Informal complaints procedure in general practice: first year's experienceBMJ 1994; 308 doi: https://doi.org/10.1136/bmj.308.6943.1546 (Published 11 June 1994) Cite this as: BMJ 1994;308:1546
- P C Pietroni,
- S De Uray-Ura
- Marylebone Health Centre, London NW1 5LT
- Centre for Community Care and Primary Health, University of Westminster, London W1M 9FB.
- Correspondence to: Dr PC Pietroni
- Accepted 7 April 1994
Objective: To evaluate the first year's experience of an informal patient complaints system that encourages extensive patient participation,
Design: Audit of an informal complaints procedure.
Setting: The Marylebone Health Centre, London.
Subjects: 39 complaints received over the audit period.
Main outcome measures: Types of complaints (administrative, about doctors or medical care or both, staff about patients, mixed, other) and resolution of complaints (how complaints were dealt with and their resolution).
Results: 37 of the 39 complaints were resolved within two weeks. Two complaints sent direct to the family health services authority were resolved (with patients' agreement) by the informal complaints procedure.
Conclusions: The informal complaints procedure was more cost effective than the family health services authority system and was comparatively straightforward to implement within the practice without major organisational restructuring. The two way process of the procedure ensured patients received a quick response to complaints and helped morale of health centre staff.
Informal in house complaints procedures are more cost effective than formal family health services authority systems
Practice based systems result in rapid resolution of complaints
Practice based systems facilitate audit of performance and encourage policy and procedural changes
Informal complaints procedures represent good customer relations and help morale of practice staff
No major organisational restructuring is required
The increased frequency of complaints by patients about providers of primary health care has been the subject of many reports both within medicine and in the media.*RF 1-6* The secretary of state's recent decision to set up a working party7 has highlighted the need for a mutually agreed system which protects both the public and professionals from the resource implications of these complaints. Defence organisation surveys showed that between 1980 and 1992 there was a 10-fold increase in complaints and that over 30% of such claims were successful.8 Women general practitioners aged under 50 have 50% fewer claims made against them than their male colleagues, but over the age of 50 women doctors are at slightly greater risk.8 Specialist publications for general practitioners have carried several surveys underpinning the stress felt by doctors associated with complaints.
Several factors have been identified as a cause of the increase in complaints. Not least is the secretary of state's statement that “complaints are to be encouraged.” Other factors arise out of the new contractual obligation, the patient's charter, and the more active role of community health councils. The purchaser provider split with the emphasis on the patient as customer has probably also changed public perception, though there is no evidence that the increase in complaints reflects a decrease in standards. Family health services authorities have at times been overwhelmed with complaints, and several have set up joint working groups with local medical committee representatives in an attempt to establish new guidelines.
Formal and informal reports on handling complaints agree that more locally based procedures should be developed and that the cumbersome and time consuming formal family health services authority hearings should be supplemented with additional procedures. It is also important to remember that within the United Kingdom the medical professional as a whole carries a very low professional negligency indemnity insurance as compared with that of other professional bodies. In the United States doctors carry negligence indemnity five times greater than that carried by the average British doctor.5 It is in order to prevent the trend to a more legalistic and expensive system that experiments in informal procedures are so necessary.
Background to project
The Marylebone Health Centre was established as an experimental primary health care centre to explore new ways of delivering care to an inner city population. The practice has a list size of around 5000 with a 30% turnover. There are two full time and two part time doctors. The sociodemographic distribution of the patients is very mixed, 34% not having English as their first language and over 200 classified as homeless. A practice based underprivileged area (Jarman) score was 61.4 (ward average 17.2).9
Part of the brief was to encourage patient participation and patient empowerment. Thus a “user” group of patients was established in 1987 and has proved popular with patients and staff alike. The aims of the group were:
To promote dialogue about current provision of primary health care and encourage suggestions for improvement
To plan and run jointly a health education and self care programme with the aim of improving patients' health and increasing their responsibility for maintaining their own health
To develop a voluntary, mutual self help scheme.
This programme has been detailed elsewhere.10 The group meets every two months to discuss patients' complaints and is made up of 12 members.
