Complaints culture

Complaints to the regulator against doctors have hit a record high, rising more sharply than for any other health professional. Is this down to poor practice or a changing complaints culture? Sara Williams investigates

Last year the GMC revealed that complaints around the conduct of doctors reached “record” levels, rising by 23% compared to the previous year, following a steady rise since 2007 (69%).1

Information from medical regulators outside the UK identifies this as an international issue; in Denmark alone, complaints rose by 88% from 2007-2011.

What do the figures mean?

Certain factors, such as a doctor’s gender, the organisational culture and the specialty in which they work, affect the likelihood of receiving a complaint

The three most prevalent types of complaint to the GMC were:

• concerns with investigations or treatment, such as the failure to diagnose or inappropriate prescribing
• problems with communication, such as not responding to people’s concerns
• perceived lack of respect, such as being rude.

The figures indicate that certain factors, such as a doctor’s gender, the organisational culture and the specialty in which they work, affect the likelihood of receiving a complaint. For example, men received more complaints than women, while psychiatrists, GPs and surgeons attracted the highest complaint rates proportionate to their representation on the register.

"Certain factors, such as a doctor’s gender, the organisational culture and the specialty in which they work, affect the likelihood of receiving a complaint"

The findings need to be put into perspective as the majority of UK medical treatment is delivered to a very high standard in increasingly difficult times. The rise in complaints is symptomatic of the challenging environment that doctors are working in, rather than a decrease in performance.

GPs were one of the most complained about specialties, yet that same year the National Clinical Assessment Service (NCAS) reported a sharp drop in the number of GPs who were suspended amid professional concerns. This reversed an upward trend, as the figure almost halved compared to the previous year. So why are more patients complaining?

GPs were one of the specialties that experienced the biggest rise in complaints. Dr Clare Gerada, the chair of the Royal College of GPs, said that the rise was driven by an emerging complaints culture: “When you see such a rapid increase, such a sudden change, it’s unlikely to be the fact that doctors have become less caring or less competent.”

Complaints in surgery saw a similarly large rise. Claire Hopkins, a consultant ENT surgeon at Guy’s and St Thomas’ Hospital, says that complaints are rising alongside other factors. “In addition, we are constrained by the EWTD, resulting in less continuity of care, and changes in remuneration to hospitals, such that there is pressure to see more patients.”

"When you see such a rapid increase, such a sudden change, it’s unlikely to be the fact that doctors have become less caring or less competent"

Dr Isabeau Walker, consultant anaesthetist at Great Ormond Street Children’s Hospital, agrees that a rise in surgical complaints is down to the increasing complexity of medicine. “Our patients are getting sicker, our services are turning over more rapidly and we are handing over more patients. Healthcare is changing; we have higher expectations of our surgeons, and are increasingly asking them to perform trickier tasks. The perception is that anything is possible, so we expect our surgeons to be able to deliver anything.”

The GMC’s findings echo a recent report by the new health service ombudsman, Julie Mellor; the report identified a 50% rise in complaints from people who felt they had not received a clear or adequate explanation in response to their complaints.2 Responding to the report, Katherine Murphy, chief executive of the Patients Association, called for a cultural change in how the NHS handles and responds to concerns from patients.

How to avoid complaints

Complaints are an opportunity to improve your practice and avoid potentially escalating issues. By better communicating with patients and managing their expectations, most complaints will disperse.

Effective communication

Most complaints are rooted in poor communication. Understandably patients experience difficulties in assessing the technical competency of a doctor, so will frequently judge the quality of clinical competence by their interactions with a particular doctor.

Developing good communication skills will improve clinical effectiveness and reduce medicolegal risk. It is often said that body language speaks louder than words. A mismatch between verbal and non-verbal communication can lead to a strained encounter for both doctors and their patients. Being aware of your own body language is the first step in understanding how your body language is perceived.

Claire Hopkins says that the potential for miscommunication increases when treating a patient whose first language is not English, and translators are becoming a limited commodity. She explains: “The complaints that I have been aware of relate primarily to miscommunication, particularly when the consultation occurs through a translator, or perceived failings in continuity of care, rather than a question of clinical competence. They could often be avoided by offering to make a further appointment, perhaps with a friend, or with a member of nursing staff.”

Key statistics around complaints to the GMC

• In 2011, 8,781 complaints were made against doctors to the GMC; up from 7,153 in 2010
• This equates to 1 in 64 doctors on the register
• 17.5% (1,537) were limited to preliminary enquiries only, 26.5% (2,330) progressed to full investigations and the rest were discontinued.

Voxpops

“Many referrals to the GMC could be avoided early if we weren’t so defensive and communicated more effectively. Complaints are mostly the result of poor communication; often we are too wrapped up in what we are doing to consider that and keep the communication channels open. People complain because they feel they have been ignored and feel a deep sense of frustration. We could avoid many issues by talking to a patient’s family early on in the process.”

Dr Isabeau Walker, consultant anaesthetist, Great Ormond Street Children’s Hospital

“Expectations are rising, and if expectations can’t be met, people are more likely to complain. GP practices are busier than they have ever been, and the pressures on time are immense; when practices are too busy there is a real risk that communication can deteriorate. It always helps if you can see the situation through the patient’s eyes. That sounds trite, but explanation and communication can go a very long way.”

Professor David Haslam CBE, National Professional Adviser, CQC

 

Managing patients’ expectations

As the gap between patient expectations and what the NHS can deliver continues to widen, patients are likely to be left dissatisfied. As commissioning is implemented, doctors may find themselves with multiple responsibilities that raise the potential for conflicts.

Doctors will not only be managing patients’ expectations on a one-to-one basis, but also on a community level. Claire Hopkins points out that a difficult situation arises when clinicians reach the limits of their ability to diagnose and treat common symptoms. “We have to be careful, be honest, reassure that we can find nothing to treat at present, but leave the door open for the patient to come back, or suggest someone who could offer a second opinion.”

"Doctors will not only be managing patients’ expectations on a one-to-one basis, but also on a community level"

Although patients’ expectations are sometimes unrealistic, eg, the doctor will have unlimited availability, will solve all the issues at once and all treatments will be 100% effective, these expectations can be addressed if they are identified early on.

Being open

Complaints can feel personal – many doctors describe how they feel angry, hurt and betrayed. The first step is to take some of the emotion out of the situation. Try not to react defensively by refusing to engage with the complaints process. Complaints are stressful and time-consuming; often a prompt, well-balanced response to a complaint will be enough to defuse the situation. When it comes to complaints the best approach is do it once and do it well; complaints often do not get resolved because they are not investigated in a timely manner. The NHS Complaints Regulations require a complaint to be acknowledged within three working days and responded to within the agreed timescales.

"Complaints are stressful and time-consuming; often a prompt, well-balanced response to a complaint will be enough to defuse the situation"

Where there are differences of opinion between you and a patient, or a patient’s relatives, there is much to be gained by acknowledging and empathising with their situation rather than becoming defensive. See them not as a critique of your clinical acumen, but as an opportunity to listen to a patient and improve your skills for the future. An apology goes a long way in defusing a situation, and is not an admission of liability.

The future

As patients’ expectations grow, doctors will have to acquire new skills to manage them effectively, especially in the new commissioning environment; responding defensively will not deliver protection from complaints. A balance must be created where doctors are treated fairly and patients are assured of their safety.

Useful links

Communication skills workshops

The concerns around communication reflect MPS experience of the underlying reasons for dissatisfaction. MPS has created a series of communications skills workshops free to MPS members.

Complaints advice

In the past 18 months MPS received more than 4,500 calls relating to complaints. MPS has a series of factsheets and booklets on our website.

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