Reforming the NHS Complaints Procedure. Report on the responses to a consultation

Report on the responses to a consultation prepared by Scottish Health Feedback Scottish Health Feedback 5 Leamington Terrace Edinburgh EH10 4JW 0131 228 2167 enquiries@scottishhealthfeedback.co.uk September 2003

CONTENTS 1. Introduction...1 1.1. Consultations on Patient Focus and Public Involvement... 1 1.2. Background to the consultation on Reforming the NHS Complaints Procedure 1 2. Aims and methods of the analysis of responses... 3 2.1. Aims... 3 2.2. Methods... 3 2.3. Presentation of results... 3 3. Who responded and how... 6 3.1. Respondents... 6 3.2. Methods of gathering responses... 7 3.3. Structure of responses... 8 4. Results of the analysis... 9 4.1. Structure of Results section... 9 4.2. Responses to Feedback form questions... 9 4.3. Responses to paragraphs within the draft document... 44 4.4. Responses to the Annexes to the draft document... 52 4.5. Emerging themes... 53 5. Summary and Conclusions... 60 5.1. Feedback form questions... 60 5.2. Emerging themes... 64 5.3. Conclusions... 64 Appendix 1: Methods of analysis Appendix 2: List of respondents Appendix 3: Additional points made in response to feedback questions Appendix 4: Alternative proposals in response to Question 10

Reforming the NHS Complaints Procedure Report on the responses to a consultation 1. Introduction 1.1. Consultations on Patient Focus and Public Involvement The White Paper Partnership for Care 1 was published by the Scottish Executive in February 2003. Among many other proposals for the NHS in Scotland, this confirmed the commitments in an earlier paper, Patient Focus and Public Involvement 2, published in December 2001, to introduce and implement a framework for a change in the way in which the health service interacts with the people it serves. Shortly after Partnership for Care, the Executive published three consultation papers, each presenting more detailed proposals for one aspect of this programme, namely: - Reforming the NHS Complaints Procedure - A new public involvement structure for NHSScotland - Patient rights and responsibilities. Accompanying each paper was a set of feedback questions covering key aspects on which the Scottish Executive was seeking opinions. People wishing to give their opinions were free either to use the structure provided by these questions or to comment in any other way. The Scottish Executive commissioned Scottish Health Feedback 3 to analyse and report on the responses to these consultation papers. This report presents the results of the responses to the first of these consultation papers, Reforming the NHS Complaints Procedure. A shorter Executive Summary is available separately, from the address given at the end of this Introduction. 1.2. Background to the consultation on Reforming the NHS Complaints Procedure The current UK-wide NHS complaints procedure was introduced in April 1996. Feedback from patients and NHS staff suggested that it needed updated. Together with other UK Health Departments, NHSScotland commissioned an independent evaluation of the operation of the complaints procedure. The evaluation and comments on its conclusions and recommendations confirmed the need to develop a revised procedure. 1 Scottish Executive Health Department, 2003 2 Scottish Executive Health Department, 2001 3 Scottish Health Feedback (SHF) is an independent research agency. It is not part of the Scottish Executive. The Scottish Executive funded SHF to undertake this analysis and produce an independent, objective report. Scottish Health Feedback 1

An advisory group of representatives of NHS staff, the public and patients was established to consider the evaluation report, the comments received on it and to advise on the development of a new NHS Complaints Procedure. The Advisory Group aimed to develop proposals for creating a complaints procedure which would be credible, easy to use, demonstrably independent and effective. These proposals are set out in the consultation paper and are aimed at: creating a more patient focused approach to local resolution; better support for local resolution in Family Health Services; replacing the internal independent review process with one carried out by an appropriate national body; and creating a quality assured process that would assess the effectiveness of the complaints procedures in each NHS Board area. The consultation paper was distributed across Scotland and responses were collated by the Scottish Executive and forwarded to Scottish Health Feedback for analysis. This Report, and the Executive Summary based on it, can be viewed on the website Scottish Health on the Web (SHOW): http://www.show.scot.nhs.uk/complaints Hard copies are available from: Mrs Dylais Mattison Ground East Rear St Andrews House Regent Road Edinburgh EH1 3DG Scottish Health Feedback 2

2. Aims and methods of the analysis of responses 2.1. Aims The aim of the analysis has been to produce an impartial, comprehensive yet reasonably succinct overview of the responses received to the consultation paper. This will inform the Scottish Executive Health Department in further development of the proposed changes and policies outlined in the paper, so that they may take account of the information, views and insights offered. It was essential that the way this summary was arrived at should be transparent, and this has influenced the methods used and the way the results are presented. 2.2. Methods Each response was read in full and broken down into comments. Each comment consists of a continuous section of text dealing with a particular part of the consultation document or a particular issue or theme. Each comment was coded in one or more of the following three ways, as appropriate: in relation to one of the feedback questions accompanying the Consultation Document in relation to the Section or paragraph to which it refers in the Consultation Document in relation to a more general theme or themes that emerged as significant from the content of the responses themselves (see below). More general comments relating to the approach underlying the Consultation Document, or broader issues that either did not correspond to one of the accompanying questions or spanned more than one of them, were analysed according to the major themes they addressed. These themes could not be predicted in advance but emerged from reading the responses themselves. More detail on methods of analysis is given in Appendix 1. 2.3. Presentation of results The style of presentation of the results has been heavily influenced by the requirements of comprehensiveness and impartiality. It is not the job of this report to come down on one side or another in relation to any particular issue, but to summarise fairly and fully the comments made by all parties. The results of the analysis are therefore presented at two levels. 2.3.1. Detailed results by feedback question, paragraph and additional theme In Section 4, detailed summaries are given of the comments relating to: Scottish Health Feedback 3