In 1991 a patient liaison worker was appointed to supervise all aspects of the practice's non-clinical relationship with patients. She reports directly to the practice manager under the guidance of the practice management group. Her training was in quality assurance, medical audit, and hospital accreditation. It is a full time post funded by the family health services authority.
The informal complaints procedure was designed to provide complainants with an explanation of the circumstances surrounding an adverse event. It was decided from the outset that the procedure should be a two way process and be available both to patients and to staff - that is, staff could report an adverse event concerning a patient. The informal complaints procedure does not replace or prevent access to the formal complaints procedure. Explanatory leaflets and posters were distributed at the reception and waiting room area and patients were also informed through the practice newsletter.
A patient complaints committee was recruited, made up of volunteers from the user group, and a complaints form designed to be completed for each incident (fig 1). Two patients on the committee had lodged complaints previously with the health centre and therefore had a full understanding of the informal complaints procedure. Figure 2 shows the procedures which were followed once a complaint was received. Figure 3 shows the investigation form used.
All complaints were treated as separate incidents and audit undertaken of the first year's experience (January to December 1993). A total of 39 complaints were processed during the period, divided into five categories (table I).
Administrative - Five complaints concerned administrative procedures, including repeat prescriptions, telephone system, receptionist, administrative staff action or inaction, and appointment procedures.
Doctors or medical care or both - Fourteen complaints were directed at individual doctors or the medical care at the centre.
Complaints from health centre staff about patients - There were 10 complaints from health centre staff about patients, including complaints directed at individual patients for rudeness, repeated failed appointments, etc.
Mixed - Five complaints concerned delay or difficulty in getting prescriptions, rudeness of doctor, medical care, appointments system, telephone system, waiting time, and doctor from deputising service.
Other - Five complaints from patients did not fit into any of the above four categories. Most were directed at other NHS services - for example, concerning length of waiting lists for treatment.
Table II shows the outcome of the 39 complaints One was not resolved.
In the five years before the informal complaints procedure the practice had only two formal complaints lodged against it. One involved the medical defence organisation. As expected with any innovation, however, once the procedure was in place many new examples were found.
In the year of the scheme 39 complaints were recorded10 from staff (table I). Most were resolved within three days, two (concerning doctor from deputising service and medical care) requiring an investigation period of three weeks before being resolved.
The total time spent and amount of correspondence generated by all 39 complaints were less than those in relation to the two complaints received in the preceding five years. Hence personal stress was considerably reduced. Two complaints that were sent direct to the family health services authority were directed (with the patients' agreement) to the informal complaints procedure, so reducing involvement of the authority. The two complaints were satisfactorily resolved.
The procedures for administering such a scheme are comparatively straightforward and do not require major organisational restructuring. Appointing a patient liaison worker to pilot and manage the scheme in our centre was no doubt a factor in its success, but practice managers should be able to undertake the task within existing job descriptions. Recruiting patient representatives as members of the complaints panel ensures equity and helps patients feel that they are represented and that the procedures are not there merely to protect staff.
For health centre staff the reciprocity of the scheme ensured that their own grievances and complaints about patients could be acknowledged and were validated as appropriate by an “independent” panel. The reciprocity of the scheme also improved morale of staff.
Many of the complaints resulted in review of existing practice procedures and development of practice protocols and standard setting. For example, staffing arrangements were altered after a complaint about delay in answering the telephone at busy times. Issues of confidentiality need to be properly addressed, especially when the complainant is not the patient. Consent forms need to be issued and confidentiality statements signed by patients, patient representatives, and all staff involved in investigation of the complaint.
The cost implications of a practice based informal complaints procedure are minimal when compared with the cumbersome and lengthy procedures currently in place. Family health services authorities may therefore wish to finance the initial start up costs of similar schemes through developmental budgets and patient's charter initiatives.
Patient complaints have helped the practice reflect on its performance and encouraged the development of policy and procedural changes. Complaints procedure may be an inappropriate term for good customer relations.
We thank Dr Sally Hargreaves, of the Kensington and Chelsea and Westminster Family Health Services Authority, for supporting this project.