Policy: WtPCT CG 005 (version 3)
Management of complaints within the National Health Service (NHS)
Complaints Regulations and recording of patient compliments
Policy and Procedures
Approved: Senior Management Team – June 2007
By: Walsall Teaching Primary Care Trust Board
Replaces: Policy WtPCT CG 005 (version 2)
Review Date: July 2008
Responsibility: Complaints Manager
1. Summary
1.1. Patients are the purpose of the National Health Service (NHS), and as such Walsall
Teaching Primary Care Trust (tPCT) is committed to delivering excellent patient
services and high standards of customer care.
1.2. However, there will always be occasions when patients tell us that this has not been
their experience. Complaints provide an opportunity for us to listen to what patients are
saying about how it feels to be a patient within our services. In view of this, the tPCT
actively seeks to create a climate within which people feel able to raise concerns and
complaints.
1.3. The tPCT is committed to ensuring that all complaints are dealt with sensitively, fairly
and courteously within the parameters of the national regulations for responding to
NHS complaints. The tPCT also seeks to ensure that staff feel equipped, empowered
and supported in dealing with patient complaints.
1.4. Walsall tPCT believes that as an organisation we need to learn from complaints, and,
where appropriate, to respond by changing the way in which we do things. The tPCT
will establish arrangements for the Board, various tPCT Committees and Task Groups,
Directors and Service Managers to receive feedback from complaints to positively
influence decisions about risk management, service improvement, staff training and
organisational development.
1.5. The aim of this documentation is to clarify arrangements within Walsall tPCT for the
handling of all formal complaints raised with the organisation within the NHS
Complaints Procedure. The policy and procedures apply to all staff across the
organisation at all times.
1.6. The procedures also set out arrangements relating to Primary Care Independent
Contractor formal complaints (eg: General Practitioners, Dentists, Pharmacists and
Opticians) and for handling Joint Complaints.
1.7. The tPCT welcomes positive feedback from patients, as this helps to identify good
practice. The procedures detail arrangements for dealing with patient compliments.
1 Walsall tPCT Complaints Policy
2. The Policy
2.1. All complaints will be recorded and managed in accordance with established
procedures, which have been designed so as to ensure that systems are in place to
enable fair, timely, confidential handling of complaints, operating within the framework
of national regulations and guidance. Arrangements will also be established to respond
to compliments from patients.
2.2. Reports will be submitted to the Board and relevant sub-committees, as well as to
Associate Directors for Service Areas and Clinical Governance Task Groups. This
process will incorporate submission of an annual report to the Board.
2.3. Through these reporting processes the organisation will actively respond to
opportunities to learn from complaints with a view to reducing risk, developing staff and
service and organisational improvement.
3. Implementation
3.1. The Director of Commissioning and Performance Management has executive board
level responsibility for complaints management. However, the Chief Executive is
ultimately responsible for complaints handling and will take an active interest in all
formal complaints. Ordinarily, the Chief Executive will sign correspondence to
complainants detailing the outcome of complaint investigation.
3.2. A nominated Complaints Manager, reporting to the Associate Director of Governance,
will be the designated officer responsible for:
3.2.1. receiving and recording all formal complaints and compliments;
3.2.2. for managing the application of the NHS Complaints Procedure in respect of
individual complaints within the framework of the national regulations,
including preparation of final responses to complaints on receipt of
investigation findings;
3.2.3. for responding to contacts from the Healthcare Commission, the Health
Service Ombudsman or other relevant bodies about patient complaints;
3.2.4. for arranging response to compliments, as appropriate;
3.2.5. for ensuring that patient information about access to the NHS Complaints
Procedure is available;
3.2.6. for monitoring and analysing complaints data, and for submitting reports to the
Board, to appropriate Committees and Task Groups, and to Associate
Directors and Service Managers in respect of complaints and compliments, as
well as for complying with national statistical reporting requirements;
3.2.7. for ensuring that policies and procedures for complaints management are in
place and are accessible to staff across the tPCT, and that training is available
to support tPCT staff in complaints handling.
