The Care Quality Commission gets tough over NHS complaints John Tingle
I
n recent months, there have been a number of published reports on complaints in the NHS. They all seem to say the same thing—namely, that the NHS complaints system is largely unfit for purpose and that there must be fundamental changes to the system. The reports highlight over-defensive attitudes on the part of healthcare providers and managers, poor communication with patients, overcomplicated complaint processes, and so on. However, these problems are not new and have been around for as long as the NHS complaints system has existed. Historically, this system has been noted for its complexity and its ability to alienate most of the people who come in contact with it. What compounds these failures is that the lessons of previous complaints never seem to be learned. Most complaints revolve around basic failures in communication, which never should have happened in the first place. In a post-Mid Staffordshire NHS, public and government tolerance of NHS errors and complaints is extremely low. Positive action is demanded to develop a patient-centric culture to ensure proper caring, communication, safety and quality processes. What is clear is that NHS health professionals, hospitals and other health organisations cannot be left to police themselves. When it comes to complainthandling, there needs to be effective supervision and, in the event of non-compliance, some exacting sanctions and consequences. Nobody likes to be complained against and it is natural to be defensive. Yet not many health professionals or healthcare organisations seem to regard patient complaints the way, say, supermarkets do—as invaluable and useful customer insights into their business.
The Care Quality Commission ( CQC) report
John Tingle is Reader in Health Law, Nottingham Law School, Nottingham Trent University
116
The CQC report Complaints Matter (2014) promises appropriate supervision and sanctions against trusts and other health organisations that do not have—and maintain—proper complaint-handling processes. The report details the CQC’s current work on complaints in the NHS and how that work will form part of its revised inspection regime. As well as detailing the new operational mechanisms that the CQC will follow on complaints, some early complaint trends from the CQC inspections are given. For example, the CQC receives a huge amount
of contact from people telling them about poor care: ‘This number is increasing across health and social care sectors. In 2013/14, there was a total of 18 455 concerns about regulated services received by our National Customer Service Centre—about 50 a day’ (CQC, 2014: 12) The report states that the public awareness of the CQC is increasing and that it is working to understand better how to gain maximal value from this public feedback.
CQC partnerships The CQC has established partnerships with a number of national health and social-care charities to increase their access to people’s experience of both good and bad care. The CQC receives an average of 280 items of feedback each month across all the partners. Of these, 42 (15%) are positive comments and 238 (85%) are care concerns: ■■ Of the 238 concerns, on average 24 (10%) are serious enough to prompt the CQC to make a safeguarding referral to the local council because someone may be at risk of, or experiencing, abuse. ■■ Fourteen concerns (6%) prompt the CQC to carry out a responsive inspection or bring forward the date of a planned inspection. ■■ On average, 57 concerns (24%) prompt the CQC to raise the issues with the service provider and seek a response. ■■ For around 103 concerns (43%), the relevant inspector advises that no immediate action is needed, but the information will be used to inform the next scheduled inspection. ■■ Sixteen concerns (7%) require no action because the areas raised had been covered at a recent CQC inspection. ■■ Twenty-two concerns (9%) do not give enough information or do not prompt any action because the concern is about an experience that took place too long ago and/or there have been changes to the service in the meantime.
Complaints in CQC’s new approach to regulation: Key lines of enquiry (KLOEs) In October 2014 the CQC introduced a mandatory key line of enquiry (KLOE) for inspections of hospitals, mental health services, community healthcare services, GP practices, out-of-hours practices and adult social care services that looks at how well complaints and concerns are handled. The CQC states that the KLOE asks how people’s concerns and complaints are listened to, acted on and used to improve care quality. A number of prompts, stated in the report, accompany each KLOE and will be used by inspection teams when considering their assessment.
© 2015 MA Healthcare Ltd
John Tingle discusses a new publication on complaints in health and social care by the Care Quality Commission (CQC)
British Journal of Nursing, 2015, Vol 24, No 2 © MA Healthcare Ltd. Downloaded from magonlinelibrary.com by 129.059.095.115 on September 20, 2016. Use for licensed purposes only. No other uses without permission. All rights reserved.
