By the time one enters consultant life, most doctors will have been named in at least one complaint. No matter how much good you do in your work, from time to time mistakes will be made and patients and their advocates may wish to point these out to you. In many cases, complainants are simply seeking an apology, or the reassurance that such an event will not befall another patient. In other cases, complainants will seek compensation for what they perceive as poor care, or an unacceptable outcome.
Within the NHS setting, Trusts should have a complaints team, who usually coordinate a response from the Trust, but effectively on your behalf. In the private sector, it is possible to feel very isolated when a complaint arrives and moreover, the complaint may feel more personal. Despite the obvious stress inherent to such a situation, there are always avenues available for support.
Patient perceptions are key
In many cases, complaints are made as a result of a patient’s perceptions of events, rather than the reality. While this may be unfair at times, this does allow a skilled communicator the possibility of being able to proactively deal with an incident that might otherwise lead to a complaint, putting the patient’s mind at ease and occasionally putting a positive spin on the whole episode.
For example, if a surgical complication occurs, it is clearly essential to inform the patient. Explaining how the complication occurred in a clear manner – along with the steps that you took to minimise collateral damage and the likely recovery time – often leads to the patient being grateful that you – by definition, an experienced clinician - were there to deal with the situation, even though you were the operator in the first place! Conversely, failing to acknowledge your mistake is likely to be incendiary, if its effects are noticeable to the patient.
Furthermore, patients are perhaps more likely to complain if they have had a suboptimal experience of care until the point of the complication. For example, if the hospital receptionist is rude, theatres are running late, the notes go missing, the anaesthetist swears audibly and finally a complication occurs, you can expect redress more often than if all had been serenity up until that point.
As a surgeon, I always teach my juniors that everything that happens in the operating theatre is the surgeon’s responsibility. This is certainly true in private practice, but moreover, in traditional private practice, everything that happens in the patient’s entire experience from walking in the hospital door reflects on you and your practice. If you choose to work in a hospital with poor parking, a rude receptionist and less than presentable lavatories, this will also reflect poorly on you and your brand. You can and you should address such failings via your hospital management, preferably before unwanted complaints are received. While you will have to work with a rich variety of personalities in your working life, you should adopt a zero tolerance approach towards suboptimal facilities and attitudes. Consider carefully what you would expect if you were a patient visiting the hospital.
"...In many cases, complaints are made as a result of a patient’s perceptions of events, rather than the reality...."
Prevention… … is better than a cure. There are those who are serial complainants, for whom nothing will be good enough, however, it should be possible to reduce the number of complaints that you receive by some very simple measures:
· Provide excellent care
· Give patients enough time in clinic
· Ensure that you explain things carefully and in easily understandable terms
· Manage patients’ expectations appropriately: “under-promise and over-deliver”.
· Provide clearly written information leaflets (preferably reviewed by lay people).
· Make sure that you are available for queries/ concerns as much as possible: do you want to give patients your mobile phone number?
· Audit your results so you know what you are talking about and can provide accurate data on your outcomes.
· Ask for feedback from patients and respond to it.
· When things do go wrong, stop and think before continuing to act. Would it be more sensible (safer?) to stop and come back another day?
· When things have gone wrong, explain what has occurred honestly and clearly without delay. Explain what, if anything, will need to be done to improve the situation. Remember that a complication does not always lead to a complaint.
· Be clear about the financial side of the clinical situation: is further requisite care covered? Ideally, patients will either be insured, or will be receiving treatment as part of a ‘package’ of care, which will include such eventualities.
· Consider whether you – or the patient – wish for a second opinion at an early stage. Should you fund this yourself?
· Never change your medical notes. If this were to be uncovered in a subsequent investigation, it would raise major doubts about your probity and undermine your version of events.
So you have a complaint:
The GMC’s Good Medical Practice states that you “must be open and honest with patients if things go wrong. If a patient under your care has suffered harm or distress, you should:
a. Put matters right (if that is possible)
b. Offer an apology
c. Explain fully and promptly what has happened and the likely short-term and long-term effects”
Apart from your duty to respond to a complaint, there are many reasons why you should respond:
· To try and provide the patient with a satisfactory outcome and if not, then to help them understand the situation as best they can
· To maintain your relationship with them
· To protect your reputation
· To reduce the chance of a complaint to another body:
oThe hospital
o The GMC
o The press
· To reduce the chance of a claim
· To learn from the event to reduce the chance of it recurring (what was it that so vexed the patient – and did they have a point?)
· To show that you have reflected for revalidation purposes
Where care has not been negligent, most complaints pertain to bad or suboptimal communication or unrealistic expectations. In most cases, lessons can be learned, which can be put into practice to improve your service for future patients.
What to do when faced with a complaint
NHS
Within the NHS setting, all complaints are now handled within a process outlined by the NHS and social care complaints procedure, which was developed in 2009; this includes situations where NHS patients are treated within private hospitals. There are two stages in the complaints process: local resolution (e.g. within the NHS body or Trust) and the Parliamentary & Health Service Ombudsman (PHSO). The PHSO’s ‘Principles of Good Complaint Handling’ include:
· Getting it right
· Being customer focused
· Being open and accountable
· Acting fairly and proportionately
· Putting things right
· Seeking continuous improvement
Private hospital ISCAS members
When complaints are made to a private hospital regarding private medical care, a different but similar code of practice applies in most such situations in the UK. The overwhelming majority of UK private hospitals are members of the Independent Sector Complaints Adjudication Service (ISCAS), whose Code of Practice sets out the standards that its members should adhere to when handling complaints about their services. The ISCAS code reflects the PHOS principles outlines above.
