Complaints - what the research and policy says
- All providers of health and social care are required, as part of their registration requirements with the CQC, to have a complaints procedure.
- There is a lack of national data for complaints about social care in England.
- Complaints information can be utilised for quality and service improvement.
- Handling formal complaints can be time-consuming and costly for service providers.
- Staff training should include 'the importance of listening, encouraging complaints and learning from them. (Lister et al, 2008).
- Some people are reluctant to complain. Fears may include withdrawal of the service, being seen as a 'trouble maker', being treated differently (Francis, 2013; Healthcare Commission et al., 2006).
Complaints - what the research and policy says in more detail
'An effective complaints function is important in keeping people's faith and trust in services and is an essential building block of a high performing organisation.' (National Audit Office, 2008)
In England there is no national collation of data for complaints about social care other than those that reach the Ombudsman. The Care Quality Commission has no responsibility for considering individual complaints or for monitoring the outcomes of complaints. The Health and Social Care Information Centre collects data on NHS complaints, but not social care. This lack of data makes it difficult to comment on the effectiveness of complaints handling, satisfaction levels or whether complaints lead to service improvements. There may, however, be good practice locally.
A National Audit Office (NAO) (2008) study gave estimates on the volume of social care complaints for the period 2006-7 based on data from the census. During that time there were approximately 17,100 complaints about adult social care services, 795 of which were not resolved and reached the Ombudsman. It should be noted that numbers of complaints do not necessarily reflect badly on the service (Lister et al, 2008). If people feel very comfortable complaining and believe they can influence change, the number of complains is likely to increase.
There are clear advantages for organisations in effectively dealing with complaints. Working in partnership with people using the service and carers, and fostering a responsive open attitude, is likely to reduce the need for formal complaints which can be time-consuming and costly to handle. Complaints handled badly are also likely to have reputational impact. The NAO included an estimate that the average cost of dealing with a social care complaint at the first stage was £570. It found that 95 per cent of complaints were resolved at the first stage and that costs escalated significantly for later stages. These statistics alone should encourage service providers to ensure they are open to comments and complaints and can deal with them informally and reach early resolution.
Many people are reluctant to complain and this is reflected in attitude surveys in other countries (Lister et al, 2008); there are a number of reasons. For example, it may be difficult for people to find their way around the system, where English is not the person's first language, or because they have a cognitive impairment. Some people are reluctant to complain because they worry that it may have an impact on the service they receive. They may fear being seen as a 'trouble maker' and being treated differently as a result of their complaint; this concern was raised repeatedly in Healthcare Commission inspections (Healthcare Commission et al, 2006). Being able to complain without fear of retribution was also raised in the Department of Health (DH) online survey (DH, 2006d), that underpinned this Dignity in Care guide.
The Public Enquiry into events at Mid Staffordshire Hospital (Francis, 2013) found a reluctance to complain among patients and their families for fear of the consequences and in some cases 'because they wanted to get on with their lives'. People may fear that the process will be long and complex or that nothing will be done about their concerns (Lister et al, 2008). The NAO survey (2008) also found that the most common reason for not complaining was lack of faith that anything would be done.
The Francis report goes on to note that this fear of consequences does not just apply to the disadvantaged and that 'even those with medical qualifications may be reluctant to complain if they fear that this will lead to a deterioration in the way that their relative is cared for'. Francis points to the perceived power imbalance between those providing and receiving care as partially responsible for people's reluctance to complain (Francis, 2013).
It may be particularly difficult for a person to make a complaint about someone providing a face-to-face service on a daily basis - for example a home-care worker or residential staff - particularly if the complaint only applies to one aspect of their otherwise good work. People receiving Personal Budgets have reported that being close to their staff makes it difficult to mention things they are not happy about (SCIE service user advisory group on safeguarding, 2010). The NAO survey (2008) also found that 17 per cent of people were reluctant to complain for fear of damaging the relationship with their provider.
When people do choose to make a complaint, the outcome may not be satisfactory. With regard to dementia care in the NHS, an Alzheimer's Society survey (2009) asked the views of over a thousand carers. Of the people that had been through the complaints process, 'only 7 per cent were happy with the outcome, with 44 per cent not at all happy and 45 per cent only partly happy." In the international study by Lister et al (2008) people who made a complaint "most often wanted an explanation, an apology and reassurance that the same thing would not happen to others". Providing an apology without admission of liability is problematic for service providers but the research shows that "it is the empathy that lies behind apology that is important" (Lister et al, 2008).
There is a lack of up-to-date data in social care but the NAO survey (2008) concluded that:
'the social care complaints system has a number of shortcomings. These include: few complainants receiving advocacy services; limited evidence that lessons have been learned and services improved as a result of complaints; and a lack of monitoring of satisfaction with handling and outcomes. There is also a need for a stronger voice for those who receive services in their own homes or in registered care homes'.
It is difficult to know if there has been any progress since this report but there are clear opportunities for service improvement and quality assurance for service providers and commissioners. A series of complaints can be an important alert for the organisation that something is wrong. Information sharing between local services and the commissioner on the number, type and outcomes of complaints can inform quality assurance processes as well as serve as an early warning system.
A culture change is required to ensure that complaints are seen as an opportunity for improvement. Commissioners and managers need to encourage the right attitude to complaints among staff, to reduce blame, to focus on satisfactory outcomes and service improvements.