PATIENT SAFETY ‘Do people who use the service know how to make a complaint or raise concerns, are they encouraged to do so, and are they confident to speak up?’ ‘How easy is the system to use? Are people treated compassionately and given the help and support they need to make a complaint?’ ‘Is the outcome explained appropriately to the individual? Is there openness and transparency about how complaints and concerns are dealt with?’ (CQC, 2014: 15) Inspection teams use evidence from a variety of sources to answer the KLOEs, including evidence from ongoing local relationships, local and national data, pre-inspection information gathering, and on-site inspection. The CQC then awards a rating: ‘Outstanding’, ‘Good’, ‘Requires improvement’ and ‘Inadequate’. How well providers handle complaints feeds into the CQC’s overall rating of how responsive they are.
Self-report for hospitals The CQC is also rolling out a ‘self-report’ for hospitals and other health bodies that can tell the CQC how they handle complaints before the CQC inspect. This will provide the CQC with a useful focus for inspection. The CQC will follow the structure of the trust selfreport on complaint handling. The questions come under the following headings: leadership, governance, awareness, investigation, timeliness, learning and evaluation. For example, under the governance heading, the CQC ask: ‘Please describe the trust’s governance arrangements for complaints: how often are they discussed at board level? What committees review the handling of complaints and compliments, and any themes within them?’ (CQC, 2014: 18) The CQC states that during site visits its inspectors will usually review up to five complaint files, which should be selected by the inspector and not the provider. At least one serious complaint should be in the sample. Most complaints should be closed so that the full process from start to finish can be seen (though open ones can also be considered). The CQC inspection measures and mechanisms on complaint handling by hospitals and other healthcare providers as described in the report look thorough, promising and are to be welcomed.
© 2015 MA Healthcare Ltd
State of complaints in health and social care services The CQC has analysed the data about written complaints in the NHS and found that the number of written complaints received by all NHS hospital, mental health and community health services increased every year since 2011/12. The CQC report looks at rates of complaints and a number of other related matters over a 3-year period. It reveals a number of themes: awareness and knowledge of complaints processes; accessibility of complaints process and support available;
British Journal of Nursing, 2015, Vol 24, No 2
responsiveness to and treatment of people making a complaint; learning from complaints; and openness and transparency about complaints (CQC, 2014: 31). The CQC says: ‘We found that people were concerned that complaints could impact on current or future care and were often unhappy with the speed of the complaints handling process’ (CQC, 2014: 32) The report notes that there is a discrepancy between the views of staff and the experiences of people who have made complaints, and that this needs further investigation.
Primary care According to the CQC, many organisations in adult social and primary care settings report low numbers of complaints: ‘Almost 30% of GP and dental practices that returned data to the HSCIC [Health and Social Care Information Centre] had not received any written complaints in the previous 12 months. The number of concerns received by CQC regarding adult social care services has increased since the beginning of 2012/13, but this has been at a slower rate than for NHS services. We have seen a large increase in concerns we receive about primary care, but some of the increase will be because CQC’s regulation of the sector is fairly new’ The report itself looks into these care areas in more detail.
Report’s conclusions The report draws a number of important conclusions—that there is wide variation in the way complaints are handled and that much more could be done to encourage an open culture where concerns are welcomed and lessons learned: ‘While most providers have complaints processes in place, people’s experiences of the system are not consistently good. This must change. Services should encourage and embrace complaints’ (CQC, 2014: 39)
Conclusion The CQC, it seems, is becoming recognised by the public as an effective public watchdog, with teeth, for the NHS. Poor NHS complaint handling is an age-old problem, which has been stubbornly resistant to change, despite successive Government efforts over many years. In a post-Mid Staffordshire NHS, the public’s and Government’s attitude and resolve to making sure those terrible events are never repeated is absolute. This CQC report on complaints and the mechanisms adopted by them to regulate health providers fairly reflects that absolute resolve. The proof will be in the pudding, as the saying goes, but the CQC approach in the report shows great promise. Hopefully, through its new regulatory regime, it will turn the tide of poor complaint handling in the NHS. BJN Care Quality Commission (2014) Complaints Matter. http://tinyurl.com/ muayc2p (accessed 12 January 2015)
117 © MA Healthcare Ltd. Downloaded from magonlinelibrary.com by 129.059.095.115 on September 20, 2016. Use for licensed purposes only. No other uses without permission. All rights reserved.
