommendations made by CHAI investigations(AvMA) or to take further measures to ensure they are implemented (CA);the role of the panel in the independent stage should be clarified;the proposals do not adequately recognise the complexity of issues, particularly theincreasing diversity of different providers of NHS care and overlaps between theseproviders and between primary and secondary care.30. In giving evidence about the relationship between complaints and claims fornegligence the Chief Medical Officer said;'I think we … will have a single gateway. … Ministers have not yet … decided how they want to take forwardthe medical litigation proposals. The two systems must be very closely aligned. Whether they are completelyintegrated - I think there are arguments in a number of directions on that one …28 March 2005 • <strong>Making</strong> <strong>things</strong> <strong>better</strong>? A <strong>report</strong> on reform of the NHS complaints procedure in England •

… Many people who are seeking compensation through the courts will do so after they progress the complaintto a certain stage, and they will often do so partly because of the inherent nature of the complaint but partlybecause the complaint has been handled badly, they have become more aggrieved during the process ofhandling the complaint. So the improvement in the complaints system will have a direct bearing, I think, on theway that redress, compensation, litigation is handled. The second thing is, I think there is a distinction betweencomplaints which have to do with the diagnosis, treatment and care and complaints which have to do with theconvenience of services. … Finally I think there is the whole question of the threshold for offering compensationand indeed the fact that most surveys show that patients, on the whole, want an explanation, an apology and areassurance that what had been learned from the complaint will be used to benefit future patients.Compensation is not top of their list. …'31. When asked about arrangements for training to support complaints handling thethen Chief Nursing Officer said:'… A lot of the issues around complaints have their roots in not communicating well. So we are at the momentworking to look at the programme for training. We are working with higher education institutes to look at bothpre-registration medical and non-medical training to see whether we can improve the component ofcommunication training that goes into those programs. We are also working with the NHSU to look atintroducing a common orientation programme to the NHS; and part of that component on day one will include,although basic, work around communication skills. We are also doing some more segregated work. Forexample, we are running programmes with front of house staff - medical receptionists, porters, reception desks -to get them to improve their communication skills. Then, specifically around the management of complaints, wehave some pieces of work that are already on-going. For example, we are doing some work around developingnational specifications for training in complaints and investigations. That specifically will be targeted at thosefront-line staff dealing with that - complaints managers, PALS services. We also are beginning to put togethersome work around training seminars specifically for primary care trusts, wards and staff around managingcomplaints, and we are in the very last stages of putting together a good practice tool kit which is aroundsupporting improvements in local resolution. We have also had some other programmes going. For example,over the last three years we have put 40,000 ward team leaders - ward sisters, modern matrons, charge nurses -through leadership programmes; and a very specific component of that has been around communications skillsand also resolution of issues and also about how you should proactively seek comments from patients andusers.'Beginning to implement the changes32. On 1 April 2004 the Healthcare Commission became operational, having existedin shadow form for some time. On 9 July the NHS (Complaints) Regulations were laidbefore Parliament and came into force on 30 July 2004. Although the intention hadbeen to implement the Complaints Regulations in full from June 2004, Ministers decidedon a phased implementation following an approach from the Shipman Inquiry. TheInquiry's 5th <strong>report</strong> was likely to address complaints handling in some detail and wasdue to be published later in 2004. Reports from the Ayling and Neale Inquiries (aboutdoctors who had repeatedly failed to observe proper standards of care) were alsoexpected. Therefore, the local resolution stage of the complaints procedure remainedbroadly unchanged. The 2004 Regulations consolidated and rationalised the statutoryrequirements for local resolution by NHS bodies and introduced the reformedindependent review stage carried out by the Healthcare Commission. They do notrequire NHS Foundation Trusts to have a complaints procedure in line with the provisionregarding local resolution in the regulations, although the independent review stagedoes apply to them and they are in the Health Service Ombudsman's jurisdiction. TheDepartment intends to issue revised regulations in 2005.Further changes - abolition of the Commission for Patient and PublicInvolvement in Health (CPPIH)33. On 22 July 2004 the Secretary of State for Health announced the outcome of areview of the Department of Health's arm's length bodies. The aim was said to be tostreamline them, reduce bureaucracy and release resources to frontline NHS care.Among those to be abolished is the CPPIH. Patients' Forums will continue and theDepartment said that 'stronger, more efficient arrangements to provide administrativesupport and advice' to them would be set up. A clear quality framework for Forumactivities would be established and communicated to Forums. The best body to do thatwould be identified in discussion with the Healthcare Commission and stakeholders.• <strong>Making</strong> <strong>things</strong> <strong>better</strong>? A <strong>report</strong> on reform of the NHS complaints procedure in England • March 2005 29