- each of the feedback form questions - each individual paragraph - specific themes not covered by either of the above. It is possible, therefore, to select any aspect of the consultation paper and go immediately to the relevant section of this report to see what was said about it, where the balance of opinion lies, and what issues were raised. In addition, many respondents made individual points in relation to the feedback questions which did not form part of any clear common thread of opinion, and were therefore difficult to summarise collectively. These have been summarised individually and presented in Appendix 3. The numbers of respondents making a point are reported throughout, together with indications of what kinds of respondent these were (individuals, NHS Boards, voluntary organisations and so on). This makes for comprehensive and, we believe, balanced coverage but would be difficult reading from beginning to end. 2.3.2. Overview A more accessible overview can be obtained by going straight to Section 5. The first part of this is organised according to the feedback questions, giving brief summaries of the main views expressed. This is followed by a review of the main additional emergent themes, and finally by a concluding section giving an overall picture and drawing out some of the important threads. For most readers it is probably best to read Section 5 first, then to refer to those parts of Section 4 where they wish to explore particular questions, paragraphs or themes in more detail. If they then wish to see what additional individual issues were raised in relation to a feedback question they can refer to the relevant part of Appendix 3. 2.3.3. A note on numbers A summary of over a hundred responses cannot avoid reporting numbers. We do so throughout this report, indicating how many respondents shared a particular view or made similar points. This gives the reader some broad indication of the extent of support for or opposition to each aspect of the proposals. However, a consultation is not a referendum. Each response to the consultation is valid in its own right, and should be considered as such. This report is a summary of, and a guide to, the responses; it is not a substitute for reading the responses themselves. We do not make any judgement on what weight should be placed on any response. It is for the reader to make such judgements, not ourselves as impartial reporters. Such judgements may be influenced by many factors, among which is the nature of the source of the response. An individual member of the public, an NHS Board, a professional Scottish Health Feedback 4

association, an organisation representing patients interests: these are different kinds of respondent, speaking from different perspectives, speaking as individuals or on behalf of many others. Regardless of the source, we have reported each comment equally. However, recognising that comments from different kinds of source may be seen as qualitatively different, wherever we report numbers of responses sharing a particular view we indicate not only the total, but the breakdown by category of respondent. Thus it is always possible to see how many of these respondents were individuals, how many were NHS Boards, how many service user organisations, and so on. This is a compromise. Even within a category, there are large variations in the size and nature of responding organisations. Some professional bodies represent thousands of people, some perhaps a few dozen. Some service user organisations are large, some small. Size is not the only criterion, however: for example, some organisations may have expert knowledge that gives extra credibility to their comments on some particular aspect of the proposals. Ultimately, the only way to give the reader the full picture would be to identify the source of every view. This would make this report impossibly long and difficult to read, and it would cease to be a useful guide or summary. We have therefore adopted the compromise explained above, leaving the reader the burden of deciding what weight to put on the numbers. It should always be borne in mind that the full text of all responses is publicly available. 2.3.4. Original responses The full text of all responses (except where the respondent has requested otherwise) is being made available by the Scottish Executive Health Department on its website: http://www.show.scot.nhs.uk/complaints Scottish Health Feedback 5

3. Who responded and how 3.1. Respondents There were 174 responses to the Reforming the NHS Complaints Procedure consultation document. Of these, 24 responses were from NHS Boards or NHS Trusts, 36 were from service user organisations, 58 were from individuals, 24 were anonymous responses and the remainder (34) from other sources. Table 3-1 shows the sources of all responses. It should be noted that because of the great diversity of respondents, definitions of the categories need to be broadly interpreted: they are deployed here merely to provide convenient labels for grouping and some respondents may find themselves under unfamiliar headings. When responses came from an individual giving an organisational address, it was not always clear whether that person was responding in an individual capacity or on behalf of the organisation. When in doubt, it was treated as an individual response. This means that some people who wrote from, for example, a local authority or an NHS Trust address, have been categorised as individual, perhaps because they used the pronoun I rather than we. Service user organisations is a very wide category and includes, as well as Health Councils, organisations such as Community Councils. Community Care Forums, local mental health organisations and so on. The justification for this broad grouping is that all potentially represent the interests of people who are or might be users of NHS services. NHS Boards includes Special Health Boards and the Common Services Agency, and a collective responses from an NHS Board and Trusts in one area Professional bodies include, as well as bodies like the British Medical Association and Royal College of Nursing, any grouping of people on the basis of their profession or professional interest (including, for example, a Pharmaceutical Committee, the NHS Scotland Chief Executives Group, and the trade union UNISON) Public bodies include any non-departmental body or agency The one respondent classified as a commercial organisation is the Scottish Pharmaceutical Federation, a trade association. A complete list of respondents by category is given in Appendix 2. Scottish Health Feedback 6