As per the NHS complaints process, the ISCAS Code focuses on local resolution of the complaint, wherever possible. If complaints are not resolved at this first stage, then the complainant can escalate their complaint by asking the private healthcare provider to conduct a review of the handling of the complaint (Stage 2). If still dissatisfied, the complainant can request an independent external adjudication of their complaint (Stage 3), which is handled by ISCAS; the external adjudicator is entirely independent of ISCAS per se, and - according to the Code - will have the necessary skills and experience to fulfil such a role. For a complaint to proceed to Stage 3, complainants must accept the finality of the decision made by the adjudicator, and that any decision brings the complaints process to a close. It is important to note that a decision either way does not preclude a complainant from seeking subsequent legal action.
Other complaints
Not all small private hospitals and clinics are ISCAS members. When a complaint is made against such a facility, the procedure for handling complaints may vary, but each registered organisation will have its own policies and procedures to follow.
When a complaint is made against you - rather than your private hospital – you may wish to involve your hospital, if it is appropriate to do so. If not, there are some key principles, based on those outlined above, that may help lead to resolution of the complaint:
· Acknowledge the complaint promptly and promise to investigate and respond. Consider whether an apology at this stage is appropriate, e.g. “I am sorry to learn that you are dissatisfied with…”
· Establish the facts, collecting evidence as you go.
o What happened? Why?
o Has harm occurred?
o Was it preventable?
o Can it be put right?
o Was the patient warned of this outcome as a possibility during the consent process?
o Were there any ancillary factors that perhaps increased the chance of a complaint being made, e.g. rude staff, poor facilities, theatre list overrunning etc.?
· Consider whether it is appropriate to involve your medical defence organisation or insurer at this early stage; in some cases it is mandatory to inform them as soon as you are aware of a complaint, even if trivial. They are excellent sources of advice. If you have any doubts about the clinical care that you have provided, it would certainly be appropriate to involve them early.
· Respond appropriately and promptly to the patient.
o Is a meeting preferable to a letter?
o Is it worth writing a letter too?
o If you do meet, ensure that you have allocated sufficient time for the meeting.
o Is it worth having a witness present (e.g. a nurse, or a representative of the hospital)?
o Try to respond to all aspects of the complaint.
· Offer an apology, if this is appropriate. The expression of sympathy for events is quite different to admitting liability and in many cases is all that complainants are seeking.
· If the complaint is regarding a clinical matter, provide the facts and consider detailing the rationale used in your clinical decision-making to help patients understand why the situation has arisen. Provide as accurate a prognosis as you can and options henceforth.
· If appropriate, consider offering a second opinion. This can be:
o Via the NHS, if appropriate.
o Private, funded by the patient / insurance. This is certainly appropriate if you are absolutely sure of the clinical situation and know that you have done nothing wrong.
o Private, funded by you (or potentially your hospital if you have involved them). The decision as to whether you should fund this is entirely up to you, but may be appropriate if you are unsure of your ground from a clinical perspective. Funding a consultation yourself demonstrates to the patient that you are offering holistic care as part of your patient experience and should not be seen as admitting liability. In any case, you might be able to arrange for a colleague to see the patient free of charge (but be grateful to them!).
· If appropriate, inform the patient of the lessons that have been learned as a result of this complaint; many complainants are seeking assurances that a similar episode will not befall another patient.
· Document your discussions clearly.
· Put the problem right – if indeed you can. In the case of clinical problems, this might involve further treatment:
o If you are carrying out a procedure, ensure that you take detailed informed consent again.
o The decision whether to charge or not will depend on your initial discussions / agreement with the patient. In some situations, the hospital may charge but you may choose not to. Some hospitals offer guarantees (e.g. ‘Price Promise’) to include surgery for all eventualities; you may or may not be bound by these.
o Consider a second opinion before proceeding.
o Document the procedure and surgical findings clearly.
o Explain the outcome to the patient clearly.
· If a patient is still complaining, you should certainly involve your hospital (if appropriate) and / or your indemnifiers.
Vexatious complainants
The NHS and ISCAS members should have policies in place to deal with complainants who choose to continue to complain in a manner that interferes with the complaint’s investigation, or which involves behaviour that is unacceptable. This may include: inappropriate language, multiple emails and voicemails, the involvement of irrelevant third parties (including other hospitals and potentially the press) and – fortunately rarely – leafleting your local hospital with messages of dissatisfaction with your care! Complainants exhibiting such behaviour are sometimes referred to as ‘vexatious’.
ISCAS has its own policy for dealing with such complaints. In the event of you being unfortunate enough to be faced with a vexatious complainant in the private sector, it is strongly recommended that you involve your indemnifiers. In extreme cases, it may be necessary to take legal action against the complainant.
Should you offer a refund or goodwill payment?
A payment to a complainant is not at all unreasonable and may lead to resolution of the situation, however, it is important that such a payment is not termed a ‘refund’, as the use of such a term calls into question the quality of the services provided. This could then lead to questions regarding liability for the complaint. Instead, you could consider making a payment as a gesture of goodwill to a complainant and should include such a phrase in your communication. Such a payment does NOT mean that you have admitted any liability for the event leading to the complaint.
If you are considering making such a payment – and it is a very personal decision – it would be wise to discuss this with your indemnifier first. Apart from phrasing such an action appropriately, you should consider:
· How much are you happy to pay?
o All or part of your fee?
o If a proportion of your fee, how did you arrive at that conclusion?
o Your fee only, or the hospital’s too?
o Would the hospital consider contributing, if appropriate?
· Consider the timescale of such a payment. With the passage of time, many complaints regarding clinical outcomes may change and it is important that the patient’s condition has stabilised. This may take many months, or potentially longer.
· Remember that making a goodwill payment does not eliminate the chance of a subsequent legal claim.