2 Walsall tPCT Complaints Policy
Procedures for Management of Complaints within the National
Health Service (NHS) Complaints Procedure and Recording of
Patient Compliments
Contents
1 Introduction
2 The Purpose of Complaints Management
3 Our Values and Standards
4 Who Can Complain?
5 Early Resolution – a Three Stage Approach
6 Formal Complaints – Procedures for Local Resolution
6.1 How to make a Formal Complaint
6.2 Timescales for Complaints
6.3 Processes for Local Resolution of Complaints
6.4 Primary Care Independent Contractor Complaints
6.5 Joint Working
6.6 Lay Conciliation
7 Requests to the Healthcare Commission for Independent Review
8 Matters Excluded from Consideration under the NHS Complaints Procedure
8.1 Staff Complaints
8.2 Commissioning Decisions
8.3 Performance Management or Disciplinary Action
8.4 Legal Action
9 Information and Support for Complainants and Staff
9.1 Patient Advocacy Services
9.2 Patient Information
9.3 Staff Information and Training
9.4 Persistent, Serial or Vexatious Complainants
9.5 Withdrawal of Treatment
9.6 Media Enquiries
10 Monitoring and Reporting
11 Compliments
12 Related Legislation, Policies and Procedures
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APPENDICES
A Early Resolution – a three stage approach
B Formal Complaints Procedure
3 Walsall tPCT Complaints Policy
Walsall Teaching Primary Care Trust
Procedures for Management of Complaints within the National Health Service
(NHS) Complaints Procedure and Recording of Patient Compliments
1. Introduction
All NHS organisations are required to have procedures in place for the management of
complaints, and as a minimum these procedures must satisfy the requirements of the
national NHS Complaints Procedure regulations.
Walsall tPCT believes that patients or their representatives should not be hindered when
making complaints, and that complainants should be able to have confidence that their
concerns will be dealt with professionally and be given proper consideration.
A complaint may be easily resolvable by staff on the spot, or with assistance from the Patient
Advice and Liaison Service (PALS), or may need to be dealt with within the National Health
Service Complaints Procedure (ie: formal complaints). In the case of all complaints the tPCT
is committed to resolution at the earliest possible stage.
These procedures outline how the tPCT handles formal complaints raised by or on behalf of
our service users about tPCT services. The procedures also highlight arrangements for
handling Primary Care Independent Contractor complaints.
2. The Purpose of Complaints Management
The primary function of complaints management is to address the concerns of the
complainant. This may include provision of an explanation, the offer of an apology and
assurance that the matter has been investigated and action taken to prevent a reoccurrence.
The secondary function of complaints management is to ensure that patient experience
feedback received via complaints is used to enable the organisation to learn, develop and
improve standards.
3. Our Values and Standards
3.1. Walsall tPCT aims to take complaints seriously and to manage complaints
sensitively, confidentially, thoroughly and effectively.
3.2. The tPCT will always seek to ensure that complaints are dealt with fairly and
equitably, and is committed to promoting handling of complaints that does not
discriminate against the complainant or the complained against on the grounds of
gender, age, colour, race, culture, sexual orientation or any other factor. In doing
so the Complaints Department will consider on a case-by-case basis the
presentation and format of information and correspondence in order to ensure that
our handling of the complaint and the organisation’s response are accessible and
appropriate for the individual.
3.3. Staff are expected to work strictly within the Trust’s confidentiality and Data
Protection policies. The Complaints Department stores all files in lockable storage
and access to the Complaints Database is password protected with restricted
access for relevant staff only. Complaints reports will be anonymised and will
contain no references to patients or complainants by name or any other identifying
factor. Disclosure of information to external agencies will only be with the
complainant’s permission unless there is an over-riding legal requirement to
release such information. The Complaints Department will seek advice from the
tPCT’s Information Governance Manager and, if necessary, the tPCT’s solicitors in
the event that clarification is required.
4 Walsall tPCT Complaints Policy
3.4. The tPCT promotes a solution-focused approach aimed at satisfying the patient,
and believes in offering an apology whenever appropriate.
3.5. The tPCT aims to resolve complaints at the earliest possible stage, and with this in
mind adopts a three stage approach to resolving complaints (see section 5).
3.6. The tPCT aims to provide an accessible complaints management service, and will
always aim to respond to formal complaints within the national timescales unless
there are exceptional circumstances that mean that this is not possible. On such
occasions the Complaints Department will seek to keep complainants informed of
progress.
3.7. The tPCT recognises the importance of listening to and learning from our service
users about their experiences in order to inform patient-centred decision-making
about service improvement and staff and organisational development. With this in
mind the tPCT aims to be proactive in learning from complaints and, where
appropriate, to take action and initiate change in response to complaints. The
tPCT will also use complaints to inform clinical governance and risk management
in order to maintain and improve the quality and safety of our services.
4. Who Can Complain?
Any person can complain who is, or has been, a user of our services, or who has or may be
affected by decisions we make about health services. A complaint may be expressed either
verbally or in writing.
Complaints can be received from an appropriate representative, such as a relative, friend,
carer, local representative (Member of Parliament or Local Councillor) or advocacy service
acting for the individual. However, ordinarily the Complaints Department will require
documented evidence of consent from the patient.
