COMMITTEE FOR HEALTH, SOCIAL SERVICES AND PUBLIC SAFETY

Departmental Briefing on Complaints Procedure

2 July 2009

Members present for all or part of the proceedings:

Ms Sue Ramsey (Acting Chairperson)
Mr Thomas Buchanan
Mr Alex Easton
Mr Sam Gardiner
Mrs Carmel Hanna
Mr John McCallister
Mrs Claire McGill

Witnesses:

Mr Andrew Browne )
Dr Jim Livingstone ) Department of Health, Social Services and Public Safety
Ms Paula McGeown )

The Acting Chairperson (Ms S Ramsey):

I welcome Paula McGeown, Andrew Browne and Jim Livingstone from the Department of Health, Social Services and Public Safety. I invite you to make a presentation, after which members will comment or put questions to you. On behalf of the Committee, thank you very much for attending today.

Dr Jim Livingstone (Department of Health, Social Services and Public Safety):

It is a pleasure to be here. I am accompanied today by Andrew Browne, the deputy director of the safety, quality and standards directorate, and Paula McGeown, the project manager for the implementation of the new complaints procedure.

I will start by providing some context. In a typical year, approximately 500,000 inpatients are treated in Northern Ireland’s hospitals, 700,000 people attend accident and emergency, and there are approximately 1·5 million outpatient appointments. In addition, there are 7·5 million GP consultations, and 200,000 contacts are made with social services. It is a very busy system. There are at least 10 million interactions a year, which generate some 5,000 complaints, or 0·5% of those interactions. It is important to see the matter in that context. However, that does not mean that we should be complacent or even interpret those figures as showing that there is nothing wrong with the Health Service, that no mistakes are made or that there are no issues about which complaints can rightly be made. However, that is an important start.

The new complaints procedure was introduced in April 2009, replacing a system that was in place since 1996. Why change? A review in 2006 gathered much information from public attitude surveys and consultations with many bodies. A key finding was that more than 65% of the public expressed a lack of confidence in the effectiveness of the complaints procedure. There was a perception that it was a complicated, long-winded and protracted process.

In line with similar developments in Scotland and England, we developed, over a year or two, a procedure that placed much more emphasis on local resolution and the provision of support for complainants. It was a culture change to treat complaints as valuable learning events to improve the quality of services. It also dealt with the issues that complainants had raised and attempts to resolve them to their satisfaction.

The removal of the independent review process was a key change. If complainants were not satisfied with a local resolution, they asked the relevant health board for an independent review. About 3% of complaints reached that stage, of which well under 1% resulted in an independent review. It is debatable why the figure was so low. However, if we bear in mind the lack of public confidence and the time taken by the process, the small number of independent reviews was symptomatic of people having no confidence that it was worth proceeding to the next phase. There was evidence of many complaints getting as far as the independent review process and stopping because patients felt that there was no point in pursuing the matter. The evidence demonstrated minimal public confidence in the process.

The new process still provides for an independent investigation of complaints. Therefore, when complainants are not satisfied, they have the opportunity to refer their complaint to the Northern Ireland Ombudsman. We allocated additional resources to the ombudsman’s office for more staff in anticipation that it would undertake many more independent investigations.

The new procedure also places requirements on trusts and the Health and Social Care Board about what they must do, in what timescale and to what level of quality. Those are set out in departmental directions that have been in effect since 1 April 2009.

Work on the implementation of the new procedure began more than 12 months ago after public consultation. Since then, a programme of work in which Paula has been involved has led to new training courses, procedures and formats to ensure that complaints are picked up quickly and efficiently and dealt with speedily. For example, there is now a requirement that a written complaint must be acknowledged within two days and a formal response provided within 20 days, which is much faster than previously.

