“Being seen and being heard”

What we can learn from two studies about complaining (or not) to regulators

A guest blog from Emerita Professor Louise Wallace and Dr Gemma Ryan-Blackwell, The Open University.

Two new studies shed fresh light on the challenges of complaining to regulators. The first, Barriers and enablers to making a complaint to a health or social care professional regulator was recently published by the PSA. The second was conducted independently of the regulators, supported by a nationally awarded research grant, ‘Witness to harm, holding to account’. Professor Louise Wallace and Dr Gemma Ryan Blackwell were among the investigators of the latter study and provide their views on what can be learnt by regulators from these two pieces of work. 

Two studies - similar stories and some new insights 

The PSA’s qualitative research report involved health and social care practitioners and service users: some had raised concerns with a regulator about the conduct of a colleague or a healthcare professional providing a service to them; and some had not, but had had a poor experience with a healthcare professional. The research found out why people raise concerns, the barriers and enablers they face, as well as suggestions on how regulators could improve the process. It presents a socio-behavioural model of the complaints journey, and its recommendations are aimed at regulators and the wider health and social care systems. It is uplifting to read a commissioned report that covers an area of real importance to regulators, and which comes up with actionable recommendations. This report is digestible, practical and worth the read. 

By contrast, our research was a qualitative survey of people who said they had been harmed and raised a concern with nine of the UK’s 13 statutory health and social care regulators. This study is going through academic peer review and will soon be published on the OU’s website. Below, we pick out common and new insights in both research reports.

Why raise a concern, or not?

Both studies found people had complex motivations for raising a concern to a regulator. This is often a combination of preventing it happening to others (patient safety), accountability (often with an admission of wrongdoing), and justice (doing the right thing for the common good). In our study, we also found people wanting an apology, which is not part of the fitness to practise (FtP) process. 

In both studies, having knowledge or experience of the complaints process, and/or professional knowledge of the sector, and/or a supportive family advocate are all characteristics of those who take the plunge and complain. 

Where people already had experience of thorough and supportive local interventions, these were noted in the language of the PSA study as “positive barriers” to raising a complaint. In other words, this is basically what should happen at a local level and staff should be confident in local resolution processes. 

Does it matter if you raise a concern?

The PSA’s research additionally highlighted why some complaints never reach a regulator. For example, some healthcare professionals (HCPs) do not complain because they have little faith or even distrust local complaints system or find there is a lack of support when they consider complaining. Regulators of course cannot investigate what they do not receive, but lack of credible and thorough local investigation may mean that a wider range of concerns are not being referred, putting patient safety at risk. This is a strong rationale for publicising ways of raising concerns locally within the service and to a regulator. 

On the flip side, some of those registrants referred to a regulator may include those  whose conduct could have been more effectively dealt with at a local level. This could be where there are ongoing serious concerns about a registrant’s misconduct or health issue posing a serious risk. If they were dealt with more thoroughly by the employer, it could help increase confidence that the employer will manage situations that colleagues are concerned about, without them needing to go directly to the regulator themselves. 

Employers have a key role in ensuring local investigations are satisfactory, and that concerns are raised about registrants whose practice may put others at risk as our interviews with  employers have shown.[i] In the PSA’s report, they describe those professionals who didn’t complain as ‘not knowing where the line should be drawn’. In our own research we found that employers found it a difficult juggling act to determine which disciplinary or health issues were their responsibility to refer on. For example, some did not refer on agency staff, leaving these registrants to continue to work in other organisations and presumably put others at risk. Employers welcomed regulator-employer liaison functions precisely because they enabled employers to funnel only the most important cases to the regulator.[ii]

So you raised a concern, now what? 

Both studies found that raising a concern was a daunting and, in many cases distressing, experience, with some fearing that raising a complaint would worsen their situation. In our research several people were resolute in their determination to complain despite the impact this might or did have on them. But many did not realise that having laboured to navigate the website, amass an account of their experience and submit it, they might be embarking on a long journey with the regulator over many months and even years. This could involve the regulator coming back to them for more information and even a witness statement and being cross examined at a public hearing. [iii],[iv]

As shown in our research, both patients and colleagues experienced ‘friction’ in the process, a lack of empathy, and where the outcome was not what they wanted, disappointment. In our research, the lack of communication and sometimes the outcome of not investigating a complaint further, led to distrust of the competence and integrity of the regulators. Often, both their trust in their local organisation and in regulation is also diminished. The PSA report found that the ‘admin burden’ of retelling of their story was ‘thankless’, ‘draining and could be prohibitive’. The PSA report includes a recommendation to regulators to provide support services. Howecer, in our study, few people found regulator support (or referral to Victim Support) alleviated their distress.

Interventions

The PSA commissioned research co created with service users, healthcare professionals and the PSA a list of things that needed to be changed by regulators to support complaints to them by healthcare professionals. Our study undertook co-creation of the list of interventions with people who have raised concerns, registered professionals, employers, unions and the regulators.  We also recommended co-creation of interventions and evaluation in practice by regulators every time they introduce a new process. i, ii

Some interventions in the PSA study have been suggested previously, and some are already in place such as the existence of alternatives to online reporting, and the need for regular updates on a complaint’s progress. Our research found that when concerns are being taken forward into investigation and pre-hearing stages, (when more information is likely to be required from the individual), updates may be sporadic and unpredictable. This led us to recommend that the communication needs of individuals are recorded by regulator staff, as some people will simply not want to hear anything until there is an outcome, while others may want regular updates at predictable times even if there is nothing further to add yet, so they can ‘tune out’ in between these points. 

As is often the case in this field there are calls for more upstream intervention including a greater emphasis on learning and patient safety rather than blame. Making this happen and changing the legal frameworks is already a well-worn path. Having a central one stop advice line is not novel but needs testing to see how it impacts the routing and relevance of concerns that end up with regulators. 

There is welcome reference in the PSA report to the prevention of re-traumatisation through a trauma-informed approach to communicating with complainants, particularly when it comes to giving evidence. This mirrors our recommendations. We also recommended that regulators capture a ‘pen picture’ of the person and their complaint and have this available to all staff within the FtP journey. This could help them to avoid having to retell a harrowing story each time they speak to another staff member or lawyer. 

Together, the insights and recommendations from both studies could help ensure complainants can be confident that they are ‘seen’ and their story has been ‘heard’. 

Footnotes

[i]Wallace, LM & Greenfield M Employer support for health and social care registered professionals, their patients and service users involved in regulatory fitness to practise proceedings in the UK. BMC Health Serv Res (Vol. 24 article no. 1268https://link.springer.com/article/10.1186/s12913-024-11646-0

[ii] Wallace, L.M., Greenfield, M. Engagement of health and social care employers in professional regulatory fitness to practise – missed regulatory and organisational opportunities?. BMC Health Serv Res 25, 255 (2025)

https://doi.org/10.1186/s12913-025-12343-2 

[iii] Ryan-Blackwell, G. & Wallace, LM. (2024) Witness to Harm, Holding to Account: What Is the Importance of Information for Members of the Public Who Give Evidence and May Be Witness in a Regulatory Hearing of a Health or Care Professional? Health Expectations. 27(4) E14168

[iv] Ryan Blackwell G, Wallace LM, and Ribenfors F (2024) A novel content and usability analysis of UK professional regulator information about raising a concern by members of the public. Health Expectations 27(5) 

https://onlinelibrary.wiley.com/doi/epdf/10.1111/hex.70027