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EDITORIAL

For this is not the liberty which we can hope, that no grievanceever should arise in thecommonwealth; that let no manin this world expect; but whencomplaints are freely heard,deeply considered and speedilyreformed, then is the utmostbound of civil liberty attainedthat wise men look for. JohnMilton (1644) Areopagitica

T he authors discussed complaints dur-ing an interactive session ofDementias 2008 conference (www.mahealthcareevents.co.uk/cgi-bin/go.pl/conferences/past/10th_dementias_02_08/index.html).

People with dementia and the familycaring for them are often in need of helpfrom agencies across the health and socialcare spectrum, sometimes at home, some-times in hospital or elsewhere. Dementia

may leave the individual unable to speakeffectively for him-/herself, but it can alsolead him/her to misread the activities,intentions and motives of those caring forhim/her. Everyone is vulnerable in thisscenario. Media representations may useshallow or one-sided accounts of problemsfor eye-catching headlines, when the com-plex, multi-factorial, multi-dimensionalrealities deserve quieter, careful explora-tion (Panorama, 2007).

There is no doubt that service frequent-ly fall short of the acceptable. Scandalshave been the spur for major develop-ments of design and resource; yet evennow coroners are sometimes moved toquestion the safety of hospitals (Lashley,2007) and lucid, able older people recountdreadful experiences (Wenger, 2007).

So it is that individuals surprise them-selves by finding they must say or write: Idont want to complain but

How well does the NHS deal with complaints?Do we consider every complaint as anopportunity to improve? A leading London

restaurant chain uses its menu to imploreits customers to: compliment, complain,suggest improvements, because a com-plaint offers the restaurant the ability toput a problem right and satisfy a demand,

whereas a customer leaving unhappy isunlikely to return and may tell friendsabout their experience.

Do we understand the nature of com-plaints received? Can we differentiatebetween those complaints where gettingthe issue off my chest is enough andthose where the issue has completelytaken over the life of the complainant,and occupies all their waking thoughts?The evidence indicates that we deal withthe important with insufficient urgency,and that we fail to empathize with com-plainants.

Do we recognize the difference betweenthe cause of a complaint and the effect ofthe complaint on the complainant? Do weconcentrate more on dealing with the

effect of an adverse event or the cause?Do we say sorry? Can we admit fault?Have we perfected the art of using won-derful weasel words that imply that we aresorry without any admission of fault orindication that we will do anything differ-ently in future?

Do we react in an appropriate way tocomplaints? Do we dismiss complaints(why are people so ungrateful?) or do weover-react and allow complaints to makeus question our ability (and our future) topractice our chosen profession?

Why is it so hard for NHSprofessionals to getthe balance right?It is important that we pose these ques-tions to help ourselves and our staff tounderstand why people complain and how

we can best deal with both cause andeffect. We can and must do better.

Remember that most staff who becomepatients are critical of some aspect of theservice.

Some complaints seem to be minor even ridiculous such as the relative who

kept a diary of the consistency of custardserved to her husband. This might seem tobe a trivial matter, but it reflects the con-cern which families have when a depend-ent, vulnerable, loved one is taken fromthem and placed in the hands of others. Itis important to respond sensitively and

with appropriate measure: the full panoplyof a complaints procedure should be avoid-able. Sledge hammers do not facilitate thebest use of nuts.

Health and social care agencies hithertohave been constrained by separate systemsfor investigating complaints. This hasposed problems because there are manyoccasions when care of an individual withchronic, complex disorders, includingdementia, requires that they move fromone main care provider to another. Thehealth-care system has three tiers ofenquiry: local, Healthcare Commissionand Ombudsman. This has meant multi-ples of potential for loss of continuity,

repetition of schedules, delay and accumu-lated expense. Patients and families oftenfeel frustrated and dismissed. Professionalsmay feel persecuted; presumed guilty with-out recourse within a quasi-judicial proc-ess which offers scant protection for theinnocent.

Making Experiences Count is a new sys-tem which will bring together schemes forreceiving and responding to complaints inhealth care and social care in Englandfrom 2008 (Department of Health, 2007,2008). It seeks to make a positive fromcritical interactions between services andthose they are intending to help. It is atwo-stage system emphasizing the advan-tages of local resolution. This may bestrengthened by an independent advisorfor particular cases. If local resolution can-not be achieved, recourse will be to theOmbudsman.