In the event that the patient is unable to provide written consent, then the Complaints
Department will consider whether the representative is an appropriate person to bring the
complaint on behalf of the patient, and may seek to obtain consent from the next of kin if this
is someone other than the person bringing the complaint.
Similarly, in the event that the complaint relates to a patient who has died, then the
Complaints Department will consider whether the representative is an appropriate person to
bring the complaint.
5. Early Resolution - a Three Stage Approach
The Complaints Procedure is designed to ensure that all complaints are dealt with efficiently
and effectively, but also promotes the ideal that all staff have a role in ensuring that patients’,
users’ and carers’ complaints are listened to and resolved at the earliest possible stage.
In support of a culture of early resolution the tPCT adopts a three-stage approach to
managing complaints (Appendix A):
5.1. Stage One – staff immediately on site or who receive first contact from the patient
or their representative, whether face-to-face of via the telephone, should seek to
resolve the patient’s concerns as immediately as possible in order to avoid
unnecessary escalation to the formal procedures. In doing so staff are expected
to:
deal with all such contacts positively, professionally, courteously and
sympathetically;
offer an apology whenever possible and appropriate;
5 Walsall tPCT Complaints Policy
focus on resolution, solutions and learning;
gain support and/or advice from other appropriate staff or from their manager
as necessary;
document the contact, and forward a copy to the Patient Advice and Liaison
Service (PALS) for logging as an informal contact, clarifying that the matter
has been dealt with and resolved.
If informal resolution by staff is unable to satisfy the complainant, then the patient
should be offered the opportunity to progress to stage two and/or three.
In the event that the patient’s concerns are too complex or serious to resolve
informally, or in the event that the patient’s concerns are received in writing, then
the matter should immediately progress to stages two and/or three.
5.2. Stage Two – Matters which cannot be resolved by front-line staff should be
referred to the Patient Advice and Liaison Service (PALS). PALS can often help to
resolve patient concerns through liaison between the patient or their representative
and the service. PALS are also responsible for keeping a record of patient
comments, suggestions and informal complaints. Advice and support can be
sought from tPCT’s PALS Co-ordinator.
5.3. Stage Three – Concerns raised by patients or their representatives that cannot be
resolved immediately by staff or with the involvement of PALS will usually be dealt
with within the NHS Complaints Procedure as a formal complaint (Appendix B), if
this is the patient’s wish. In addition, concerns raised in writing will ordinarily be
dealt with within the formal procedures, and as such advice should be sought from
the Complaints Department in respect of any complaints received in writing.
There will always be occasions when patients actively opt to pursue their concerns through
the formal procedure in preference to stage one or stage two, or following involvement in
stage one and/or two. Whilst the tPCT encourages the three stage approach to avoid
unnecessary escalation of complaints, complainants are entitled to use the formal procedure
if they wish to do so. Staff must not hinder patients from pursuing a formal complaint if this is
their preference and should provide any patient or their representative with information about
the Complaints Procedure on request.
If staff recognise that a complaint needs to move to stage two or three, but are uncertain
where to refer the complainant, then they should seek advice from PALS or from the
Complaints Department who will be happy to advise.
6. Formal Complaints – Procedures for Local Resolution
6.1. How to Make a Formal Complaint
As detailed above, Walsall tPCT promotes an ideal of Early Resolution.
However, if staff on site are unable to resolve the complaint to the complainant’s
satisfaction, then the complainant should be provided with information to enable
them to contact PALS and/or the Complaints Department, or, particularly in the
case of complex complaints, should be encouraged to put their concerns in writing
to the Complaints Department if they feel comfortable to do so.
Alternatively, if the complainant prefers, then their complaint can be forwarded to
the Complaints Department by the member of staff or manager who has dealt with
them at stage one, or via PALS. In such cases complaints must be forwarded as
soon as possible, and certainly within 24 hours, and should include contact details
for the complainant (name, address, telephone number) and details of the nature
of the complaint and any action taken so far in response to the complaint.
6 Walsall tPCT Complaints Policy
Complaints can also be e-mailed in confidence to the tPCT’s web-address.
6.2. Timescales for Complaints
Normally a complaint should be made within 6 months from when the matter being
complained about occurred, or within 6 months of the date of discovering that there
may be the basis of a complaint, provided that this is within 12 months of the
incident occurring.
Where a complaint is made after this time period, the Complaints Manager may
decide to investigate if they are of the opinion that:
Having taken account of all the circumstances, the complainant had good
reason for not making the complaint within the time frame; and
Notwithstanding the time that has elapsed it is still possible to investigate the
complaint effectively and efficiently.
