Could improving the complaints process improve patient safety?

Health Business analyses the Parliamentary and Health Service Ombudsman’s ‘Breaking down the Barriers’ report and examines what improving the complaints process could mean for improving patient safety and care outcomes for older patients.

People aged 65 and over are some of the most frequent users of NHS and social care services, but a recent report found that the Parliamentary and Health Service Ombudsman received far fewer complaints from this age group than would be proportionally expected. Older patients are some of the most vulnerable in the NHS and a lack of knowledge and confidence to complain could have disastrous impacts on patient safety and outcomes, as it means that many continue to suffer in silence and could lead to missed opportunities to improve services for others in the future.

The Parliamentary and Health Service Ombudsman is an independent complaint handling service that is responsible for making final decisions on complaints that have not been resolved by NHS England. The Ombudsman service published the ‘Breaking down the Barriers’ report after witnessing evidence of the particular barriers older people and their carers face when they want to raise concerns about poor care, with the hope of instigating action to help complaints be heard.

Ageing population
Caring for older patients is an ever increasing issue as the UK currently faces the prospects of an ageing population. According to the Office of National Statistics, approximately one in 10 people in the UK will be 75 or over by 2030, with the number of people over 85 set to double in the same time frame.

As it currently stands, people aged over 65 make up over half of all the time spent in hospital beds, but only account for one sixth of the country’s population. Additionally, people 85 or older account for one in 44 of the population, but account for approximately one sixth of the time spent in hospital beds.

Data from a national survey conducted by the Parliamentary and Health Service Ombudsman found that 76 per cent of the UK population aged over 65 had used an NHS service in the past 12 months, of which 14 per cent indicated that they had been unhappy with something when using these services. However, of these older patients who encountered issues, only half went on to complain. With a growing number of potential older patients who rely on health and care services, ensuring that there is complaints process in place that allows them to have their voice heard and encourages them to speak up could be vital to ensuring good quality of care.

Knowing how to complain
One of the key barriers that is preventing older people from engaging with the complaints process is that they don’t know how to make a complaint or who they should be complaining to. The Parliamentary and Health Service Ombudsman found that one in 10 people over the age of 65 did not know where to go to complain about a public service such as the NHS, with 15 per cent replying that they would not know where to go if they were unhappy with how an organisation has dealt with a complaint.

Furthermore, 18 per cent of over 75s said that they did not know where to go to make a complaint, with 26 per cent saying they would not know what to do if they were unhappy with how a complaint had been handled. A contributing factor to this is that complaints processes are increasingly being transferred to online services. An obvious limiting factor is that many people over the age of 65 are not as computer literate as younger generations, with only a third of over 75 year‑olds having access to internet at home.

The survey found that many older people lack awareness of complaints processes as they are directed to communication channels that are unfamiliar and not easily accessible to them. Only 17 per cent of people over the age of 75 found out about complaints services online, compared to an average of 26 per cent across all age groups.

A participant at a focus group in Manchester said: “The problem is that when people have a problem they don’t know where to go; they are referred to a computer which they don’t have; they are referred to a library which is too far away to get to and they wouldn’t know what to do anyway.”

Another factor that influenced older patients’ decisions to not complain was a lack of support. Over 3.5 million people over the age of 65 in the UK reportedly live alone, with 49 per cent of those over 75 living alone. Additionally, those over 75 are likely to live a more isolated life, with 11 per cent reporting to have no close friends at all, compared to two per cent of 18-24 year-olds. This absence of a support network can limit patients ability to raise concerns, due to a lack of confidence or a lack of communication skills due to their condition.

The report highlights that many older people may require additional support and encouragement to make a complaint, as they are unlikely to take this step without the intervention of a family member, friend or advocacy group. The survey found that among those older people who have complained about the NHS over the past 12 months, only 28 per cent received additional support to make their complaint. Of those who had not complained about an issue they faced, 14 per cent indicated that they would lack confidence to do so.

A consistent theme from focus groups was that bureaucratic hurdles deterred many older patients from complaining without additional help and that access to additional information, such as leaflets, could enable more older patients speak up and better understand the process.

Impact on treatment
The report also found that many older patients were deterred from complaining due to concerns that it could have an adverse affect on the way they are treated in the future. 56 per cent of patients over 65 who had experienced a problem and not complained cited concerns about the impact it would have on future treatment as a contributing factor.

While a proportion feared about the negative impacts of making a complaint, the report also found that a large number felt that complaining would make little difference so would not be worth the hassle.

Among those older patients who experienced problems and did not complain, 32 per cent felt that complaining would not make a difference. This was found true for patients even when a problem is having an ongoing impact on their quality of life. One patient speaking at a focus group in Poole spoke of a cataracts operation that went wrong and left her blind in one eye. The woman in question said that this had a big impact on her independence and ability to drive, but didn’t pursue complaining as she thought it would be too much hassle and she wouldn’t ‘get anything from it’.

The Parliamentary and Health Service Ombudsman concludes that organisations across health and social care are missing key opportunities to learn from what they are doing well and where improvements are needed, recommending that patients need to be proactively encouraged to give feedback and supported to raise concerns or complaints.

A key part of improving this process is increased communication, with the report suggesting that every organisation working within the health and care sector should make every service user aware of how to complain and point them to support services that are available to help them make that complaint.

Additionally, it recommends that patients must be reassured that their future care will not be compromised if they speak up. Creating a culture where it is OK to open up a dialogue about issues is important, so as not to alienate older people and leave them to suffer in silence. Older people often need additional support in order to complain, and the Ombudsman service recommends that increased targeted support and information for older people and they carers could be incredibly useful.

It also directs organisations to use the ‘My expectations’ report on raising concerns and complaints, which offers advice on how to meet people’s expectations, as well as measure how effectively they are doing this and how the process of complaint handling could be improved. Commissioners of healthcare services are also directed to use ‘My expectations’ as a framework for determining how well organisations listen and respond to complaints.

Moving into the future, the report promises that the Parliamentary and Health Service Ombudsman will continue its work to raise awareness of its service and offer targeting information to enable people to complain. Plans have recently been proposed for the Parliamentary and Health Service Ombudsman to merge with the Local Government Ombudsman, and the report suggests that this would help to reduce the complexity of the complaint system by streamlining the process for patients, especially those with complaints that straddle health and social care boundaries.

‘Breaking Down Barriers: Older people and complaints about health care’ was originally published by the Parliamentary and Health Service Ombudsman in December 2015. The full report can be found here:

‘My expectations’ was originally published by the Local Government Ombudsman, the Parliamentary and Health Service Ombudsman and Healthwatch in November 2014. The full report can be found here:

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