Responsibility for appointing Forum members would move to the NHS AppointmentsCommission.Neale and Ayling Inquiry <strong>report</strong>s34. The inquiries into how the NHS handled allegations relating to the performanceand conduct of these two doctors <strong>report</strong>ed on 9 September 2004. Recommendationsfrom the Neale Inquiry included:Doctors should spend time observing the Patient Advocacy and Liaison Service (PALS) process and befamiliar with the process. …All PALS appointees should be of middle/senior grade. …Unified and centralised training should be provided for all PALS officers.Complaints handling should be aligned to quality management and patient services rather than claimsmanagement. …The head of the unit dealing with complaints should be an appropriately trained middle manager. …Complaints handling should be mandatory for all levels of clinical, nursing and administrative staff. …Complaints statistics should be included in the Profiles of Trusts and used by the Healthcare Commissionin routine audit procedures. …'35. The recommendations from the Ayling Inquiry included:providing accredited training for all PALS officers in dealing with sensitive andintimate concerns - Strategic Health Authorities (SHAs) should require confirmationfrom NHS Trusts of the completion of such training within the next 12 months;addressing the emerging issue of visibility and accessibility of PALS in primary caresettings by getting the Modernisation Agency to develop a model of best practice -if appropriate, patients' forums could monitor the effectiveness of service provisionagainst this model. The implementation of this model and associated performancemeasures should be a formal component of CHAI's reviews of PCTs;providing ICAS staff with the same training in handling concerns and complaints ofan intimate and sensitive nature as that recommended for PALS staff, with thisforming part of the service specification for ICAS. Satisfaction surveys should bebuilt into the work of ICAS on completion of their work with each complaint so thattheir performance can be routinely monitored and a cycle of continuousimprovement be established;requiring all NHS Trusts and health care organisations, such as deputising services,directly employing staff to make a formal declaration of any other concurrentemployment, not only for health and safety reasons but also to ensure a record iskept of other organisations with an interest in the individual's performance. Failureto make such a declaration should be a disciplinary matter. This requirementshould be appropriately adapted for PCTs to be kept informed of other professionalemployment undertaken by general practitioners (GPs);ensuring that copies of any written records regarding complaints and concernswhich name an individual practitioner are placed on that practitioner's personnelfile, to be kept for the length of their contract with that organisation. This shouldbe made known to the practitioner;ensuring that the regular <strong>report</strong>s on patient complaints and concerns, made to NHSTrust Boards and other corporate governance bodies, not only analyse trends insubject matter and clinical area but also indicate whether a named practitioner hasbeen the subject of previous complaints.Changing the social services complaints procedures36. In September 2004 the CSCI consulted on their proposals for the independentreview stage of the social services complaints procedures. That consultation said thatcapacity for joint reviews with the Healthcare Commission would be developed in 2005-2006. Two separate consultations by the Department for Education and Skills and theDepartment of Health respectively, on the children's and adults' parts of the socialservices complaints regulations, were issued in October 2004. The intention was tointroduce the new procedure in April 2005 (but it is now likely to be implemented laterin the year).30 March 2005 • <strong>Making</strong> <strong>things</strong> <strong>better</strong>? A <strong>report</strong> on reform of the NHS complaints procedure in England •

37. Both the Health Service Ombudsman and the Local Government Ombudsmen forEngland responded to the consultations. Both expressed concern about the complexityof the process, the lack of clarity for complainants and the lack of alignment betweenCSCI and the Healthcare Commission in relation to health and social care complaints.The fifth <strong>report</strong> of the Shipman Inquiry38. This <strong>report</strong>, Safeguarding patients: Lessons from the past - proposals for thefuture was published in December 2004. It considered the handling of complaintsagainst and the raising of concerns about GPs, General Medical Council procedures andits proposal for revalidation of doctors. The <strong>report</strong> proposed a significantly differentsystem for handling complaints about GPs. The recommendations included:extending the time limit for lodging a complaint to 12 months;ensuring all complaints about GPs are <strong>report</strong>ed to the PCT within two days ofreceipt and giving patients the option to lodge complaints directly with the PCT;ensuring a member of PCT staff conducts a triage (initial assessment) of allcomplaints to decide whether they are 'private grievances' or if they raise clinicalgovernance issues. Private grievances should be dealt with by the PCT staff (or theGP, if lodged there). Clinical governance complaints should be called in by the PCTif lodged with the GP, and all such complaints should receive a second triage by agroup of two or three senior people from the PCT. The aim of that would be todecide whether the PCT should arrange an investigation or whether the complaintshould be referred instead to some other body such as the police, the GeneralMedical Council or the National Clinical Assessment Authority (NCAA);setting up joint teams of investigators from across PCTs to investigate clinicalgovernance complaints. They should be properly trained in investigation. The aimof the investigation should be decide what happened and <strong>report</strong> to the PCT;ensuring that the group which conducted the second triage considers what actionto take, either itself or by referring the matter elsewhere. If the investigationteam's <strong>report</strong> is inconclusive then the complaint should be referred to theHealthcare Commission;ensuring that intended or actual legal proceedings are not a bar to an NHS bodyinvestigating a complaint. If the NHS body is taking disciplinary proceedingsrelating to the subject matter of the complaint against the person complained of, acomplainant should be entitled to see the substance of the <strong>report</strong> of theinvestigation on which the disciplinary proceedings are to be based;allowing, in some circumstances, an NHS body to defer or discontinue its owninvestigation if the matter is being investigated by the police, a regulatory body, astatutory inquiry or some other process. However, an NHS body should never losesight of its duty to find out what has happened and to take whatever action isnecessary for the protection of the patients of the doctor concerned. It should alsoprovide such information to the complainant as is consistent with the need, if any,for confidentiality in the public interest;allowing PCTs to refer a complaint to the Healthcare Commission at any pointduring the first stage of the complaints procedures. Cases raising difficult orcomplex issues or involving issues relating to both primary and secondary caremight be referred to the Healthcare Commission for investigation at the time of thesecond triage, or later if the investigation raises more complex issues than wereinitially apparent. Referral to the Healthcare Commission should also take place incases where an investigation has found that it cannot reach a conclusion becausethere remain unresolved disputes of fact. The referral would be so that theHealthcare Commission could carry out any further necessary investigation and, ifappropriate, set up a panel to hear oral evidence about the facts in dispute anddecide where the truth lay;establishing objective standards, by reference to which complaints can be judged,as a matter of urgency. These standards should be applied by those making thedecision whether to uphold or reject a complaint and by PCTs and other NHS bodieswhen deciding what action to take in respect of a doctor against whom a complainthas been upheld. Those standards must fit together with the threshold by referenceto which the GMC will accept and act upon allegations, so as to form acomprehensive framework;• <strong>Making</strong> <strong>things</strong> <strong>better</strong>? A <strong>report</strong> on reform of the NHS complaints procedure in England • March 2005 31