6.3. Processes for Local Resolution of Complaints
On receipt of a formal complaint, the Complaints Department will undertake to:
6.3.1. Provide the complainant with a written acknowledgement of their complaint
within two working days. In the event that the complaint has been received
verbally then the acknowledgement will include a summary of the complaint
for the complainant’s approval. In the event that the complaint has been
raised via a representative, then proof of consent will be sought if evidence
of this has not already been provided;
6.3.2. Log the details of the complaint on the Complaints Department confidential
database system, to which will be added details and correspondence
relating to the complaint as it progresses;
6.3.3. Arrange for thorough investigation via the Associate Director and/or Service
Manager, with the purpose of answering the complainant’s questions and
resolving outstanding concerns if possible. The Manager will be expected
to provide a written report summarising the outcome of the investigation to
the Complaints Department within a given deadline;
6.3.4. Produce a final written response within 25 working days detailing the
findings of the investigation, offering an apology if appropriate, and
highlighting any actions or learning to improve the service that have
resulted from the investigation. The 25 day timescale begins from receipt
of the complaint, although in the event that the complaint summary requires
approval or proof of consent is required, then the 25 day timescale will not
begin until those have been received in the Complaints Department. The
final complaint response will ordinarily be signed by the Chief Executive, in
line with the requirements of the statutory regulations.
6.3.5. Whilst it is the tPCT’s aim that the 25 working day timescale should always
be met, this must be balanced against the need to provide a professional,
thorough and accurate response. On exceptional occasions that it is not
possible to provide a response within the 25 day timescale, the Complaints
Department will keep the complainant informed of progress.
7 Walsall tPCT Complaints Policy
6.3.6. Local resolution is frequently found to be successful, and the vast majority
of complaints do not progress past this stage. The tPCT remains
committed to local resolution of complaints whenever possible. However, if
the complainant remains dissatisfied then in many cases they may be
offered the opportunity to discuss remaining concerns with an appropriate
manager and/or conciliation using the services of a lay conciliator. In the
final response letter the complainant will also be advised of their right to
request Independent Review from the Healthcare Commission within six
months.
6.3.7. Either the tPCT or the complainant may refer a complaint to the Healthcare
Commission should the complaint remain unresolved after six months from
receipt.
6.4. Primary Care Independent Contractor Complaints
All Primary Care Independent Contractors are responsible for managing their own
complaints within NHS statutory guidelines and are required to have arrangements
in place to achieve this. Patients or service users who wish to make a complaint
about an Independent Contractor (General Practitioner, Dental Practitioner,
Optician or Pharmacist) or one of their employees should contact the appropriate
Practice Manager in the first instance.
Walsall tPCT will only become involved in the following circumstances:
When a complainant does not wish to approach the Practice directly;
When a complainant is dissatisfied with the way the Practice has handled the
complaint and wishes to receive advice about next steps;
When a Practice requests support with handling the complaint, or
Should the Healthcare Commission request our involvement during or
following Independent Review of a complaint.
In all cases Walsall tPCT will liaise with the individual Practice concerned.
Complainants who wish to make a complaint about an Independent Contractor, but
who would prefer not to do so directly, may ask the tPCT to facilitate the
complaints process on their behalf. In such cases the responsibility for
investigation and responding to the complaint remains with the Independent
Contractor, and this will be explained to the complainant. The tPCT’s role will be
facilitative, and will include receiving the complaint, passing the complaint to the
Independent Contractor, chasing progress and receiving the response. The
response will be forwarded unchanged to the complainant with advice about the
next stages of the NHS Complaints Procedure should they remain dissatisfied.
Whilst the tPCT will not change Independent Contractor responses to complaints,
the tPCT will provide support and advice to Independent Contractors and promote
good practice in handling complaints across the borough.
Independent Contractors from whom Walsall tPCT commissions NHS services for
its patients are required to report to the tPCT on an annual basis the number and
type of complaints that have been dealt with at Practice level.
6.5. Joint Working
On occasions complaints are received which relate to services provided by another
organisation, or which relate to services provided by two or more separate
organisations.
8 Walsall tPCT Complaints Policy
Complaints relating to other organisations will be forwarded promptly and the
complainant informed (permission will be sought if considered necessary). In the
event that a complaint is referred to the tPCT and at least one other organisation,
then the tPCT will seek to co-operate with that/those other organisation(s) and will,
in discussion with the complainant, agree how best to provide a response.
The method of investigation will need to take account not only of the NHS
Complaints Procedures but those adopted by the other organisation(s) if non-NHS
(eg: Local Authority). If a joint response is to be prepared then one of the
Complaint Managers should be nominated to take the lead and to be the main
point of contact for the complainant throughout the process.