There is extensive advertising in every hospital and health and social care setting, including family practitioner services, to ensure that people know about the new procedure and how, and to whom, to complain. More than 2,000 posters and 110,000 leaflets have been distributed to family practitioner services, and trusts and hospitals are customising those same templates for their own purposes. Five thousand health and social care staff have been trained in how to deal with complaints effectively and in a way that recognises the importance of the patient or client who makes the complaint and the potential value of that complaint in learning how to improve service quality.

The departmental directions also stipulate a requirement on the part of the board and the health and social care trusts to ensure that staff are trained. That is a change from 1996, because the review found that any training that was put in place then virtually dwindled away later. Therefore, the requirement now is that staff are continually kept skilled and trained in how to deal with complaints.

Complaints are signs of real concern or hurt by patients or clients who deserve resolution. It is fair to say that, in the past, many people characterised complaints procedures in health and social care and many other sectors as being irritants that had to be managed away and simply dealt with. There is now a clear difference in approach. Complaints are recognised as a symptom that something is wrong, something must be done, something must be learned and something must be improved. We are determined that that culture change in the health and social care service — towards ensuring that we have a system that listens, learns and improves — will flow from this step and many others.

The Acting Chairperson:

The review is said to have kicked in in 2006 because public surveys found that more than 65% of respondents lacked confidence in the complaints process. What is that percentage now? The Committee is receiving information that people remain unhappy about the way in which complaints will be handled. Therefore, questions remain.

Dr Livingstone:

The new procedure has been in place since only April 2009, so we are not in a position to say too much, because a public attitude survey will be conducted later this year. The most recent information produced that figure of 65% in respect of the old procedure. We will monitor the public attitude survey to find out how that percentage changes in relation to the new procedure. We are also committed to putting in place a detailed evaluation process that will begin in 2010. By that time, judgements will be based on one full year of the new procedure’s operation.

The Acting Chairperson:

I know that the new procedure has been in place since only April, but, between then and now, has anyone contacted the Department to say that they are not happy with it or to raise any queries?

Ms Paula McGeown (Department of Health, Social Services and Public Safety):

There have been no individual complainants. We have had an Assembly question for written answer related to the complaints procedure, but no individual complainant has contacted the Department.

The Acting Chairperson:

I will raise one now, and I am sure that other members will raise queries of their own. The Department talks about the Northern Ireland Ombudsman providing the second-stage complaint function. However, the ombudsman’s 2007-08 annual report states:

“The average time for a case to be examined, enquiries made and a full Report issued at Report Stage was 61 weeks.”

The concern is that a complaint taken to the second stage faces a lengthy waiting time before achieving a resolution. That is what the ombudsman is saying.

Dr Livingstone:

Again, that is for cases that were dealt with in the previous year, which is why we have allocated £200,000 to the office of the Northern Ireland Ombudsman so that it can increase its resources to cope with any independent investigations that are sought by unsatisfied complainants.

The Acting Chairperson:

Based on the additional funding for the ombudsman’s office, can a commitment be provided now that complaints will not take 61 weeks?

Dr Livingstone:

I would be very unhappy if complaints took 61 weeks to resolve. One reason why the new procedure was introduced was to speed up the process, and we are committed to undertaking a full evaluation in 2010, when we will have a full year’s data to review. We will examine whether it is faster, because that is a main aim; whether it gives better resolution; and whether it generates good learning that can be applied to improve quality of services. If the new process is not achieving those objectives, it will have to change.

Mr Easton:

That was one of my questions. It might be worth writing to the ombudsman. My reading is that the process will take 61 weeks, no matter what. It might be interesting to gauge what the ombudsman has to say. If I am right, the ombudsman can investigate only maladministration cases. If that is the case, is there the possibility that some complaints cannot be investigated by the ombudsman? If that is so, how will that situation be addressed?

I do not know whether you consulted on the new complaints procedure and whether you involved community groups or individual patients. Did you undertake an extensive consultation?

Let us say that I am in an accident and emergency department, and a doctor does something stupid. How do I know where to complain? How do you deal with verbal complaints as opposed to written complaints? Not everybody wants to put a complaint in writing, and they may not be capable of doing so.