Table 3-1: Source of responses to Reforming the NHS Complaints Procedure Source of response Number of % of responses * responses (n=174) Individuals 58 33% Service user organisations 35 20% (including Local Health Councils) Anonymous 24 14% NHS Boards 16 9% Professional bodies 16 9% NHS Trusts 8 5% Public bodies 5 3% Voluntary organisations 6 3% Courts and legal bodies 1 0.6% Commercial organisations 1 0.6% Local authorities 0 0% Academic bodies 0 0% Other (including GP surgeries and GP 4 2% subcommittees) * percentages have been rounded Where responses were received from individuals, an attempt was made to determine whether the individual was a health professional, a service user organisation or other. There was limited success with this classification, with the majority of individual responses being classified as unspecified. Table 3-2 shows the distribution of responses from those replying in an individual capacity. Table 3-2: Responses from individuals Type of individual Number of responses % of individual responses (n=57) Health professional 15 27% Service user organisation 9 16% Other 3 5% Unspecified 30 52% In total, there were 83 (50%) people who responded on behalf of an organisation and 45 (26%) people who responded in an individual capacity: it was unclear for the remainder (42 or 24%) in which capacity they were responding. 3.2. Methods of gathering responses Scottish Health Feedback 7

Six of those responding on behalf of an organisation or group gave details of how the responses had been collected. Methods of gathering and collating views on the consultation document included: focus discussion groups, summaries of written comments, working groups, notes from meetings and informal discussions with individuals. Those who described their method of response gathering included four service user organisations (including three health councils), one health board and one professional body. 3.3. Structure of responses The consultation document was provided to potential respondents with an accompanying feedback form consisting of 12 questions that related specifically to the document. The feedback form was the sole method of response for 76 (43%) of the respondents. A slightly larger number (n=91 or 52%) responded using their own format including comments, references to paragraphs and/or answers to questions presented in the consultation document. The remainder of respondents (n=8 or 5%) responded using both the feedback form and their own format. Fifteen respondents submitted identical responses (each responding in an individual capacity). Scottish Health Feedback 8

4. Results of the analysis 4.1. Structure of Results section The results section has been structured in the following way: Section 4.2: Responses to Feedback form questions Each question is presented along with a summary of the responses to that question. Respondents answered these questions both directly, i.e. using the feedback form structure, and indirectly, that is, they addressed the questions within a response using their own structure. The main strands in all responses are summarised, and it is made clear how many respondents of which categories gave particular views. Most questions also prompted many additional points, each made by only one or a small number of respondents; these are presented separately in Appendix 3 in order to keep the length of the main text manageable. Section 4.3: Comments that relate to specific paragraphs within the document Section 4.4: Comments that relate to specific Annexes to the document Section 4.5: Emergent themes Summaries of comments that do not relate to specific questions or paragraphs but that have been identified as emerging themes from the responses. Section 5 then draws together all of the results into a summary. This structure has been adopted to enable the reader to go straight to the question, or section of the document, in which he or she is interested, and see a summary of all the comments relating to that question or section. It inevitably entails some repetition, because some topics were commented on in more than one place. Verbatim quotations have been included sparingly to illustrate pertinent points, with the category of respondent indicated. Full reports of all comments made in relation to a question, paragraph, section or theme are provided in the coding reports, fully attributed. 4.2. Responses to Feedback form questions There were 12 questions listed on the pre-prepared feedback form: Question 1: Does the information in the consultation document give you enough information on the proposed procedure? Question 2: Do you feel that the draft procedure would be easy to use? Scottish Health Feedback 9

Question 3: Do you feel that the draft procedure would be demonstrably independent and effective? Question 4: Do you agree with the roles and responsibilities set out in paragraphs 27-28? Question 5: Do you agree with the proposals for supporting individuals in paragraphs 29-33? Question 6: Do you agree with the proposals for facilitation in the Family Health Services set out in paragraphs 43-48? Question 7: Do you agree with the further recommendations for improving local resolution set out in paragraph 51? Question 8: Do you agree with the role identified in paragraphs 55-59 for Liaison Officers in Hospital and Community Health Services procedure? Question 9: Two options are offered for improving the independent review stage. Which option would you support? A National Complaints Authority (paragraphs 63-69) An earlier role for the Ombudsman (paragraphs 70-73) Question 10: Do you feel that there is an alternative option that we should consider? Question 11: Do you agree with the further recommendations for improvement set out in paragraph 75? Question 12: Are there any other comments that you would like to make about the draft NHS Complaints procedure? Comments relating to each of these questions are described in turn below. At the start of each section, numbers are given of those responding, tabulated according to the category of respondent and, where relevant, to whether they agreed or disagreed with the proposition in the question. Only those expressing a definite opinion are counted in these tables. Others may have made comments pertaining to the question, without expressing a definite opinion one way or the other, and these are taken into account in the following summary. Scottish Health Feedback 10