The agreed process, with timescales, should be clearly documented for all
concerned and agreement reached on sharing any financial resource implications.
Information relevant to the complaint should be made freely available across
services and organisations to relevant officers, with the complainant’s consent and
with due regard to issues of patient/client confidentiality.
Joint responses will need to be appropriately agreed by all organisations to which
the response relates, and in most cases it is recommended that the final response
should be jointly signed. The response to the complaint should include details of
the next stage if the complainant remains dissatisfied, which may be different for
each organisation.
6.6. Lay Conciliation
The tPCT engages a small number of lay people to act as complaint conciliators.
Conciliation is an extension to the Local Resolution stage of the complaints
procedure.
Conciliation may be used for tPCT or Independent Contractor complaints, but can
only be embarked upon with the agreement of both parties.
Conciliation will be offered to the majority of complainants where the Complaints
Department consider that this might help to resolve the complainant’s concerns
without the need for Independent Review, and where in the judgement of the
Complaints Manager there are no factors to contra-indicate against the
engagement of a lay conciliator (such as indicators of potential aggression or
abuse).
Once a Conciliator has been appointed to take the case they will generally speak
first with the complainant to establish what matters remain unresolved and to
identify what outcome the complainant is seeking to satisfy their complaint. The
Conciliator will then speak with the service complained against, and may bring the
two parties together in a conciliation meeting if both parties are agreeable to this
and if this is felt to be a helpful step in resolving the complainant’s concerns.
On completion of conciliation the Conciliator will submit a report to the Complaints
Department detailing the steps taken during the conciliation, any actions agreed
and any further recommendations for resolving the complaint.
On completion of conciliation the Complaints Department will write to the
complainant with details of the outcome of conciliation, at which point the
complainant will be reminded of their right to approach the Healthcare Commission
to request Independent Review should they remain dissatisfied.
9 Walsall tPCT Complaints Policy
Lay conciliators can submit an application for payment from the tPCT of a nominal
fixed fee per conciliation, mainly to help cover expenses.
7. Requests to the Healthcare Commission for Independent Review
The Healthcare Commission is responsible for reviewing formal complaints about the NHS
that have not been resolved at local level, operating in compliance with the statutory
directions laid down in the national complaints regulations.
The Healthcare Commission can only review complaints that have already been raised with
and responded to by the NHS, but where the complainant is dissatisfied with their formal
written response.
The request for the Healthcare Commission to review a complaint must be made within six
months of the date of the final response letter, and can be requested in any case where:
complainant is not satisfied with the result of an investigation by an NHS Trust or
Independent Contractor;
An investigation into a complaint has not been completed within 6 months of the
date on which the complaint was made; or
Where the Complaints Manager has decided not to investigate a complaint on
the grounds that it was not made within the statutory timescales.
As soon as is reasonably practicable the Healthcare Commission must notify the
complainant as to whether it has decided to take no action, whether the matter is to be
referred back to the local NHS body or provider for further local resolution, or whether an
Independent Review is to be carried out.
Walsall tPCT will co-operate with any Independent Review of any complaint which is the
subject of investigation by the Healthcare Commission, and will respond to all requests for
information or documentation in a timely manner. In doing so, the Complaints Department
will give due regard to the relevance of information requested and the responsibilities of the
tPCT to comply with Data Protection legislation.
On completion of an Independent Review, or if the Healthcare Commission decides to take
no action, the complainant has the right to approach the Health Service Ombudsman.
Similarly, Walsall tPCT will co-operate with any investigation carried out by the Health
Service Ombudsman, and will respond to all requests for information or documentation in a
timely manner.
8. Matters Excluded from Consideration under the NHS Complaints Procedures
The following complaints are excluded from the remit of the Complaints Regulations:
A complaint made by an NHS body, which relates to the exercise of its functions
by another NHS body;
A complaint made by a primary care provider, which relates either to the exercise
of its functions by an NHS body or to the contract or arrangements under which it
provides primary care services;
A complaint made by an employee of an NHS body about any matter relating to
their contract of employment;
A complaint made by an independent provider or an NHS Foundation Trust about
any matter relating to arrangement made by an NHS body with that independent
provider, or NHS Foundation Trust;
A complaint which relates to the provision of primary medical services in
accordance with arrangements made by a Primary Care Trust with a Strategic
Health Authority under Section 28C of the 1977 Act, or under a transitional
agreement;
10 Walsall tPCT Complaints Policy
A complaint which is being, or has been, investigated by the Health Service
Ombudsman;
A complaint arising out of an NHS body’s alleged failure to comply with a data
subject request under the Data Protection Act 1998, or a request for information
under the Freedom of Information Act 2000.
