Memorandum by the Health Service Commissioner
for England (HO 1)
1. In my Annual Report for 2000-01, which
covers English complaints only, I provided information about the
activity of the Office and about work to improve its performance
and to develop our practice. I also dealt with four themes arising
from cases: failures in communication and complaints handling;
complaints about the standard of care given by nursing staff;
inadequate supervision of and support for junior medical staff;
and problems caused by vexatious and unreasonably persistent complainants.
Since that Report was published in June 2001, a number of significant
developments have occurred that might affect on the workload and
effectiveness of my office, including consultation on the NHS
complaints procedure and discussions about the handling of clinical
2. During 2000-01 my office received 2,595
complaints against NHS bodies and practitioners in England, compared
with 2,526 in the previous year. In the first six months of this
year, 1368 new complaints were received, an increase of over 5
per cent on 2000-01. 241 complaints were accepted for investigation
during 2000-01 and 204 investigations reports were issued, of
which 77 per cent concerned matters of clinical judgement. In
the period from 1 April 2001 to 31 December 2001, my office issued
141 investigation reports and 152 complaints were accepted for
3. In 2000-01, my Office continued to make
improvements in its performance against targets designed to ensure
that our service was more responsive, transparent and swift. 82
per cent of correspondence received by the Office was dealt with
within 18 days. The period between the receipt of all papers and
the issue of a formal statement giving notice that my Office proposed
to investigate the complaint fell on average from 7.3 to 6.6 weeks.
In addition, revised processes for managing external professional
advice, designed to reduce throughput times, were implemented
and a Directorate for Professional Advice was established.
4. Other developments aimed at improving
the Office's service include: the establishment of more robust
arrangements for administrative support; the introduction of an
improved case-file management process; work on integrating the
investigation and advisory processes; and the introduction of
an occasional newsletter to be circulated widely within the NHS
5. Although the backlog of old cases at
the end of 2000-01 has been reduced, it remains a matter for concern.
The Office has recruited a large number of new investigation staff,
both to assist with this and to replace staff who left (many of
whom joined the plethora of new regulatory and investigatory bodies).
Inducting and training these new staff, while reducing the number
of old investigations to a minimum, will be a particular priority
for the remainder of 2001-02 and the following year.
6. A continued feature of many of the complaints
dealt with by my Office is that many of these complaints are related
to poor communication or failures in the way that complaints are
handled. Problems with communication take many forms. In some
cases, poor communication meant that patients, or their relatives,
were not made fully aware of the seriousness of their situation;
some of the pain and distress that followed could have been avoided.
In others, failure to listen to relatives and friends has led
to inadequate or delayed treatment for the patient.
7. I have often drawn attention to justified
concerns about the way in which NHS bodies have sometimes handled
complaints. These cases have involved every aspect of the NHS
complaints procedure, from interpretation of the statutory Directions
to the quality of reports produced by Independent Review Panels.
Examples of good practice in compliant handling appear at annex
A to my Annual Report.
8. Many of the complaints about clinical
care that I investigate include consideration of the care given
by nursing staff. The contact patients have with nurses during
their care is often greater than contact with medical staff, even
for out patients and patients visiting general medical practitioners.
It is thus not surprising that concerns about nursing care figure
in many of the complaints coming to my Office. In my Report, I
welcomed the Department of Health's publication Essence of Care,
which sets out benchmarks for clinical practice in areas of care
most often provided by nursing staff.
9. In most cases, the arrangements for delegation
of tasks to junior medical staff, and for their supervision and
support, have been of a good standard. But in some they have not.
In the period covered by the Annual Report, I reported on six
such cases. The reasons why senior staff were not called upon,
or were not available at the time, varied: pressure of work, an
error of judgement as to the seriousness of the situation, or
on call arrangements that were not clear to all. I believe it
is the responsibility of senior clinical staff to create the circumstances
in which barriers to communication between senior and junior staff
can be identified and dealt with.
10. Most complainants behave entirely reasonably;
however, a few do not. All organisations, including my own, have
to be mindful that they have responsibilities to their staff and
to others who use their services as well as to the complainant
of the moment. A growing number of NHS organisations in England
are devising policies for managing such situations. I welcome
this. Such policies provide support for the often difficult work
of NHS complaints managers. It is desirable that any restriction
placed on complainants should be the result of a fair and consistent
policy, and that complainants should be regarded as vexatious
or unreasonably persistent only for good reasons, and not just
because they are forceful and determined.
NHS COMPLAINTS PROCEDURE
11. The Department of Health has undertaken
work to evaluate and reform the NHS complaints procedure. This
culminated in a listening document "Reforming the NHS complaints
procedure". I welcome the opportunity to comment on that
document; many of the concerns it contained reflect my own views
on the strengths and weaknesses of the NHS complaints procedure.
The experience of my Office is that complainants are more likely
to be satisfied by a procedure that is speedy, involves thorough
investigation of their concerns, and results in action that reduces
the likelihood that the problem complained about will happen again.
12. To this end, I believe that there have
to be commonly understood performance standards for dealing with
complaints, and that these should include time limits. In addition,
a more comprehensive description of the standards expected of
NHS bodies in their management of complaints would support the
reasonable expectations of the complaints process of both staff
13. I believe that complainants should have
recourse to a stage in the complaints procedure beyond local resolution;
and that the Independent Review Panel stage, or something like
it, offers both complainants and NHS bodies the benefits of local
knowledge and prospect of effective action. I therefore believe
that the Independent Review process, or something like it that
operates in a more independent, consistent and authoritative way,
should be retained. However, I have also suggested that there
should be a "fast track" to my office. Some complainants
already come to me directly, and I do investigate some of those
cases. I believe that there are some complaints that are more
likely to be satisfactorily resolved by an investigation by my
office than by a panel-type hearing. All these issues are under
discussion with Department of Health officials.
14. In my experience, NHS bodies have found
themselves in difficulty when they wished to make a small consolatory
payment in response to a justified complaint but believe that
they could not do so under current Standing Financial Instructions.
It seems to me that if a Code of Practice for the NHS were established
which recognised that financial redress was sometimes appropriate,
considerable stress and expense might be avoided for all parties.
In the longer term, this approach might see a break in the traditional
link between an admission of personal liability and financial
redress, which is a feature of the current system. These points
are also relevant to the discussion led by the Chief Medical Officer
(and in which I am taking part) of possible reform of the clinical
M S Buckley