I
n recent months, there have been a number of published reports on complaints in the NHS. They all seem to say the same thing—namely, that the NHS complaints system is largely unfit for purpose and that there must be fundamental changes to the system. The reports highlight over-defensive attitudes on the part of healthcare providers and managers, poor communication with patients, overcomplicated complaint processes, and so on. However, these problems are not new and have been around for as long as the NHS complaints system has existed. Historically, this system has been noted for its complexity and its ability to alienate most of the people who come in contact with it. What compounds these failures is that the lessons of previous complaints never seem to be learned. Most complaints revolve around basic failures in communication, which never should have happened in the first place. In a post-Mid Staffordshire NHS, public and government tolerance of NHS errors and complaints is extremely low. Positive action is demanded to develop a patient-centric culture to ensure proper caring, communication, safety and quality processes. What is clear is that NHS health professionals, hospitals and other health organisations cannot be left to police themselves. When it comes to complainthandling, there needs to be effective supervision and, in the event of non-compliance, some exacting sanctions and consequences. Nobody likes to be complained against and it is natural to be defensive. Yet not many health professionals or healthcare organisations seem to regard patient complaints the way, say, supermarkets do—as invaluable and useful customer insights into their business.
The Care Quality Commission ( CQC) report
John Tingle is Reader in Health Law, Nottingham Law School, Nottingham Trent University
116
The CQC report Complaints Matter (2014) promises appropriate supervision and sanctions against trusts and other health organisations that do not have—and maintain—proper complaint-handling processes. The report details the CQC’s current work on complaints in the NHS and how that work will form part of its revised inspection regime. As well as detailing the new operational mechanisms that the CQC will follow on complaints, some early complaint trends from the CQC inspections are given. For example, the CQC receives a huge amount
of contact from people telling them about poor care: ‘This number is increasing across health and social care sectors. In 2013/14, there was a total of 18 455 concerns about regulated services received by our National Customer Service Centre—about 50 a day’ (CQC, 2014: 12) The report states that the public awareness of the CQC is increasing and that it is working to understand better how to gain maximal value from this public feedback.
CQC partnerships The CQC has established partnerships with a number of national health and social-care charities to increase their access to people’s experience of both good and bad care. The CQC receives an average of 280 items of feedback each month across all the partners. Of these, 42 (15%) are positive comments and 238 (85%) are care concerns: ■■ Of the 238 concerns, on average 24 (10%) are serious enough to prompt the CQC to make a safeguarding referral to the local council because someone may be at risk of, or experiencing, abuse. ■■ Fourteen concerns (6%) prompt the CQC to carry out a responsive inspection or bring forward the date of a planned inspection. ■■ On average, 57 concerns (24%) prompt the CQC to raise the issues with the service provider and seek a response. ■■ For around 103 concerns (43%), the relevant inspector advises that no immediate action is needed, but the information will be used to inform the next scheduled inspection. ■■ Sixteen concerns (7%) require no action because the areas raised had been covered at a recent CQC inspection. ■■ Twenty-two concerns (9%) do not give enough information or do not prompt any action because the concern is about an experience that took place too long ago and/or there have been changes to the service in the meantime.
Complaints in CQC’s new approach to regulation: Key lines of enquiry (KLOEs) In October 2014 the CQC introduced a mandatory key line of enquiry (KLOE) for inspections of hospitals, mental health services, community healthcare services, GP practices, out-of-hours practices and adult social care services that looks at how well complaints and concerns are handled. The CQC states that the KLOE asks how people’s concerns and complaints are listened to, acted on and used to improve care quality. A number of prompts, stated in the report, accompany each KLOE and will be used by inspection teams when considering their assessment.
© 2015 MA Healthcare Ltd
John Tingle discusses a new publication on complaints in health and social care by the Care Quality Commission (CQC)
British Journal of Nursing, 2015, Vol 24, No 2 © MA Healthcare Ltd. Downloaded from magonlinelibrary.com by 129.059.095.115 on September 20, 2016. Use for licensed purposes only. No other uses without permission. All rights reserved.