The principles have been accepted fol-lowing extensive research, collectinginformation and views from patients,carers, families and professionals(Department of Health, 2006). TheLocal Government and Public

Complaints: finding a positive

and productive approach

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Involvement Health Bill 2007 placedduties on the NHS to consult withpatients and the general public and uponlocal authorities to inform, involve andconsult with local people. It followedconcerns which were highlighted by theShipman reports and distillation of expe-riences from the Ombudsman (Abraham,2007). These changes are complementedby the Independent Complaints AdvocacyService which provides additional sup-port and guidance to both patients andfamilies.

There are high hopes that the new sys-tem will make best use of these painfullearning experiences. It aims to make theavenues for complaints (and compliments)accessible, integrated (across health andsocial care and across sectors within both),effective and prompt, inspiring confidencefrom patients and professionals, and pro-moting organizational learning. It will beprogressed through a programme of earlyadopters supported by Voices forImprovement Networks, and complaintsforums involving commissioning and exec-utive staff. A regulator will be responsiblefor ensuring a high standard of response tocomplaints and the adoption of learningpoints to improve practices.

The emphasis on a quick, respectfuland grateful response when a criticismis received gets accurately to the heart ofeffective complaints handling. Mistakes

will be made but their recognition andthe implementation of rescue strategies isall that can be reasonably asked.

Failure or denial of communicationand unhelpful attitudes not errors ofprofessional judgment or practice are atthe basis of most unresolved complaints.

A phone call from a senior officer onthe day a criticism is received, followedby an arrangement to meet, listen andlearn, will mean that the written response

can be timely and has a fair chance ofaddressing all the issues. An explanationof what has happened and why, together

with details of changes which are to beimplemented to reduce the likelihoodof similar problems, are what most com-plainants desire.

Conclusions Making Experiences Countheralds a newera which will help all of us, when tangling

with difficulties arising in the care of con-ditions such as dementia, to achieve theattributes of informality, common sense,inquisitorial rigour, and freedom fromprecedent while paying attention to theparticular. BJHM

Michael PyrahChief Executive

Central and Eastern Cheshire PCT Middlewich

Cheshire Jane Byrne

Senior Lecturer and Consultant Psychiatrist Department of Psychiatry

Wythenshawe Hospital Manchester

Claire HiltonConsultant Psychiatrist

Central and North West London FoundationNHS Trust Northwick Park Hospital

Harrow

David Jolley Consultant Psychiatrist and

Honorary Reader Personal Social Services Research Unit

Manchester University Manchester M13 9PL

Abraham A (2007) The Ombudsman and Paths to Justice. Paper presented to the Institute ofadvanced Legal Studies, June 27 2007. www.ombudsman.org.uk/about_us/FOI/whats_available/documents/speeches/institute_advanced_legal_studies.html (accessed 8 April 2008)

Department of Health (2006) Our health, our care,our say: making it happen. Department of Health,London (www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4139925accessed 12 April 2008)

Department of Health (2007) Making ExperiencesCount. A new approach to responding to complain

A document for information and comment.Department of Health, London (www.dh.gov.uk/en/Consultations/Closedconsultations/DH_075652 accessed 12 April 2008)

Department of Health (2008) Making ExperiencesCount. The proposed new arrangements for handlinghealth and social care complaints. Detained policybackground.Department of Health, London (www.dh.gov.uk/en/Consultations/Responsestoconsultations/DH_082715 accessed 12 April 2008)

Lashley B (2007) Coroners plea on hospital. Manchester Evening News 30 July (www.manchestereveningnews.co.uk/news/health/s/1012/1012362_coroners_plea_on_hospital.htmlaccessed 8 April 2008)

Panorama (2007) Please look after dad.Panorama 3December (http://news.bbc.co.uk/1/hi/

programmes/panorama/7104212.stm accessed 8 April 2008) Wenger C (2007) Patients dossier on dirty ward.

http://news.bbc.co.uk/1/hi/wales/north_ west/7057733.stm (accessed 12 April 2008)

KEY POINTSn Services sometimes fail to provide acceptable care to patients and their families.n Complaints provide free, immediate and useful comment and should be welcomed a

foster mutual respect, learning and improvement.n Older people, especially those with dementia, are vulnerable to misuse or misunder

require particular care and attention to matters of communication.n Making Experiences Count is a new approach to handling complaints which brings health

care systems together in pursuit of these principles.

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