4.2.1. Feedback form Question 1 Question 1: Does the information in the consultation document give you enough information on the proposed procedure? Question 1 was answered either directly or indirectly by 109 respondents (see Table 4-1). Of these, the majority, 67%, felt that the document did give them enough information on the proposed procedure and 33% felt that it did not. Suggestions for improving the document so that it would provide enough information were made both by respondents who replied yes and those who replied no. Table 4-1: Respondents to Question 1 Category of respondent Yes n = 73 67% Response to Question 1 (n = 109) % of total Yes responses No n = 36 33% % of total No responses NHS Trust 2 3% 2 6% NHS Board 6 8% 4 11% Courts and Legal bodies 0 0% 0 0% Public body 1 1% 0 0% Commercial organisation 0 0% 0 0% Service user organisation 15 21% 13 36% Voluntary organisation 0 0% 2 6% Professional body 2 3% 1 3% Individual 23 31% 7 19% Other 3 4% 2 6% Anonymous 21 29% 3 8% *percentages have been rounded Respondents from: NHS Trusts, NHS Boards, public bodies, service user organisations, voluntary organisations, professional bodies and those responding in an individual capacity all suggested that more information, presented in a clearer way would aid understanding of the proposed procedure. The main points that were made by respondents were that: Insufficient detail/explanation of the roles of the facilitator, the complaints officer and the liaison officer are provided leading to confusion and poor understanding of the procedure. (9 respondents: 1 NHS Trust, 3 NHS Boards, 1 public body, 3 service user organisations, 1 anonymous) It would appear that there is a possibility of confusion in terms of the role of Liaison Officer and that of the Complaints Officer. Scottish Health Feedback 11

Service user organisation Q1: No. More about the role/function of the proposed `facilitator and `liaison officer. Anon A flowchart to illustrate the proposed procedure would have made it easier to understand and to compare to the current complaints procedure. (5 respondents: 1 professional body, 3 service user organisations, 1 voluntary organisation) a flowchart/pathway might have been beneficial in clarifying the complaints handling/ management process and also brought some clarity to the points at which the process is anticipated to change so as to bring added value and improvement. Professional body The document may be difficult to understand for those without prior knowledge of the NHS structure and the current complaints procedure. (9 respondents: 7 service user organisations, 2 individuals) I think that it would not be very easy for anyone reading this document, with no prior knowledge of the NHS Complaints Procedure, to understand how the proposed changes differ from the current process. Individual Comments were also made to suggest that: the language used in the document was too complex and needs to be vetted by an expert in Plain English (6 respondents: 4 service user organisations, 1 individual, 1 other); the document was too vague and lacking in substance which may lead to a feeling that structure is emphasised more than process (8 respondents: 1 NHS Trust, 1 NHS Board, 3 service user organisations, 2 individuals, 1 other); and the timescales included in the procedure are too vague. (5 respondents: 1 NHS Board, 1 NHS Trust, 2 service user organisations, 1 professional body) Many points were raised regarding areas of the procedure that were either not discussed in sufficient detail or not discussed at all. These are listed in Appendix 3. There was some questioning of the need for a whole new procedure and whether the existing procedure could have been revised instead. This questioning arose from some respondents views that there was a lack of sufficient details regarding the Evaluation Survey and from their concern over the validity of the findings. Scottish Health Feedback 12

4.2.2. Feedback form Question 2 Question 2: Do you feel that the draft procedure would be easy to use? Question 2 was answered either directly or indirectly by 103 respondents (see Table 4-2). Of these, 52% felt that the draft procedure would be easy to use and 48% did not. Table 4-2: Respondents to Question 2 Category of respondent Yes n = 54 52% Response to Question 2 (n=103) % of total Yes responses No n = 49 48% % of total No responses NHS Trust 1 2% 3 6% NHS Board 3 6% 5 10% Courts and Legal bodies 0 0 0 0% Public body 1 2% 1 2% Commercial organisation 0 0% 0 0% Service user organisation 10 18% 16 33% Voluntary organisation 1 2% 1 2% Professional body 1 2% 2 4% Individual 19 35% 10 20% Other 4 7% 0 0% Anonymous 14 26% 11 23% *percentages have been rounded One service user organisation and one NHS Board felt that it was difficult to answer this question without full and detailed knowledge of the current procedure. Of those who did make a direct comparison, one public body felt that the new procedure would be easier to use than the old procedure whereas one NHS Trust and one service user organisation felt that it would not be easier, or were not convinced that it would. Nine respondents (3 service user organisations, 1 voluntary organisation, 2 individuals and 3 anonymous) commented that there were too many people and bodies involved in the procedure and that this may make it difficult for members of the general public to understand and use it. A variety of respondents (1 NHS Trust, 2 NHS Boards, 3 service user organisations, 2 individuals and 1 anonymous) suggested that the procedure may be difficult to explain to patients and that there may be particular confusion regarding the differences between the roles of the complaints officer, the liaison officer and the facilitator. To aid understanding of the procedure, it was suggested that guidance notes, including flowcharts to illustrate the complaints process, are provided along with the procedure document (suggested by 1 NHS Trust, 4 NHS Boards, 6 service user organisations, 2 voluntary organisations, 1 individual and 1 other). The guidance notes should be appropriate for use by a lay person and it was noted that the new procedure will Scottish Health Feedback 13