Mr Andrew Browne (Department of Health, Social Services and Public Safety):

My understanding is that maladministration, as such, is not defined in legislation. However, the ombudsman takes that to mean any kind of poor administration or any wrong application of the rules. We believe that that gives him wide powers to investigate the breadth of complaints about the Health Service.

Mr Easton:

You think that that is the case?

Mr A Browne:

That is my understanding. I would not like to speak for the ombudsman.

Mr Easton:

You are not totally sure?

Mr A Browne:

We are confident that the ombudsman can deal with complaints. You heard that there were 5,300 complaints last year. We are confident that the ombudsman can deal with those complaints where the complainant remains dissatisfied.

The Acting Chairperson:

The Committee should seek clarification of the terminology.

Mr Easton:

You are reasonably confident, but not quite confident enough. I would like further clarification.

Dr Livingstone:

We are happy to look into that and come back to you. We may take some further legal advice. The new legislation and directions will have been subject to legal scrutiny. We will happily look into that matter.

The Acting Chairperson:

I do not think that anyone is being critical. Anything that improves standards in the health sector is to be welcomed. However, we need to raise questions on issues that concern us.

Dr Livingstone:

I am happy to take that on board. Paula, will you deal with the question on the scope of the consultation and the involvement of actual complainants and users?

Ms McGeown:

The consultation began in November 2006. However, before that, much pre-consultation was conducted, which involved the health and social care services and many voluntary and community bodies. There were many workshops. We worked closely with the former health and social services councils, and they facilitated workshops in the community and voluntary side. Those took account of elderly people, women and some groups in the Belfast area.

Mr Easton:

Did that also consider mental-health issues?

Ms McGeown:

Yes, it did; we had one meeting with a mental-health group in the Belfast area. The consultation was extended for a further four weeks to accommodate the number of responses. I do not have the notes with me, but I think that there were 90 or 91 responses. The summary of the consultation was published on the Department’s website in late 2007 or January 2008. The information is readily available, and there is a list of all the people who were consulted and who responded. There was extensive consultation and a long review process. It seems to have gone on for ever. [Laughter.]

Dr Livingstone:

The issue of verbal complaints is not easy, which is why the training of health and social care staff is particularly important. Complaints managers are now specifically identified. Usually, a complainant will first make a verbal complaint, and the procedure is to capture that complaint in writing. Without that, a verbal complaint becomes hearsay, and that is hard to follow up. Therefore, it is important to capture the complaint in writing. If the complainant does not commit to writing, there is a procedure to enable a complaints manager to take the information verbally and record it in writing. The manager will then ensure that the complainant is satisfied with what has been written.

The Patient and Client Council is an important new dimension; it has a specific role in helping and supporting complainants. If people feel unable to make a face-to-face complaint directly to an individual or organisation, the Patient and Client Council is available to help and support them. All our advertising — I have brought some leaflets and posters for members to view — clearly sets out the contact details for the Patient and Client Council.

We are trying to cover every contingency. For example, there will be individuals who may have difficulty writing or people whose first language is not English. All our leaflets and posters are being printed in a number of languages other than English. It is about making the complaints procedure more accessible, and that is a key issue to consider during the evaluation. We will consider whether the process is accessible and whether there are elements about the procedure that put people off or make it difficult for them to make a complaint.

It is about a cultural change. It is about moving away from the mindset that besets many organisations in the public sector — and the private sector, for that matter — that a complaint is an irritant that has to be managed away. We now look on complaints in the same way as incident reports, as key events from which we must learn. In many cases, there is something to be learned that will enable us to improve quality. It is about valuing complaints, being positive and welcoming them, and making sure that they can be made. If there are any barriers to the complaints procedure, that needs to be addressed.

Mr Easton:

Can you guarantee that the posters will be in accident and emergency units, outpatient units and GPs’ surgeries so that people can clearly see how to make a complaint?