A complaint about which the complainant has stated in writing an intention to take
legal proceedings; and
A complaint about which the NHS body is taking or is proposing to take
disciplinary proceedings in relation to the substance of a complaint against a
person who is the subject of a complaint.
8.1. Staff Complaints
Staff complaints cannot be considered within the NHS Complaints Procedure.
Employment issues should be considered within the relevant Human Resource
policies.
Staff concerns about clinical governance, Health and Safety, unsafe or unethical
practice, near miss or actual incidents will be considered as appropriate via Clinical
Governance, Incident Reporting, Risk Management, Whistle-blowing, Clinical
Performance and/or Health and Safety processes.
8.2. Commissioning Decisions
Disputes regarding individual patient care commissioning decisions will be
considered via the tPCT’s procedures for consideration of single patient funding
decisions. Complaints about Continuing Care decisions will be considered via
separate processes for management of Continuing Care.
8.3. Performance Management or Disciplinary Action
Whilst the tPCT recognises the benefits of adopting a “no blame” approach to
complaints investigation, we have to recognise that there will be occasions when
investigation of the complaint may indicate at any stage in the process that
disciplinary investigation should be instigated.
Under the statutory regulations matters about which the NHS body is taking or is
proposing to take disciplinary proceedings in relation to the substance of a
complaint against a person who is the subject of a complaint cannot be
investigated as an NHS complaint. Therefore, in the event that disciplinary
proceedings are to be instigated, the Complaints Procedure will be halted and the
complainant advised in writing.
Complainants have no rights to receive information relating to outcomes from
disciplinary investigations.
8.4. Legal Action
The NHS Complaints Procedure does not make provision for payment of financial
compensation or monetary redress. If a complainant explicitly indicates in writing
an intention to take legal action, or indicates that they wish to make a claim, then it
is inappropriate to follow the Complaints Procedure. The issue should then be
dealt with according to the Litigations and Claims Management Policy and
Procedure (policy no WtPCT CG 010). Straightforward matters of low value like-
for-like re-imbursement may be dealt with under tPCT arrangements for
consideration of ex-gratia re-imbursement of losses.
11 Walsall tPCT Complaints Policy
If a claim is indicated and the Complaints Procedure has already been initiated,
then the Complaints Procedure should be halted and the complainant notified in
writing. Under such circumstances investigation should not cease simply because
the Complaints Procedure has been closed, as investigation will also be required
to enable a response to be provided to any subsequent claim.
9. Information and Support for Complainants and Staff
9.1. Patient Advocacy Services
Some patients find it helpful to engage the assistance of an independent advocacy
service to help them bring their complaint. These organisations will assist
individual members of the public to make a complaint regarding health care
services, and can act as the patient’s advocate.
The Independent Complaints Advocacy Service (ICAS) is a free, professional and
independent advocacy service, commissioned by the Department of Health, which
can assist members of the public in making complaints regarding health services.
ICAS support the principle of achieving early and local resolution whenever
possible. The tPCT undertakes to co-operate with ICAS in seeking early resolution
of patient complaints whenever patients request their involvement.
Walsall tPCT is happy to co-operate with any established, professional,
independent advocacy service. However, the Complaints Department will need to
obtain proof of patient consent for staff to discuss their complaint and aspects of
their care with ICAS or any other advocacy service.
9.2. Patient Information
The Complaints Department will ensure that information is available to patients
about how to access the tPCT’s Complaints Procedure, both in leaflet form and via
the tPCT’s internet website.
The tPCT will make all reasonable efforts to provide complaints literature in
formats that are accessible and easily understood by as wide a range of patients
as possible.
Complaints Department information will include details of the PALS service, and
this should make it clear that this is a tPCT service, and as such, is not an
independent advocacy service. Information about how to access ICAS will also be
publicised via patient information literature about the tPCT’s Complaints
Procedure.
9.3. Staff Information and Training
All staff should be made aware of and have access to the Complaints Procedure,
and the location and telephone number of the Complaints Manager, to enable
them to refer complainants quickly.
The Complaints Procedure will be available to staff via the Governance
Department’s “The Tower” page on the tPCT intranet, together with supporting
information to assist staff in handling complaints and to enable staff to provide
information to patients who wish to complain.
Complaints training will be available to all staff, including induction training for all
new starters. The training will also incorporate basic customer care training in
order to help promote a positive staff approach to dealing with patients and
resolving patient concerns quickly and effectively.
12 Walsall tPCT Complaints Policy
9.4. Persistent, Serial or Vexatious Complainants
The tPCT is committed to dealing with all complainants in a fair and equitable way,
and seeks to provide a full and comprehensive response to all complaints.