need to be adequately publicised to users of the health service. It was also suggested by one service user organisation that the inclusion of a complainant s journey could help to make the procedure easier to understand. The need for training to be provided to all of those involved in the complaints process was highlighted by four service user organisations, two NHS Trusts, two individuals and one voluntary organisation. In addition, it was suggested that the culture or ethos of the NHS was a crucial factor in how easy the proposed complaints procedure would be to use and how effective it would be (suggested by 1 NHS Trust, 1 NHS Board, 2 service user organisations and 3 individuals). Q2: Yes. While the procedure should be easy to apply, the success or otherwise of this is dependent on the ethos and culture which is set and supported within the organisation. NHS Board Scottish Health Feedback 14

4.2.3. Feedback form Question 3 Question 3: Do you feel that the draft procedure would be demonstrably independent and effective? Question 3 was answered either directly or indirectly by 121 respondents (see Table 4-3). Of those who responded to this question, 48% felt that the draft procedure would be demonstrably independent and effective and 52% did not. Most of the responses to this question related to the independence of the proposed procedure rather than its effectiveness. Table 4-3: Respondents to Question 3 Category of respondent Yes n = 58 48% Response to Question 3 (n = 121) % of total Yes responses No n = 63 52% % of total No responses NHS Trust 1 2% 5 8% NHS Board 4 7% 2 3% Courts and Legal bodies 0 0% 0 0% Public body 2 3% 1 2% Commercial organisation 0 0% 0 0% Service user organisation 14 24% 16 25% Voluntary organisation 1 2% 2 3% Professional body 2 3% 1 2% Individual 15 26% 27 43% Other 3 5% 1 2% Anonymous 16 28% 8 13% *percentages have been rounded Thirty-four respondents felt that the proposed procedure would not be independent as the NHS would be involved in the stages preceding the Ombudsman or courts. This view was held mainly by individuals (19) and service user organisations (7). The remainder included: two NHS Trusts, one public body, one voluntary organisation, one professional body and three anonymous respondents. Sixteen of the respondents (15 individuals and 1 voluntary organisation) pointed out that review processes adopted by public bodies must be independent and impartial in order to comply with article 6(1) of the European Convention of Human Rights 1950. It was felt that the practices and procedures of the complaints system must be seen to be totally impartial and free from NHS influence (professional body). In view of this, local resolution overseen by NHS-employed chief executives, independent contractors in family health services, facilitators funded through primary care teams, complaints officers assigned by NHS organisations, NHS staff acting as liaison officers and an NHSScotland Complaints Authority were all seen to be lacking in independence. Scottish Health Feedback 15

One of the points raised (by 1 NHS Boards, 2 service user organisations, 1 NHS Trust, 1 public body and 2 anonymous respondent) was that the Ombudsman role was a crucial factor in how independent the general public would perceive the proposed procedure to be. The Ombudsman was perceived to be sufficiently independent of the NHS to ensure an unbiased viewpoint would be taken. However, two respondents (1 service user organisation and 1 anonymous) did question whether the Ombudsman role would be sufficiently resourced to cope with all the requests for review of cases. A further suggestion was that the role could be made even more independent if the Ombudsman worked with a panel comprising of members of the general public. Opinions regarding the options for either an earlier role for the Ombudsman or a National Complaints Authority are discussed in greater detail in Section 4.2.9. Of those who commented on the effectiveness of the proposed procedure, it was noted by four respondents (2 service user organisations, 1 public body and 1 professional body) that the effectiveness of the procedure will be, in part, dependent upon the training and support offered to facilitators and liaison officers. There was concern that the effectiveness of the procedure within independent contractor services would be up to the whim of the independent practitioner (individual respondent). Also, the effectiveness was questioned: where a partner or colleague is expected to act as a Complaints Officer in respect of a close member of a practice. They are unable to provide an independent, detached and, where often is needed, firm judgement on their friend and colleague. Individual Scottish Health Feedback 16

