Learning from complaints about general practitioners

Those who worry about improving quality claim that “every defect is a treasure,” but for the patient who is the victim defects can be disasters, not treasures. Patients who experience defects in care therefore need a complaints system that allows them to express their concerns, undertakes an investigation, provides an appropriate apology, and takes action to reduce the risk of harm to other patients. If such a complaints system is also to provide a supportive environment to doctors who are the subject of complaints it needs to be part of a wider set of systems that are concerned with improving quality overall.

Dissatisfaction with the previous system of handling complaints in the NHS led to the introduction of a new system in April 1996.¹ Since then the complaints system has been separated from disciplinary procedures, and the new system for general practice divided into three levels. At the first level practices are required to have practice based complaints systems organised to comply with national criteria. The second level involves arrangements for health authorities to undertake independent review of complaints that are not resolved satisfactorily by the practice based procedure. At the third level, complaints still not resolved are referred to the health service commissioner (ombudsman), who was also given new powers to consider clinical matters.

The commissioner’s annual report for 1997-98 provides some preliminary information about the impact of the new complaints procedure in general practice,² although a complete judgment of the success of the scheme will have to await the findings of detailed research. In 1997-98 there were 38 093 written complaints received about general medical and dental services and family health services administration in England, but only 331 complaints were referred to an independent review panel.³ During the year 27 investigations into complaints about general practitioners were begun by the commissioner, and in reviewing these cases the commissioner noted the readiness of some general practitioners to remove patients from their registered lists once a complaint had been made.

In this week’s issue Jain and Ogden show how general practitioners receiving a complaint can find the experience devastating (p 1596).⁴ In some cases punishment may be the necessary response to a practitioner’s failure of care, but for most general practitioners who receive a complaint the experience appears to be a punishment in itself, regardless of the eventual decision after review of the complaint.

If the number of complaints is to be reduced, it will be necessary to do more than intimidate those general practitioners who make mistakes. They will need help in confronting their failure and correcting any deficiencies in their skills or attitudes. They will also need support to avoid depression or disillusionment with general practice as a career. The systems that contributed to or did not prevent the defect in care will also need to be corrected.⁵ Such systems might involve almost any activity of the practice or primary care group, including, for example, protocols of care, routine patterns of work, allocation of staff, or routes of communication.

If the failures of people and systems are to be corrected, a complaints system alone will not be sufficient. From April 1999 clinical governance was introduced to account for and improve the quality of care in the NHS, and complaints systems have been classified as only one component of clinical governance.⁶ If complaints systems are linked to other strategies for improving the quality of care—such as continuing professional development, audit, risk management, and critical incident reporting—the possibility of learning from complaints and reducing the number of failures in care will be increased.

However, although this is an advance, it will still not be enough. If practices and primary care groups are to support practitioners who receive a complaint, rebuild systems of work that are failing, and at the same time respond openly and honestly to complainants then clinical governance must become more than a list of loosely related activities. Effective clinical governance also demands a transformed culture.⁷

In primary care groups that have undergone this transformation the various activities of clinical governance will have become integrated with the general management of the primary care group. Concern about the quality of care will be the driving force that determines the short and long term objectives of the group, and patients’ experiences of care will have a leading role in defining quality. But practitioners who listen are essential if the group or practice is to understand fully patients’ experiences.

Therefore, one element of the new culture is the high value placed on practitioners. They should know that they are part of a health service that values them and operates systems that help them avoid failures in care. Should a failure occur, the service will not shun them but will help them cope with a complaint. In consequence, they and the practice or group will be able to continue to listen to the complaining patient or relative, rather than become defensive and allow communication to break down. Even then, a defect will not be a treasure, but if defects have become less common, they may have some rarity value.

General practice p 1596