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Who isn't complaining? Learning from those who do not complain

Our report Safer care for all launched at a Parliamentary reception on 6 September. It highlights some of the biggest challenges affecting the quality and safety of health and social care across the UK today.

We want Safer care for all to start a debate on the issues highlighted and recommendations we have put forward in the report. As part of this debate, we are planning to publish a series of guest blogs written by stakeholders from across the sector. This guest blog is from Jacob Lant, Head of Policy, Public Affairs, Research and Insight at Healthwatch England.

Complaints and feedback from patients and the public are vital sources of knowledge for the health service. Understanding who is complaining, and proactively seeking out feedback from those who do not, is vital to ensuring the NHS learns from the experiences of women, ethnic minorities, and other groups who experience poorer health outcomes overall. Yet official data about NHS complaints collected by NHS Digital currently tracks only the age of complainants and no other demographic characteristics.

At Healthwatch England, we know that most people who make a complaint don’t do it in search of compensation or retribution. They are motivated by a desire to improve care for others in the future. Seeing evidence of how past complaints have led to change and improvement makes people more likely to speak up for themselves in the future.

We also know that not everyone wants to make a formal complaint – a focus on encouraging and acting on informal feedback can empower patients to speak up through informal routes, avoiding the complexity of a formal process while giving services the same opportunity to learn and improve.

Research we conducted in 2019 found that while most trusts report publicly on the number of complaints they receive, only a minority make public any information on the changes they’ve made in response to complaints. Since then, there have been important national initiatives aimed at improving how the NHS approaches learning from complaints.

The Parliamentary and Health Service Ombudsman (PHSO) has led on development of a Complaints Standards Framework, which sets out a single national set of standards on how services should approach learning from complaints, and what feedback patients can expect to see. NHS England’s regional complaints teams have also been doing important work to compare complaints data across regions and support thematic learning on a national level.

We know that many people would like to share feedback with services on how they could improve, but only a small proportion do. The most common reason for this is that people don’t know how to share concerns.

When it comes to formal complaints, the barriers to navigating an often complex and lengthy process are even higher. Through feedback collected as part of our accessible information campaign, we know that people with sensory impairments and disabilities, as well as those who speak little or no English, often find complaints processes inaccessible.

These are also people who are already more likely to be experiencing barriers to accessing services or to receive worse quality of care. Out of 139 hospital trusts who responded to our Freedom of Information requests, only 53% reported that they always ask patients about accessible information needs at the point of first contact, and only a third (35%) told us they are fully compliant with all parts of the legally binding Accessible Information Standard.

The pandemic has also thrown up additional challenges for managing and learning from complaints, including delayed timescales for processing complaints, as well as the transition of complaints management responsibility from NHS England to Integrated Care Systems (ICSs) in some cases.

The first step to improving the accessibility of complaints processes, and ensuring that health services are proactively seeking out feedback from all patients, especially those less likely to speak up, is understanding who is complaining and who is not. To use complaints processes to address health inequalities, services need to collect more robust demographic data, including age – as currently mandated - plus gender, ethnicity, and disability at a minimum.

Our 2020 report on hospital complaints suggested several ways this demographic collection could be mandated nationally, including through an NHS Digital submission requirement, or by amending statutory complaints regulations. Services can also take the initiative to collect this data locally, although a common national taxonomy would be beneficial for regional comparisons. 

Services and ICSs should use this data to compare with demographics of patients across the service or region, to understand whether certain groups are more or less likely to complain. This would serve two purposes: allowing services to investigate whether certain groups are complaining more because they are experiencing worse care, as well as allowing services to understand which groups may be experiencing barriers to complaining and working to address these.

It’s also important to look at any complaints that have been made about the accessibility of services, to proactively address any barriers to complaining. But we know that complaints categories are not always helpful to looking at themes across a service: responding to our FoI requests, most hospital trusts told us they could not be sure how many complaints they had received around accessible information, as they had no standard way of coding these.

Lived experience groups could help services review their complaints categorisation approach to ensure there is a consistent way of logging complaints around accessibility or access for disadvantaged groups. Local Healthwatch and our partner organisations in local communities stand ready to support services in making their complaints processes more accessible, including by convening lived experience groups to feed into improving the complaints process. As part of this process, people with lived experience should be compensated for their time and input.

We’ve come a long way in recent years on shifting the mindset around complaints away from a culture of blame to a culture of learning. But there is still more to do to ensure that everyone feels equally empowered to share their experiences. Collecting the right information about who is complaining is the first step to understanding who is more or less likely to speak up and levelling the playing field. 

Related material

In the first chapter of our report Safer care for all, one of our main recommendations is to call for 'Regulators and registers work with other health and care bodies to gain a better understanding of the demographic profile of complainants and reduce barriers to raising complaints for particular groups.' Find out more in the chapter on Tackling inequalities, the full report or a list of recommendations and commitments.

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Please note the views expressed in these blogs are those of the individual bloggers and do not necessarily reflect those of the Professional Standards Authority.