4.2.4. Feedback form Question 4 Question 4: Do you agree with the roles and responsibilities set out in paragraphs 27-28? Question 4 was answered either directly or indirectly by 120 respondents: 84% did agree with the roles and responsibilities set out in paragraphs 27-28 and 16% did not (see Table 4-4). Table 4-4: Respondents to Question 4 Response to Question 4 (n = 120) Category of respondent Yes n = 101 84% % of total Yes responses No n = 19 16% % of total No responses NHS Trust 6 6% 0 0% NHS Board 9 9% 1 5% Courts and Legal bodies 0 0% 0 0% Public body 3 3% 0 0% Commercial organisation 0 0% 0 0% Service user organisation 24 24% 5 26% Voluntary organisation 1 1% 0 0% Professional body 9 9% 1 5% Individual 22 22% 9 47% Other 4 4% 0 0% Anonymous 23 23% 3 16% *percentages have been rounded One of the main comments in response to the complaints officer role was that there was difficulty in differentiating between the role of the complaints officer and the liaison officer. (This response was made by 10 of the respondents: 3 NHS Boards, 3 service user organisations, 1 voluntary organisation, 1 professional body and 1 anonymous.) To help clarify this there was a general call for greater clarity of the role of the complaints officer. Suggestions of additions to the complaints officer role were made including: Awareness raising of the nature of complaints to wider departments who also have an interest in that part of the service (1 individual) Ensuring that all NHS staff are provided with high quality training to enable them to deal effectively with patients complaints (1 public body and 1 professional body) Ensuring that there is a systematic approach to learning lessons arising from complaints (1 service user organisation) Ensuring that NHS staff certify that their account is true to the best of their knowledge and that they respond to the complainant s account of the events (15 individuals and 1 voluntary organisation) Scottish Health Feedback 17

Investigate the complaints/concerns raised (1 NHS Trust and 1 service user organisation) Monitoring complaints to establish patterns of common complaints and the operation of the complaints process, particularly evaluating the complainant s experience of using the process (1 service user organisation) Liaison with those responsible for risk management and clinical governance to ensure that information about complaints is used to improve standards of care (1 NHS Board and 2 professional bodies). Five of the respondents (3 service user organisations, 1 professional body and 1 individual) disagreed with the fourth item in paragraph 28 of the consultation document (a list of what is included in the complaint officer s role), namely ensuring that there is a local policy for dealing with vexatious and habitual complaints. It was felt that there should be both a national and a local policy in order to ensure consistency across all areas. One local health council suggested that: Ensuring there is a local policy for dealing with vexatious and habitual complaints could be construed as denying people the right to make a complaint, in the opinion of members. Service user organisation And a response from various local health councils suggested that: Protocol for handling vexatious and habitual complainants must be agreed nationally and be informed by national guidance. Service user organisation In addition to this, the title Complaints Officer was criticised by six respondents (2 service user organisations, 1 public body, 1 professional body, 1 individual and 1 other) as it has negative connotations and does not acknowledge that some people may want to comment on the system (including giving positive feedback) rather than lodging a complaint. One individual suggested that the title of Officer reeks of bureaucracy and signifies a passive rank rather than an active role. This statement was supported by a service user organisation who suggested that a change of name would make the role more approachable from the public perspective. Alternative title suggestions included: Patient Feedback Officer Patient Services Manager Patient Relations Officer, Manager or Executive Quality Improvement Officer. Comments regarding the complaints officer role included the need to acknowledge that the officer would require dedicated time, training, administrative and emotional support to perform their role effectively. (These comments were made by: 4 service user organisations, 3 individuals, 2 professional bodies, 1 other and 1 anonymous respondent.) Six respondents (3 NHS Trusts, 2 service user organisations and 1 individual) noted that it would be important that the officer had a good working knowledge of the organisation in which the complaint had arisen as: Scottish Health Feedback 18

A Complaints Officer covering a large NHS Trust with different hospitals and specialisms might be too remote from clinical services to understand the detail and nuances of complaints. NHS Trust The independence of a complaints officer employed and assigned by an NHS organisation was questioned by 14 of the respondents (6 service user organisations, 5 individuals, 2 anonymous and 1 professional body). It was suggested that: Any member of the NHS organisation is going to be biased in their assessment of a complaint. What is needed is complete independence from NHS involvement when assessing the complaint. Service user organisation and that an alternative route to employing a complaints officer with greater perceived impartiality would be to appoint complaints officers: in a manner similar to NHS Board Chairmen rather than being part of mainstream NHS staff, this would certainly enhance their independence and might engender more confidence in the impartiality of the handling of complaints. Service user organisation Clarification of the relationship between the complaints officer and the senior member of the executive team (referred to in paragraph 27 of the consultation document), in addition to clarification of the level/grade of the complaints officer, was requested by nine respondents (3 NHS Boards, 2 NHS Trusts, 1 service user organisation, 1 professional body, 1 public body and 1 other). Specifically, clarification was requested of the grade/level of the complaints officer to enable them to deal with the issues raised quickly and effectively without needing to refer, in all but the most exceptional circumstances, to more senior staff (requested by 2 NHS Boards, 2 local health councils and 1 NHS Trust). It was noted by one NHS Board respondent that that this is not reflected in the current pay structure which lists complaints staff at very junior grades. There were particular concerns about the complaints officer s role in the Family Health Service setting. It was noted that the role is currently often filled by the practice manager and that this would be likely to continue once the new procedure was implemented. The main concern (by 4 professional body respondents) was the resource implications of having a complaints officer within general practice. There were concerns that the practice manager/complaints officer would not have sufficient time to dedicate to the role. It was suggested that the new procedure should emphasise the need for protected time for the complaints officer tasks. There were additional concerns about the impartiality of a complaints officer within a general practice, particularly a smaller or more rural practice (noted by 3 service user organisations, 1 individual and 1 anonymous respondent). It was suggested that: Scottish Health Feedback 19

