The toxic cocktail that leads to patient complaints – how can the NHS line its stomach?

Dr Claire Dow is Consultant Physician at Barts Health NHS Trust. She tweets at @ClaireDow1

Think not of what you can do for your complainants, but what your complainants can do for you. (Apologies to President Kennedy.)

At the recent BGS/RCP conference on Acute Care of Older People, we were privileged to hear Dame Julie Mellor talk about patient complaints from her perspective as Parliamentary and Health Service Ombudsman.

For an audience composed mainly of Geriatricians and Acute Physicians, it came as no surprise that she felt that hospitals are poorly equipped to deal with the older people who have multiple conditions.

Dame Julie told us that the main complaints received by the Ombudsman are about inadequate personal care, dehydration, malnutrition, poor communication with families, lack of integrated care and discharge from hospital. I cannot honestly say that my team and I get this correct all of the time – but do we hear about it when we get it wrong and how can we improve care when we don’t know where it went wrong? Many who do go to the Ombudsman do so out of frustration from either inadequate explanations as to what happened, or inadequate apologies. More worryingly, most people find the complaints process worse than they thought it would be. This leads to a “toxic cocktail”: patients and families are reluctant to complain (most do so to prevent bad things happening to others), whilst hospitals and staff are defensive and this is perceived as a reluctance hear and address concerns. The consequence is lost opportunities to improve clinical care. The Delivering Dignity report from June 2012 lays out recommendations for Trusts to improve feedback about care for this most vulnerable group.

The most thought provoking part of the session was about how we as clinicians feel about the complaints system and how (dis)empowered it leaves us. 50% of those present felt that staff are defensive towards complaints due to fear of disciplinary action, blame and consequences. Many (27%) also felt that they did not have the authority or resources to resolve complaints. Following the Francis Report, this needs to be urgently addressed by the NHS and support given to us to raise the many serious issues highlighted in complainants’ stories to the Trust Board without fear of reprisal.

How can we improve the system so it is not only easier to complain but to also raise identified issues around clinical performance to senior members of the Trust? Should face-to-face meetings be the first-line of dealing with complaints, rather than at a later stage when views are more entrenched? Should there be a root cause analysis of all complaints undertaken to identify themes/ problem areas and report these to the Trust Board regularly? Should Geriatricians have time recognised in our job plans to talk to patients and their relatives? Should we undertake separate afternoon visiting-time ward rounds to explain medical complexity to the patient and their relatives and ensure that the patients and their families have a “face” alongside the ward manager that they can approach with questions and concerns? Do we as a professional society need to be explaining to patients and their families that, whilst we strive to make our hospitals safe places to be, older people are a vulnerable and high-risk group that bad things can happen to in hospital? Do we need to be talking to the “baby boomer” generation, whose parents are our patients, and give realistic expectations of what we can and cannot do for them in hospital and out?

What am I going to do to improve things and allow better feedback from my patients and their carers? I’m still not entirely sure, but I do give my work email address to relatives to be able to contact me (and have not had it abused as yet) and try to be visible on the wards (but it is very difficult over the 7 wards on 2 sites that I can have patients on). We have put the Patient Advice and Liaison Service (PALS) contact up on the wards for all to see. Every complaint is discussed in our governance meeting. As with many colleagues, I do not have the time to undertake a “pastoral” ward round for my patients, even though I feel that it would improve communication with patients and families (and therefore improve care).

As for improving the complaints system? Until Trust Boards are obliged to look not only into the number of complaints, but the root causes of them I’m not sure that anything myself or my colleagues introduce locally will be enough to prevent the “toxic cocktail” happening in my hospital. Food for thought.