Ms McGeown:

That is written into legislation, and the directions state that the arrangements must be publicised.

Dr Livingstone:

It is stated in the directions that it is the responsibility of the Health and Social Care Board, in particular, to ensure that all trusts and family practitioner services display the leaflets and posters. I cannot possibly guarantee that there is no building in which the poster is not displayed because someone has torn it down or it has fallen down. However, I assure you that, as the main commissioning body, the board fully understands its responsibility to provide the Department with an assurance that the complaints process is advertised.

Mrs Hanna:

I welcome the new procedures; they were much needed. Constituents often come to see me with complaints. Perhaps the complaint is quite minor, but, if it is not addressed, it grows and grows and gets out of control. If someone had dealt with the complaint, perhaps with a kind word or an apology, it could have been sorted out very easily.

Dr Livingstone:

The training of health and social care staff is not just about procedures. It starts with that, but it is about attitude and the way in which complainants are dealt with. It is about a cultural change in health and social care internationally, because this is a problem in many other countries. It is about persuading people that it is possible to apologise for something without accepting the blame. If complainants at least had a recognition from the person dealing with them that they were genuinely concerned and sorry, many other complaints would never go as far as they do.

Mrs Hanna:

Much of it is about attitude. We all know that smiles, politeness and friendliness make all the difference. Attitude can make a huge difference to people who are vulnerable and sick. Their condition can go downhill quickly if the attitude to them is poor. Many complaints that I have received have indicated that. Maeve Hully is the chief executive of the new Patient and Client Council. Is the council being used much yet, or is it too early to say?

Dr Livingstone:

I appreciate that we cannot keep saying that it is “too early to say”.

Mrs Hanna:

I realise that the council has only been established.

Dr Livingstone:

The bodies are only now in place. I had a meeting with Maeve today. We meet regularly now to ensure that the scope of the personal and public involvement policy, for which we are responsible and which embraces not only the complaints procedure but many other issues to do with consultation with users and patients. The council is keen to develop the capacity to provide that support to complainants.

Mrs Hanna:

The wider complaints that have been in the media recently have been about hospital cleanliness. I am sure that you are well aware of some of those. I have had some of them. There still seems to be some outstanding concerns about that. I know that those are a different kind of complaint, but they are still a complaint.

Why did you remove the independent review process? Is there a separate system for staff to complain about conditions, such as a lack of cleanliness in a ward? That goes back to the issue of whistle-blowing and the concerns and lack of confidence that some staff have about making complaints.

Dr Livingstone:

Under the previous procedure, when patients or clients registered a complaint with a trust or a GP and was unsatisfied with the outcome, they went to the relevant board at that time. The board had a panel and a convenor, who was invariably a non-executive director. A decision would be made as to whether the case would be heard, and many were sent back. That was part of the problem: there was a growing lack of confidence that people seeking an independent review were being pushed back. Just over 100 people sought independent reviews from the boards last year, about 10 of which resulted in an independent review panel being set up. It was a small component of the process.

The public attitudes survey and other sources of information pointed to a lack of confidence. People were saying that it was not worth going down that route. The numbers show that up, in a sense. If it was regarded by the public as a truly independent review process in which they could have confidence, I suspect that there would have been more than 100 requests for independent reviews.

Mrs Hanna:

It was not working.

Dr Livingstone:

It was not working. Northern Ireland is not alone in that. Scotland and England came to the same view quite independently that appealing to the strategic health authorities was not viewed by the public as an independent process. The ombudsman’s office provides an independent investigation service, which was always open to people, but it now means that people can go to that much sooner. We have to be sure that that does not create a logjam in other ways. That is, fundamentally, why the independent review process was taken away.

Mrs Hanna:

Is there a separate system for staff to make complaints?

Dr Livingstone:

The human resources division has a whistle-blowing policy. I am sorry; it is not my responsibility, so I cannot give you any details about that.