independence is compromised if complaints are dealt with solely within the practice and would suggest a role in complaints for LHCCs. It is not uncommon for patients to be deregistered as a consequence of making a complaint and this is a particular fear for patients in rural areas Service user organisation Also, there was questioning by one public body, one NHS Trust, one professional body and one service user organisation of the status or managerial leverage of practice managers and whether they would be regarded as someone of sufficient seniority for the complaints officer role: Consideration also requires to be given to the status of some of the Practice Managers and their ability to generate the managerial leverage suggested as necessary within the report. Is it envisaged that this leverage will occur as a consequence of the core quality requirements contained within the proposed GMS contract? Paragraph 28: The consultative document does not clarify how practice managers will fulfil their revised role. Consideration could perhaps have been given to pathways to be followed in each part of the service. Professional body Sixteen respondents (12 service user organisations, 1 NHS Trust, 1 public body, 1 professional body and 1 individual) gave a definitive answer regarding whether they supported the proposal for the appointment of a named senior member of the executive team by the Chief Executive of each NHS organisation. Fourteen did support this appointment but two respondents (1 service user organisation and 1 individual) felt that the responsibility of the chief executive cannot be delegated, therefore there should be no requirement placed on them to make appointments of any kind. Clarification of the role of the senior member of the executive was also requested by four NHS Boards, one professional body, one NHS Trust, one public body and one other respondent as it was noted that: It is not clear whether this person is likely to be the Designated Director for Public Involvement, though it would seem likely that in NHS organisations with such a director, this would be part of his or her role. Public body Finally, it was suggested by one NHS Board that the responsibility for delivering the organisation s patient feedback and complaints process (paragraph 27) may be better undertaken by clinical governance support staff as this would: allow greater opportunity for transferable lessons to be learned and for the complaints/feedback function to be related to performance management and review systems. This arrangement would strengthen the relationship between the organisation and the complaints officer. NHS Board 4.2.5. Feedback form Question 5 Scottish Health Feedback 20

Question 5: Do you agree with the proposals for supporting individuals in paragraphs 29-33? Question 5 was answered either directly or indirectly by 145 respondents: 68% agreed with the proposals for supporting individuals in paragraphs 27-28 and 32% did not (see Table 4-5). Table 4-5: Respondents to Question 5 Category of respondent Yes n = 98 (68%) Response to Question 5 (n = 145) % of total Yes responses No n = 47 (32%) % of total No responses NHS Trust 4 3% 4 9% NHS Board 8 8% 5 11% Courts and Legal bodies 0 0% 0 0% Public body 4 4% 0 0% Commercial organisation 0 0% 0 0% Service user organisation 12 12% 23 49% Voluntary organisation 3 3% 0 0% Professional body 10 11% 1 2% Individual 37 38% 8 17% Other 2 2% 2 4% Anonymous 19 19% 4 9% *percentages have been rounded Of those who did agree with the proposals, the following points were raised: There is a need to clarify the relationship between the local source of independent advice and support (referred to in paragraph 30) and the specialist advocacy services (referred to in paragraph 33). (7 respondents: 4 NHS Boards, 1 NHS Trust and 2 professional bodies) There will need to be adequate funding and resources to provide an adequate and accessible source of advice/support/advocacy, particularly for those living in rural/remote areas and for those with special needs. (22 respondents: 8 service user organisations, 4 NHS Boards, 3 individuals, 2 public bodies, 3 NHS Trusts, 1 professional body, 1 voluntary organisation, and 1 other) There are concerns that the existing voluntary and advocacy agencies will not be able to meet the demand for support that is generated by the proposed procedure. Some agencies may also not wish to adopt the role proposed. (8 respondents: 5 service user organisations, 2 NHS Trusts and 1 individual) There are concerns that agencies commissioned by the NHS Boards may not be regarded as independent sources of advice and support. (4 respondents: 2 service user organisations, 1 voluntary organisation and 1 anonymous) Scottish Health Feedback 21

Those complained about may also need/want to access advice and support. (5 respondents: 4 NHS Boards and 1 professional body) In addition, it was suggested that: Citizens Advice Bureaux could be commissioned as they are able to provide specialist, expert advice and already work with local authorities. They could be given extra funding for trained staff to handle health related complaints. (4 respondents: 2 individuals, 1 service user organisation and 1 anonymous) There is already a requirement on NHS Boards to commission independent advocacy arrangements and it might be helpful to build on the existing advocacy network which is already developing independent monitoring systems. (7 respondents: 3 service user organisations, 2 public bodies, 1 NHS Board and 1 NHS Trust) In England the Commission for Patient and Public Involvement in Health (CPPIH) will be identifying and disseminating quality standards for Independent Complaints and Advocacy Services (ICAS) - the proposed Scottish Health Council could do similar work in Scotland, learning from what is happening in England. (1 public body and 1 professional body) The Advocacy Safeguards Agency (ASA) was created specifically to work with commissioners in planning and commissioning advocacy provision across Scotland and to undertake independent evaluations of advocacy projects. The ASA Development Workers are involved in local Advocacy Planning and Implementation Groups for every NHS Board area in Scotland and could develop this work to include any future need, working in conjunction with NHS Boards and local authorities. (1 public body) It is important that patients know that there is a source of advice and assistance available to them, and it may be helpful if all such services are known by the same name, for example ICAS. (1 public body and 1 voluntary organisation) Forty-seven (32%) respondents did not agree with the proposals for supporting individuals. Over half of these (27) suggested that health councils should have the role of advice and support to complainants. This was the view of four NHS Boards and three NHS Trusts, 14 service user representatives, five individuals and one anonymous respondent. It was noted that health councils have been undertaking this role since their inception and that they had accumulated a wealth of knowledge and experience. This would be lost if the role was transferred from the health councils. It was suggested that the local Health Council have the role of providing advice and support and that the Scottish Health Council, in collaboration with NHS Quality Improvement Scotland, be responsible for monitoring the service and ensuring quality standards. Scottish Health Feedback 22