ensuring there is a 'single portal' by which complaints or concerns can be directedor redirected to the appropriate quarter. This service should also provideinformation about the various advice services available to persons who areconsidering whether and/or how to complain or raise a concern, including adviceservices for people concerned about the legal implications of raising a concern;dealing with concerns raised by someone other than a patient or patient'srepresentative (e.g. a fellow healthcare professional) in the same way as patientcomplaints.32 March 2005 • <strong>Making</strong> <strong>things</strong> <strong>better</strong>? A <strong>report</strong> on reform of the NHS complaints procedure in England •

Annex BBibliographyCommittee of inquiry: Independent investigation into how the NHS handled allegationsabout the conduct of Clifford Ayling. London: Department of Health, 2004Committee of inquiry to investigate how the NHS handled allegations about theperformance and conduct of Richard Neale. London: Department of Health, 2004Fifth <strong>report</strong> - Safeguarding patients: Lessons from the past - proposals for the future.London: The Stationery Office, 2004 (Command Paper CM 6394)Getting the best from complaints: Consultation on the changes to the Social ServicesComplaints Procedures for children, young people and other people making a complaint.London: Department for Education and Skills, 2004Guidance to support implementation of the National Health Service (Complaints)Regulations 2004. London, Department of Health, 2004An independent voice: Proposals for the independent review stage of the new socialservices complaints procedure - a CSCI consultation document. London: Commission forSocial Care Inspection, 2004Involving patients and the public in healthcare: Response to the Listening Exercise.Department of Health. London: Department of Health, 2001Learning from Bristol. The <strong>report</strong> of the Public Inquiry into children's heart surgery atthe Bristol Royal Infirmary 1984-1995. London: The Stationery Office, 2001 (CommandPaper: CM 5207Learning from complaints: Consultation on changes to the social services complaintsprocedure for adults. London: Department of Health, 2001<strong>Making</strong> amends. A consultation paper setting out proposals for reforming the approachto clinical negligence in the NHS. London: Department of Health, 2003The National Health Service (Complaints Regulations) 2004, London: The StationeryOffice, 2004 (Statutory Instrument 2004 No 1768)NHS complaints procedure national evaluation. London: Department of Health, 2001NHS complaints reform: making <strong>things</strong> right. London: Department of Health, 2003The NHS Plan: a plan for investment, a plan for reform. London: Department of Health,2000Reconfiguring the Department of Health's arm's length bodies. London: Department ofHealth, 2004Reforming the NHS complaints procedure. London: Healthcare Commission, 2004Reforming the NHS complaints procedure: a listening document. London: Department ofHealth, 2001Standards for <strong>better</strong> health. London: Department of Health, 2004Learning from Complaints: Consultation on Changes to the Social Services ComplaintsProcedure for Adults. Department of Health. October 2004Printed in the UK by The Stationery Office Limitedon behalf of the Controller of Her Majesty’s Stationery OfficeID177361 03/05 19585 301570Bibliography • <strong>Making</strong> <strong>things</strong> <strong>better</strong>? A <strong>report</strong> on reform of the NHS complaints procedure in England • March 2005 33

The Parliamentary and Health Service OmbudsmanWe provide a service to the public by undertaking independent investigations into complaints thatgovernment departments, a range of other public bodies in the UK, and the NHS in England, havenot acted properly or fairly or have provided a poor service.Our aim is to:• make our services available to all;• operate open, transparent, fair, customer-focused processes;• understand complaints and investigate them thoroughly, quickly and impartially, and secureappropriate outcomes;• and share learning to promote improvement in public services.For more information about who we are and the services we offer see our website atwww.ombudsman.org.uk/

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