In the year 2017-2018 there were 208,626 written complaints in the NHS in England. This suggests that complaints arise from only a tiny fraction of the 307 million GP contacts that take place each year or the 20.4 million consultant episodes recorded each year.
Nevertheless, this still amounts to 4,012 complaints a week or 572 a day. It's therefore understandable that over the course of their career most doctors can expect to have to respond to complaints from time to time.
The statutory framework for NHS complaints
Complaints about treatment funded by the NHS in England must be handled in accordance with the Local Authority Social Services and National Health Service Complaints (England) Regulations 2009, referred to as 'the complaints regulations'. The regulations set out the systems that NHS organisations must have in place to deal with complaints, who can make complaints, and how they must be acknowledged, investigated and responded to.
The exact procedures differ slightly in the various UK territories, but the approach set out in this article can be applied in any jurisdiction. The MDU website has more information on the specific procedures used across the UK.
What is a complaint?
A complaint is 'an expression of dissatisfaction that requires a response'. Complaints are not always made to clinical staff or the practice manager and it is important that all staff know how to recognise a complaint and know who to inform if they become aware of one.
Who can make a complaint?
Any person who might be affected by the decisions of an NHS organisation can make a complaint, but most complaints are brought by patients or someone acting on their behalf - for example, a parent or other person with parental responsibility if the patient is a child, or someone the patient has authorised as their representative. A representative might also bring a complaint where the patient has died or lacks capacity.
Where a complaint is made by a third party, confirm they have the patient's authority to act on their behalf. You will need to safeguard patient confidentiality when responding, although you can reassure the complainant that you will be able to investigate the concerns raised.
Why might someone complain?
Common reasons for complaints can include treatment failure, complications or simply dissatisfaction with the treatment or service, or a failure to meet patient expectations (which may or may not be reasonable).
A careful consent process and management of patient expectations about treatment or how symptoms might be investigated can help reduce the risk of complaints if there is an unwanted outcome.
While concerns about clinical care might be what the patient is complaining about, the reason the patient chooses to complain may be because of problems with communication, such as not adequately explaining what is involved in carrying out the treatment. A failure to acknowledge symptoms or not giving the impression of listening are also themes within complaints about clinical treatment.
A perception of a lack of courtesy and human empathy, of rudeness, indifference, callousness or aggression often form part of a complaint, or can even be the sole issue.
How might someone complain?
A complaint can be made to the provider or the commissioner of treatment. In practical terms that means that in most instances a complaint can be made to a GP surgery or NHS trust or to NHS England.
The NHS complaints regulations state that complaints must usually be made within 12 months of the incident that gave rise to the complaint, or of the matter coming to the complainant's attention.
Complaints can be made orally or in writing. Unless oral complaints are resolved to the patient's satisfaction within one working day, they should be considered 'formal complaints' and managed accordingly. You should never insist that a patient who wishes to make an oral complaint puts it in writing.
If a complaint is made orally, a full written record should be made by the person receiving the complaint and ideally the patient asked to agree that their concerns have been accurately recorded. The complaint should then be processed under the practice procedure, in the same way as a written complaint. This means that all patient-facing members of staff should be trained in how to manage oral complaints.
Complaints and CQC inspections
The complaints regulations require organisations to publish information about their complaints procedure and help complainants understand it, as well as how they can access help with making a complaint.
Although CQC is not directly involved in reviewing individual complaints made under the complaints regulations, having an effective and accessible complaints procedure is a requirement of CQC registration for both private and NHS providers. The requirement is set out in Regulation 16 of the Health and Social Care Act 2008, and applies to both NHS and private providers registered with CQC.
CQC inspections can review these arrangements and can require disclosure of information about complaints made to the practice or organisation. Talking to staff about the complaints process is one of CQC's key lines of enquiry when looking at a healthcare organisation.
See our website for more information on preparing for a CQC inspection.
If patients who want to complain don't know about your practice procedure or think you don't take complaints seriously, there is a high risk they will complain elsewhere. Once a complaint involves an outside body, you no longer have any control over how it is managed, and the risks of the complaint escalating increase.
If a complaint can be resolved there and then, or within 24 hours, it does not have to be treated as a formal complaint under the regulations. You can of course continue to log these complaints to identify any relevant themes and actions which might be appropriate.
All formal complaints, whether initially made orally or in writing, should be acknowledged in writing within three working days. Where a complaint is made orally, making sure that both you and the complainant have the same understanding of what the complaint is about is essential.
The complaints regulations require you to make a written record of the complaint and give a copy to the complainant. That will allow you to be sure that all relevant issues have been identified before you undertake a full investigation, and perhaps find that you've not been looking at what is important to the complainant. All complainants must also be given the opportunity to discuss how the complaint will be investigated and they must be informed when they can expect to receive a response to the complaint.
The complaints regulations state that a written response must be issued for complaints that aren't resolved to the complainant's satisfaction within one working day. This can be done by post (preferably registered) or by email. Although the complaints regulations don't impose strict time limits for a complaint response, they do require complaints to be handled in a timely fashion and the complainant kept updated of progress.