There is strong support for the role of supporting individuals to stay with Health Councils... The arguments put forward against this are weak, especially given the alternative scenario of NHS Boards across Scotland contracting with a number of different, and at times, small organisations. Health Councils do not currently allow assisting complaints to unduly influence their other roles, other than in a positive way - i.e. picking up on trends etc. The argument for Health Councils retaining this role is put forward in 'A New Public Involvement Structure for NHSScotland' The issue of supporting individuals through the complaints system is important and requires sensitivity and knowledge of the health care system by nominated individuals. Service user organisation Scottish Health Feedback 23

4.2.6. Feedback form Question 6 Question 6: Do you agree with the proposals for facilitation in the Family Health Services set out in paragraphs 43-48? Question 6 was answered either directly or indirectly by 150 respondents: 76% agreed with the proposals for facilitation in the Family Health Services as set out in paragraphs 43-48 and 24% did not (see Table 4-6). Table 4-6: Respondents to Question 6 Category of respondent Yes n = 114 76% Response to Question 6 (n = 150) % of total Yes responses No n = 36 24% % of total No response NHS Trust 4 4% 1 3% NHS Board 9 8% 3 8% Courts and Legal bodies 0 0% 0 0% Public body 2 2% 1 3% Commercial organisation 2 2% 0 0% Service user organisation 21 18% 13 36% Voluntary organisation 5 4% 0 0% Professional body 8 7% 4 11% Individual 40 35% 8 22% Other 3 3% 1 3% Anonymous 20 18% 5 14% *percentages have been rounded The main point that produced comment from the respondents was the issue of impartiality, namely: can the PCT truly act as an impartial facilitator for patients, and what mechanisms should be in place to ensure that PCTs act impartially? Individual This issue was highlighted by 26 of the respondents of which 11 were service user organisations, five were individuals (including 2 health professionals responding in an individual capacity), two were professional bodies and two were NHS Boards. The remainder consisted of: one public body, two commercial organisations, one voluntary organisation, one other and one anonymous respondent. The majority (22) of respondents who commented on this issue suggested that lack of impartiality or perceived independence of the facilitator was a matter of importance. However, two respondents (1 voluntary organisation and 1 professional body) felt that impartiality would not be questioned by complainants as long as they were happy with the service they received: Scottish Health Feedback 24

It may not be seen as sufficiently independent by complainants at the outset, but what matters is that it works. Voluntary organisation There was some concern (5 respondents: 3 professional bodies, 1 service user organisation and 1 individual) that the Primary Care Trust (PCT) would find it difficult not to become embroiled in the complaint. The impartiality of the facilitator was also questioned if the Primary Care Trust was itself implicated in the complaint. In such an instance, there were questions as to whether the PCT facilitator could be involved in the case and, if not, what alternative facilitation would be made available for complainants (response by 3 professional bodies). unconvinced about the ability of PCTs to establish themselves as truly independent facilitators between medical practitioners and patients this proposal would prevent PCTs from carrying out a facilitation role if the PCT is itself one of the parties implicated in a complaint procedure. Professional body Twenty-two respondents (9 service user organisations, 5 NHS Boards, 4 NHS Trusts, 1 public body, 2 professional bodies and 1 voluntary organisation) suggested that greater clarity of the role of the facilitator would be required. Specific areas that require clarification were identified as: The differences between the role of the facilitator and the role of the conciliator, complaints officer and independent advice service. (12 respondents) Who would be employed as a facilitator and how they would be selected. (2 respondents) Where the facilitator would be based. (1 respondent) What training the facilitator would receive. (2 respondents) How facilitation would be monitored. (6 respondents) How standardisation of practice across Scotland would be achieved (2 respondents) What grade or level of seniority the facilitator would have. (3 respondents) How the facilitator would be able to provide support and advice and provide a written response without investigating the complaint (4 respondents): In para 45 it is stated that "the role of the 'facilitator' would not be to investigate the complaint, but to provide impartial advice and support to both parties". It is not clear how a facilitator would be able to provide advice or support to a member of the public without any powers of investigation, or the ability to check the factual accuracy of the allegation Public body Scottish Health Feedback 25