However, on rare occasions some complainants may attempt to pursue the
Complaints Procedure in a manner which is deemed to be unreasonably
persistent, or even vexatious. Similarly, from time to time complainants may seek
to maintain a relentless communication via the raising of serial complaints.
Examples of such behaviour may include the persistent pursuit of unrealistic
outcomes or demands, attempts to access confidential information, persistently
unreasonable (and sometimes aggressive or abusive) behaviour towards tPCT
staff in respect of a complaint or multiple complaints, excessive and
disproportionate requests for information in respect of a complaint or multiple
complaints, persistent attempts to have complaints which are well out of time
investigated, or to have complaints which have previously been the subject of
investigation, and which may also have been considered by the Healthcare
Commission and/or the Health Service Ombudsman, re-investigated.
The tPCT will have procedures in place to deal with Persistent, Serial or Vexatious
complaints in order to ensure that there is equity, fairness and consistency in our
response to contacts of this type. Of course, it will not always be the case that a
complainant who is persistent in their contacts or who raises a number of
complaints should be dealt with via this procedure. Indeed, the tPCT believes that
the decision to apply the procedure for dealing with a complainant as a persistent,
serial or vexatious complainant should be taken rarely, and never lightly.
However, in a small number of cases the tPCT will use such procedures to limit or
restrict an individual’s access to the Complaints Procedures.
Application of the procedure for dealing with a complainant as a persistent, serial
or vexatious complainant will only be invoked when there is clear, documented
evidence that reasonable efforts have been made to respond to the complainant’s
concerns within the usual processes.
In the event that a decision is taken to limit or restrict a complainant’s access to the
Complaints Procedure, then they will be informed, in writing, with details of the
restrictions to be put in place. All such letters will be approved and signed by the
Chief Executive, or in his absence the Deputy Chief Executive.
9.5. Withdrawal of Treatment
Very occasionally patients or other members of the public behave towards staff in
a manner which is completely unacceptable. Whilst the tPCT expects staff to deal
with patients courteously and professionally, staff are not expected to tolerate
behaviour which is aggressive, abusive or threatening.
The tPCT has a Withdrawal of Treatment Policy (policy no WtPCT CG 012) which
details those behaviours which are considered unacceptable, and sets out
arrangements for dealing with unacceptable behaviour via the “yellow card/red
card” scheme.
13 Walsall tPCT Complaints Policy
The tPCT is committed to ensuring that patients are able to make complaints and
as an organisation we view complaints as an opportunity for learning. The raising
of a complaint is not in itself sufficient grounds for application of a yellow or red
card. However, if a complainant behaves in an unacceptable way towards staff,
for example, by exhibiting the type of behaviour highlighted within the Withdrawal
of Treatment Policy, then application of that policy may be appropriate.
9.6. Media Enquiries
Matters which are the subject of a complaint may come to the attention of the
media, possibly via complainants or other third parties. All media enquiries relating
to complaints should be referred to the Head of Communications and the
Complaints Manager should be informed.
That the substance of a complaint has been brought to the attention of the media
does not diminish in any way the tPCT’s responsibilities in respect of patient
confidentiality, and all complaints will continue to be dealt with on a confidential
basis. All tPCT staff are expected to maintain standards in respect of
confidentiality and information governance. Any release of information to the
media will be via the approved channels with the full involvement of the
Communications and Complaints Departments.
10. Monitoring and Reporting
The Complaints Manager is responsible for recording details of all formal complaints about
the tPCT, for analysing patterns, trends and concerns arising from complaints, and for
reporting to the Board and other relevant tPCT committees. An annual report on complaints
will also be included in the tPCT’s annual report.
The Complaints Manager will also arrange for Directors and Service Managers to receive
regular detailed reports about complaints relating to their individual areas of responsibility.
Associate Directors will be provided with a feedback form in the expectation that they should
report back to the Complaints Department learning and changes that have taken place as a
direct result of complaints, as well as clarifying action being taken in respect of any individual
complaints that risk rate above a specified level.
Responsibility for following through agreed actions, learning and service improvement arising
from complaints remains the responsibility of Associate Directors and Service Managers.
Complaints that identify potentially serious or significant concerns or shortcomings will be
reported to the tPCT’s Risk Manager and/or Clinical Governance and Clinical Audit
Managers, as well as to other relevant officers of the tPCT, in order that risk management,
auditing and monitoring arrangements can be made if necessary.
11. Compliments
It is equally important for the tPCT to receive feedback when our staff have delivered a high
standard of care, so that we can thank the member of staff or team concerned, and share
good practice with other colleagues.