Mrs Hanna:

Concerns have been expressed in the media about that recently, and I have received complaints.

Ms McGeown:

There are whistle-blowing policies in organisations, which have been published.

Dr Livingstone:

From a staff point of view, many adverse incidents fall into one of the areas of my responsibility in the safety, quality and standards directorate, where a member of staff, whether it be a cleaner, a nurse, a junior doctor or a consultant, sees something that is not right or is potentially dangerous or improper.

The main problem is the development of a culture that ensures that people feel confident that they can raise issues of that kind, particularly those that affect patient safety, and not be victimised. That is not only in Northern Ireland; it is almost universal, and there are endless conferences and publications on the subject. People have either experienced victimisation or assumed that it would happen, and the result is that one of our biggest challenges is changing the culture to encourage people to report things that are not right. Hiding or putting barriers around such information means that we are not learning about changes and improvements that need to be made to the system. That is highly dangerous to patient safety.

Mrs Hanna:

I agree that part of the solution is a culture change, but there must also be tight protocols around making a complaint.

Dr Livingstone:

We reviewed our policy on adverse incidents last year, and the implementation of a new system will begin this year. The Public Health Agency will take the lead in that process to develop a culture of learning, encourage the reporting of adverse incidents and ensure that we develop a system that is accountable and transparent, and that improves the quality of service.

Mrs Hanna:

It would be useful for the Committee to get a copy of the written protocols.

Dr Livingstone:

That is no problem.

Mrs McGill:

We are talking about making formal complaints. If someone sees something in a hospital that he or she wants to complain about immediately, who does he or she go to? Is there someone on site, or is there helpline? That is particularly important if someone has information on what is happening to a patient.

Dr Livingstone:

The procedure and training sends the message to staff and patients that they should go to the nearest member of staff with their complaints; if someone is on a ward and has a complaint, he or she should call a nurse, the sister or whoever is available and register it immediately. The member of staff who takes the complaint is required under procedure to ensure that it is registered and put in writing. If that member of staff is unable to resolve the problem immediately, there are dedicated complaints managers to make sure that it is registered and dealt with. The complaints managers are additional staff that we have funded with another £500,000 this year. The first recourse of someone with a complaint should be the nearest member of staff. A circumstance could arise in which a patient, or a client in a social care setting, feels unable to raise his or her complaint with the nearest member of staff or the organisation involved. That is why we have the Patient and Client Council in the background to provide support. Posters and leaflets provide information on how to contact that organisation.

Mrs McGill:

That information is very helpful. If someone goes to the nearest medic with a complaint, does he or she write it down?

Ms McGeown:

If the complaint can be dealt with on the sport, it will be. If it cannot, it will need to be referred to someone else. For example, if an individual wants to complain to the nurse who is providing his or her care, section 3.14 of the guidance states:

“However received, the first responsibility of staff is to ensure that the service user’s immediate care needs are being met.”

The care provider will make sure that that happens and that no one runs off to deal with a complaint when a patient needs care. If a nurse can deal with the complaint, it will be dealt with on the spot. If the complaint cannot be dealt with, it will be referred to the complaints officer. It will then become a written complaint and is, therefore, recorded.

Mrs McGill:

Does the nurse refer it to the complaints officer? Is that recorded?

Ms McGeown:

The nurse could assist the patient in writing a complaint, or the nurse could suggest that the Patient and Client Council would help the patient to formulate a complaint, write a letter or contact the complaints officer. There are different ways of proceeding.

Dr Livingstone:

We are trying to create a culture in which every member of staff is a complaints officer. Although there are dedicated complaints managers, our training tells all staff that they are responsible for dealing with complaints from the outset. It is their duty to help the patient to resolve the complaint or have it dealt with. Rather than saying that one person deals with complaints, everybody has to deal with them.