If you know that there will be a delay in responding to the complaint (for example, because of staff leave) or where the complaint is complex, you should explain this as early as possible. It might help to include this information in the acknowledgment letter.
If the organisation has been unable to respond within six months of receiving the complaint, the complaints regulations require the organisation to write to the complainant to explain why. This should not be interpreted as allowing six months for a typical complaint response - rather, this is intended as something to make the organisation to take positive steps to issue a response as soon as possible if six months have passed with no response.
The goal of the complaints procedure is to try and resolve the issues in the complaint to the satisfaction of all parties.
Where to keep the complaint documents
Complaint documents, including correspondence with the MDU, should be stored in a complaint file, either electronic or paper. Keep this separate from the clinical records.
Initial actions and seeking help with responding to a complaint from the MDU
All the staff who were directly involved in the treatment or consultations in question, or who are the subject of the complaint, should be asked for their comments and observations on the complaint. The fact that someone has left an organisation shouldn't prevent you trying to contact them as part of the complaints investigation, although this might not always be possible.
How we can help
As soon as you receive any complaint that is being formally investigated, whether at practice level or beyond, you should seek the MDU's advice by calling our helpline in the first instance on 0800 374 626. We will usually ask you to write in to us with the following information:
- a copy of the complaint
- a copy of the practice's acknowledgement
- copies of the relevant clinical records
- your draft response to the complaint.
All the above information will need to be anonymised, removing the patient's full name and address, but leaving their initials (forenames and surname) and their date of birth. The adviser will then review and provide comments on your draft. Please don't anonymise the names of staff.
Investigating and responding to complaints
The goal of the complaints procedure is to try and resolve the issues in the complaint to the satisfaction of all parties.
In order to do that, there are a number of essential steps that should be taken, including a clear analysis of what the complaint is about, what steps you will need to take to effectively investigate the concerns and a response which addresses all the complaint's concerns.
The ombudsman has guidance on good complaints handling, but when analysing a complaint, it might help to ask yourself some key questions.
- Do you understand what the complaint is about, and have you identified all the elements contained?
- Does the complaint involve any other organisations apart from yours? If so, do you need to share it with that organisation?
- If the complaint concerns one or more practice staff, will you need to interview or take an account from them?
- Are there any relevant organisational policies or procedures?
Investigating clinical concerns
Many complaints relate to the patients clinical care, and an account from the clinicians involved will clearly be a key step in investigating such concerns. Some organisations may also be able to organise review of the clinical concerns by a practitioner who was not involved in the clinical care or who is even from outside the organisation.
The ombudsman in England has published guidance on how they apply clinical standards in the assessment of complaints, covering such things as using the relevant standards in place at the time the patient was seen as a basis for assessing the clinical care.
Therefore even where this type of review is not possible, illustrating that your view on the clinical issues has been informed by reference to relevant guidelines or protocols can help show that the matters raised in the complaint have been considered objectively.
One or more of the following may help to satisfy a patient and resolve their complaint.
- A conciliatory tone with expressions of sympathy and empathy when appropriate.
- A factual account of the care relating to the complaint. There can sometimes be misunderstandings about the sequence of events or when certain events occurred, so setting out a clear timeline can be helpful.
- An explanation - in plain language, so the patient understands what happened - of why it happened and how it can be remedied.
- A response to each of the concerns expressed in the letter of complaint, clearly setting out your view of the issue and explaining clearly how you have reached it.
- An apology when things have gone wrong. Remember, an apology is not an admission of liability, and can sometimes be all that is needed to satisfy a complainant.
- In all complaints relating to NHS treatment, the complainant must be advised of their right to seek review from the relevant national ombudsman.
There may be other issues you need to resolve with the complainant, and it will be a matter of judgement as to whether this is best dealt with in the complaint response or through separate correspondence. For example, if the letter of complaint makes reference to serious ongoing symptoms, you might well need to organise a further clinical review or a second opinion while the complaint investigation is ongoing.
Sometimes complainants will ask that their care be transferred to another practitioner. A complaint on its own should not be used as justification for ending a doctor patient relationship, but it can sometimes helpful to all parties for the patient to make a 'fresh start' with another clinician.
In some organisations it will not be practicable to guarantee there will always be another practitioner available (for example in emergencies). Explaining how the practice will try to accommodate a wish for another practitioner - but might not always be able to do so - may help manage future expectations.
Complaints sometimes occur in fraught circumstances and there are occasions where complainants may have behaved inappropriately or aggressively to practice staff. You should follow your usual policy in managing such behaviour and, in so far as is possible, that process should be kept separate from the complaints process.
Meetings with complainants
Meetings can be held at any appropriate point during the complaints process. There is no requirement to offer one, or to include the person being complained about, but it can be helpful to have a meeting before any written response has been issued. That can be the case where it is hard to fully explain on paper what happened, or where you simply think that the patient would understand matters better or would prefer a meeting to a written response.