If patients, users and carers wish to commend or compliment an individual or a team, they
can do so by writing to the tPCT Chief Executive, the PALS or Complaints Department, or to
the Service Manager or staff within the team, or by completing a “Tell us what you think of
our Services” leaflet.
Compliments will be copied to Service Managers, the relevant Director and the Chief
Executive. This information will also be recorded on the Complaints Department database
and reported as part of our Monitoring and Reporting processes.
14 Walsall tPCT Complaints Policy
12. Related Legislation, Policies and Procedures
The National Health Service (Complaints) Regulations 2004 Statutory Instrument
2004 no 1768
The National Health Service (Complaints) Amendment Regulations 2006 Statutory
Instrument 2006 no 2084
Clinical Governance Strategy
Risk Management Strategy
Information Governance Strategy
Communications Strategy
Whistle-blowing Policy
Withdrawal of Treatment Policy
Procedures for handling Persistent, Serial or Vexatious Complainants
15 Walsall tPCT Complaints Policy
Appendix A
WALSALL TEACHING PRIMARY CARE TRUST
EARLY RESOLUTION – A THREE STAGE APPROACH
A complaint has been made to me.
What should I do? Can I deal with this myself to the
complainant’s satisfaction?
IMMEDIATE RESOLUTION AT SERVICE LEVEL
(NB – ALL WRITTEN COMPLAINTS should be referred straight to stage
three – formal NHS Complaints Procedure)
YES NO
I have dealt with the matter and the The complainant is still dissatisfied.
complainant is satisfied. All I need to do now Perhaps my Manager or the Service
STAGE ONE
is to make a note of the complaint and what I Manager can help or deal with this?
have done, and send it to the PALS
Department to be logged as an informal
contact.
YES NO
With my Manager/the Service The complainant is still dissatisfied.
Manager involved we have been Perhaps PALS can assist and help
able to resolve the complaint and the to resolve this matter to the
complainant is now satisfied. I just complainant’s satisfaction? I need to
need to make sure that I have check that the complainant is happy
agreed with the Manager who is for me to do this, or perhaps they
going to write this up and send the would prefer to speak to PALS
report to PALS to be logged. themselves?
PALS INVOLVEMENT
YES NO
STAGE TWO
With PALS involved we have been The complainant is still
able to resolve the complaint and dissatisfied and PALS have
the complainant is now satisfied. not been able to advise or
The PALS Department will let me assist further in order to
know whether I need to do resolve the matter. The only
anything else. remaining route for the
complainant is to pursue a
formal complaint.
I will advise the complainant that they can write to our Complaints Department if they wish to
pursue a formal complaint, or with their permission I can pass their concerns to the Complaints
Department on their behalf.
STAGE THREE – INVESTIGATION OF FORMAL COMPLAINT WITHIN
NHS COMPLAINTS PROCEDURE
16 Walsall tPCT Complaints Policy
Appendix B
WALSALL TEACHING PRIMARY CARE TRUST
FORMAL COMPLAINTS PROCEDURE
STAGE THREE – INVESTIGATION OF FORMAL COMPLAINT WITHIN
NHS COMPLAINTS PROCEDURE
FORMAL COMPLAINT RECEIVED
COMPLAINT ACKNOWLEDGED WITHIN 2 WORKING DAYS,
CONFIRMING REFERRAL TO COMPLAINTS DEPARTMENT
FORWARD TO COMPLAINTS DEPARTMENT
COMPLAINT ACKNOWLEDGED BY COMPLAINTS DEPARTMENT WITHIN
2 WORKING DAYS AS NOW BEING MANAGED WITHIN NHS
COMPLAINTS PROCEDURE, AND IF NECESSARY, PATIENT CONSENT
AND/OR COMPLAINT APPROVAL / VERIFICATION TO BE SOUGHT
SERVICE MANAGER TO BE ASKED TO COMPLETE INVESTIGATION
WITHIN STIPULATED TIMESCALE (USUALLY 10 DAYS), TO BE
RETURNED TO COMPLAINTS DEPARTMENT
COMPLAINTS DEPARTMENT TO PREPARE DRAFT LETTER
FINAL RESPONSE FROM CHIEF EXECUTIVE WITHIN 25 WORKING DAYS
OF COMPLAINT RECEIPT (or of receipt of consent and/or summary
approval/verification)
COMPLAINT ENDS CONCILIATION
REQUEST FOR INDEPENDENT REVIEW MADE TO
HEALTHCARE COMMISSION WITHIN SIX MONTHS
REQUEST FOR HEALTH SERVICE
OMBUDSMAN TO INVESTIGATE
17 Walsall tPCT Complaints Policy