Mrs McGill:

That is very welcome. You are confident that, if the scenario did arise, the nurse, or whoever it happened to be, would not be offended, and there would not be an adverse impact on anything. They would know that that particular nurse would have the necessary training to deal with the complaint in a polite and appropriate manner.

Dr Livingstone:

Much training has already been undertaken, and it will continue indefinitely. We are not introducing a process whereby the training will finish this year; it will go on. The idea is that staff should always have the skills and recognise what their duties are. The evaluation process that we will undertake from next year will test how well that happens, how effective the training is and how effective it has been in ensuring that staff respond to a complaint. Undoubtedly, we will find cases where complaints were not dealt with according to procedure; that is human nature. We will be assiduous that the evaluation process ensures that the system works much better than it did in the past.

The Acting Chairperson:

Every time documents or consultation documents are brought to the Committee, interest groups will contact us, especially on the issue of mental health. The PIPS/Greater Shankill Bereaved Families Rights Group monitored, and had concerns about, the old system. According to its research, the number of mental-health-service users accessing the complaints system has fallen consistently from a baseline of 31% in November 2007 to 14 % in September 2008 and 6% in May 2009.

The group said that people did not know how to make a complaint. It stated that people did not believe that their complaint would make any difference to the system or how the service was run. These are genuine concerns from people who have been caught up in the system, especially on the issue of mental health. Can you address that issue?

The group informed us that it received a letter from the Department on 4 March 2009, saying that the Department had no role in monitoring the effectiveness of the complaints system, and that that task falls to the Health and Social Care Board. It is like Big Brother watching Big Brother. Where does the Department stand? If the board is not dealing with the issue correctly, how can it monitor itself when, as you said earlier, it is in the legislation? Who monitors whether it is done?

Dr Livingstone:

The evidence of mental-health patients’ confidence in the system having been problematic in the past is the best evidence as to why the system had to change. There is a declining number of people in that group registering complaints. I agree that that evidence showed that the system had to change because people did not have confidence in it. I am confident that the new system will enable complaints to be dealt with better; however, I cannot be 100% confident until we have done an evaluation.

Beyond the Department and the Health and Social Care Board, the Patient and Client Council has an important role to play in providing that support to ensure that all patients and clients have the support that they need. I sincerely hope that that group sees a real change in circumstances.

The new board, which was set up under the review of public administration, must monitor the system and ensure that it works in the trusts and family practitioner services; it is accountable to the Department for that. We own the policy, so my job is to ensure that the board does its job. It can be described as Big Brother watching Big Brother. My team and I are not experts in handling complaints; rather, we are the policy-makers. Our job is to ensure that the people running the system are properly evaluated. I will not simply accept any form of evaluation; rather, I will be looking for a detailed and robust evaluation. We own the policy so, if the policy is not working, we want to change it.

As with all health and social care bodies, the Patient and Client Council has a new and important duty to have consultation schemes in place by December 2009. That onerous responsibility is set out in sections 19 and 20 of the Health and Social Care (Reform) Act ( Northern Ireland) 2009. The bodies must engage and involve users, members of the public and various groups in decision-making, planning and implementation of all services, including the complaints procedure. That heavy duty is set out in legislation. We will take receipt of those consultation schemes in December.

We will consult with the Patient and Client Council on how effective those are before we either approve them or ask for them to be amended in some respect. Bodies that deliver health and social care services now have a greater duty to give real meaning to the idea of public and personal involvement in all aspects of service-planning delivery. I hope that that deals with your question.

The Acting Chairperson:

On behalf of the Committee, I take this opportunity to thank you for coming here today and for briefing us on the issues. Members felt that they had to make certain comments. I hope that this process has helped your thinking about the complaints procedure. We need to keep an eye on the issue of mental health.

Dr Livingstone:

I agree.

The Acting Chairperson:

Sometimes, people who have mental-health issues do not go out and seek help. That is probably why there is a lack of complaints. Once again, thank you for coming along.