Even where the meeting results in the effective resolution of the complaint, remember that you must still write formally to advise of the outcome. This letter might simply contain a summary of what was discussed at the meeting and notify the complainant of their right to seek review though the relevant ombudsman. Sharing records of meetings also means that all parties can agree they're accurate.
Meetings to try and resolve complaints that remain ongoing often take place following an initial written response. Where a complaint remains unresolved and you plan to meet with the complainant, it is helpful to consider the following steps.
- Try to determine which matters remain in dispute or unresolved. This will hopefully allow you to set an agenda and use the time allocated to the meeting effectively.
- Is the nature of the disagreement something that could be resolved through discussion or further investigation, or is it that the complainant does not trust or believe the advice? Identifying areas where agreement may not be possible and managing expectations at the start of the meeting might help use time most effectively.
- Who will need to attend the meeting? Are all the relevant staff available, do you have someone available to take minutes and to chair the meeting? Does the complainant wish to have a supporter present?
Remember, an apology is not an admission of liability, and can sometimes be all that is needed to satisfy a complainant.
What if you can't resolve a complaint?
Complainants who are dissatisfied with the attempts made to resolve the complaint locally might want to seek review of their complaint and the way in which it is handled. Complaints relating to NHS funded treatment can be reviewed by the relevant ombudsman for the UK jurisdiction in question.
Any review can look at not only whether the clinical care was appropriate, but also at whether the complaint was handled effectively and in accordance with the relevant regulations.
The ombudsman can make broad ranging recommendations, which can relate to actions for organisations, for individual practitioners, for apologies or for financial remedy. While not common, some complainants choose to refer individual doctors to the GMC or to subsequently make a claim for clinical negligence.
Complaints related to privately funded treatment must be managed in accordance with that organisation's policy. Not all organisations have a route through which a complainant can seek independent review of the complaint, but many private sector organisations are voluntary subscribers to the Independent Healthcare Sector Complaints Adjudication Service, which can provide a second stage review procedure.
While we recommend you contact the MDU for advice on any complaint you receive, the ombudsman's process can be complex. We encourage all members to contact us for advice if they have concern that a complaint is unresolved and may escalate via the ombudsman or other route.
While it is not possible to avoid all complaints, good communication is fundamental to attempting to do so, and to resolving them when they occur. Data from both the MDU and the NHS show that approximately a third of all complaints have at their heart difficulties with communication, including alleged rudeness by various members of the team and 'customer service' issues, such as running late for appointments.
If something goes wrong with a patient's treatment, the patient is entitled to a prompt, full and frank explanation. In these situations, you should also apologise to the patient that the outcome has not been as you would both wish, and explain the options going forward.
Learning from complaints
Wherever possible, a response should include an explanation of any learning points have come from the complaint and what actions or changes have been implemented as a result. When doing so it is important to explain specifically and precisely what these are, as it is rarely helpful to suggest that 'lessons will be learned' or 'we will make changes to prevent this happening again' without further detail.
Not all complaints will result in learning points, however, and in some circumstances it can be helpful to explain how you have looked at what happened and why you don't think it would be appropriate to change a system or approach.
Many successful businesses spend a lot of time and effort analysing their complaints, providing unique feedback on their service. Complaints that have been suitably anonymised to preserve patient confidentiality should be shared amongst the team, as these can provide the basis for useful discussion and training at staff meetings.
State indemnity and NHS complaints in primary care
The state scheme covering claims for compensation arising from the care, diagnosis and treatment of a patient as part of the NHS in England came in to effect on 1 April 2019. A similar Welsh scheme for general medical practice indemnity came in to effect on the same day.
While these arrangements do not directly affect complaints handling, in some circumstances the scheme must be notified of occurrences which might result in a claim.
In England, for example, a notifiable patient safety incident which has or may have resulted in death or severe harm to the patient must be reported to NHS resolution, irrespective of whether or not a claim has been made or a disclosure request for patient records has been received.
In Wales, if a complaint is particularly complex or significant harm is alleged to have resulted then the practice is expected to refer matters to the scheme.
In both countries a practice must advise NHS Resolution or NHS Wales Shared Services Partnership Legal and Risk Services respectively before taking steps in relation to a complaint which 'could reasonably be interpreted as making an admission of liability'.
Further information can be found at the relevant sites for England and Wales.
It must be emphasised that the introduction of these schemes in no way undermines the need to give a detailed open and honest response to a complaint.
Understanding how to deal with complaints appropriately is a vital component of achieving safe and responsible care, both for yourself and for patients. On top of this, reflecting appropriately on complaints is part of a doctor's revalidation and all health care providers whether in the NHS or private sector must have an effective complaints procedure. Complaints are an unavoidable aspect of professional practice, and responding efficiently and appropriately is increasingly important.
Although it can be disheartening to be the subject of a complaint, following proper procedures in handling complaints and responding with empathy and objectivity can help resolve complaints at a local level and can also sometimes provide useful information when optimising practice or services.