PATIENT SAFETY ‘Do people who use the service know how to make a complaint or raise concerns, are they encouraged to do so, and are they confident to speak up?’ ‘How easy is the system to use? Are people treated compassionately and given the help and support they need to make a complaint?’ ‘Is the outcome explained appropriately to the individual? Is there openness and transparency about how complaints and concerns are dealt with?’ (CQC, 2014: 15) Inspection teams use evidence from a variety of sources to answer the KLOEs, including evidence from ongoing local relationships, local and national data, pre-inspection information gathering, and on-site inspection. The CQC then awards a rating: ‘Outstanding’, ‘Good’, ‘Requires improvement’ and ‘Inadequate’. How well providers handle complaints feeds into the CQC’s overall rating of how responsive they are.
Self-report for hospitals The CQC is also rolling out a ‘self-report’ for hospitals and other health bodies that can tell the CQC how they handle complaints before the CQC inspect. This will provide the CQC with a useful focus for inspection. The CQC will follow the structure of the trust selfreport on complaint handling. The questions come under the following headings: leadership, governance, awareness, investigation, timeliness, learning and evaluation. For example, under the governance heading, the CQC ask: ‘Please describe the trust’s governance arrangements for complaints: how often are they discussed at board level? What committees review the handling of complaints and compliments, and any themes within them?’ (CQC, 2014: 18) The CQC states that during site visits its inspectors will usually review up to five complaint files, which should be selected by the inspector and not the provider. At least one serious complaint should be in the sample. Most complaints should be closed so that the full process from start to finish can be seen (though open ones can also be considered). The CQC inspection measures and mechanisms on complaint handling by hospitals and other healthcare providers as described in the report look thorough, promising and are to be welcomed.
© 2015 MA Healthcare Ltd
State of complaints in health and social care services The CQC has analysed the data about written complaints in the NHS and found that the number of written complaints received by all NHS hospital, mental health and community health services increased every year since 2011/12. The CQC report looks at rates of complaints and a number of other related matters over a 3-year period. It reveals a number of themes: awareness and knowledge of complaints processes; accessibility of complaints process and support available;
British Journal of Nursing, 2015, Vol 24, No 2
responsiveness to and treatment of people making a complaint; learning from complaints; and openness and transparency about complaints (CQC, 2014: 31). The CQC says: ‘We found that people were concerned that complaints could impact on current or future care and were often unhappy with the speed of the complaints handling process’ (CQC, 2014: 32) The report notes that there is a discrepancy between the views of staff and the experiences of people who have made complaints, and that this needs further investigation.
Primary care According to the CQC, many organisations in adult social and primary care settings report low numbers of complaints: ‘Almost 30% of GP and dental practices that returned data to the HSCIC [Health and Social Care Information Centre] had not received any written complaints in the previous 12 months. The number of concerns received by CQC regarding adult social care services has increased since the beginning of 2012/13, but this has been at a slower rate than for NHS services. We have seen a large increase in concerns we receive about primary care, but some of the increase will be because CQC’s regulation of the sector is fairly new’ The report itself looks into these care areas in more detail.
Report’s conclusions The report draws a number of important conclusions—that there is wide variation in the way complaints are handled and that much more could be done to encourage an open culture where concerns are welcomed and lessons learned: ‘While most providers have complaints processes in place, people’s experiences of the system are not consistently good. This must change. Services should encourage and embrace complaints’ (CQC, 2014: 39)
Conclusion The CQC, it seems, is becoming recognised by the public as an effective public watchdog, with teeth, for the NHS. Poor NHS complaint handling is an age-old problem, which has been stubbornly resistant to change, despite successive Government efforts over many years. In a post-Mid Staffordshire NHS, the public’s and Government’s attitude and resolve to making sure those terrible events are never repeated is absolute. This CQC report on complaints and the mechanisms adopted by them to regulate health providers fairly reflects that absolute resolve. The proof will be in the pudding, as the saying goes, but the CQC approach in the report shows great promise. Hopefully, through its new regulatory regime, it will turn the tide of poor complaint handling in the NHS. BJN Care Quality Commission (2014) Complaints Matter. http://tinyurl.com/ muayc2p (accessed 12 January 2015)
117 © MA Healthcare Ltd. Downloaded from magonlinelibrary.com by 129.059.095.115 on September 20, 2016. Use for licensed purposes only. No other uses without permission. All rights reserved.
