Briefing for:

National Assembly for Wales Health and Social Care Committee.


The Welsh NHS Confederation response to the Inquiry into the NHS Complaints Process in Wales


Nesta Lloyd – Jones, Policy and Public Affairs Officer, Welsh NHS Confederation

Nesta.lloyd-jones@welshconfed.org Tel:  02920 349857

Date created:

8 July 2014.



1.       The Welsh NHS Confederation, on behalf of its members, wholeheartedly welcomes the opportunity to respond to the inquiry into the NHS Complaints Process in Wales following the report on the Review of Concerns (Complaints) Handling within NHS Wales – 'Using the gift of complaints', led by Mr Keith Evans.


2.       By representing the seven Health Boards and three NHS Trusts in Wales, the Welsh NHS Confederation brings together the full range of organisations that make up the modern NHS in Wales. Our aim is to reflect the different perspectives as well as the common views of the organisations we represent.


3.       The Welsh NHS Confederation supports our members to improve health and well-being by working with them to deliver high standards of care for patients and best value for taxpayers’ money. We act as a driving force for positive change through strong representation and our policy, influencing and engagement work. Members’ involvement underpins all our various activities and we are pleased to have all Local Health Boards and NHS Trusts in Wales as our members.


4.       The Welsh NHS Confederation and its members are committed to working with the Welsh Government and its partners to ensure there is a strong NHS which delivers high quality services to the people of Wales.


5.       The NHS in Wales has engaged with the Review from the start and Local Health Boards and NHS Trusts in Wales have already begun to consider, and implement, many of the recommendations highlighted within the ‘Using the gift of complaints’ report.



6.       Patients’ expectations of the NHS are growing.  It is not only about whether their treatment worked or how long they had to wait, but how they were cared for by staff, how they were spoken to and how comfortable they were made to feel.  In an age of rising expectations among the public, it is a critical issue for healthcare providers and something that the NHS must get right.


7.       Patients in Wales come into contact with the NHS more than 22 million times each year. A recent survey showed that 94% of patients were satisfied with the overall care they received and 97% of patients in Wales say they were treated with dignity and respect when using hospital services.[i]  At the same time, as Keith Evans’ Review highlights, there is always room for improvement and there is no doubt that there are areas where more can be done.  The Local Health Boards and NHS Trusts are doing more and more to encourage feedback from patients, their families and their carers to make sure they are getting these things right, and treating patients and their families in the way they should expect. 


8.       Effective feedback and complaints systems are an integral part of an open and transparent culture in the NHS. The complaints process within the NHS has become more accessible and complaints should be, and generally are, seen by the NHS in Wales as an opportunity to improve services. Whilst the Review provides a range of recommendations, and our members recognise that they need to do better in ensuring effective complaints systems, NHS organisations across Wales have already started to introduce innovative schemes and processes to make sure that frontline staff have a customer-focused approach in their interaction with patients and that patients and their families are aware of how to make a complaint.  


9.       New schemes or approaches have been introduced across the NHS in Wales, but there is always room for improvement. The NHS in Wales knows that more can still be done to improve the patient’s experience of using their services and the recommendations within the report will support this process. It is vital that the NHS in Wales has appropriate checks and procedures in place to investigate complaints and adopt an open culture within which staff, patients, families and the public feel supported to raise concerns.


The complaints process

10.   The NHS in Wales agrees that patients, and their family members, must feel supported and empowered to raise any concerns in the first instance, and then throughout the ongoing complaints process.  People need to know where to turn when things don’t happen as they should, without worrying about feeling awkward or having to battle against an organisation which may have taken a defensive stance.


11.   As the Review highlights, ‘The Putting Things Right’ scheme, introduced in 2011, has been successful in making the NHS take more responsibility for its actions and outcomes. The process is more transparent and accountable than previously and this must continue to enable people to raise their concerns and complaints. The NHS in Wales recognises that more needs to be done to ensure the complaints process is more visible, consistent and standardised across Wales, which will support and empower patients and their families through the complaints process.


12.   As the Review highlights, many patients and their families do not want to make a complaint because they feel that if they complain their care will be worse in future. For people dealing with serious health issues or who have been bereaved, the challenges of finding out how to complain can be so great that they give up.[ii] The Review highlights that patients and their family want clear and simple information about how to complain, the complaints process should be easy to navigate and the response provided by the Local Health Board / Trust is tailored to the issue they are complaining about.  


13.   Whilst the Review indicates some organisations are not always open, and this leads to needless and repetitive complaints, Health Boards and Trusts are actively seeking out the views of patients to ensure that services improve. The all Wales total number for complaints has increased since the introduction of ‘The Putting Things Right’ scheme, which may demonstrate that patients and their family are more actively engaged with the health service. However, despite an increase in complaints, it is vital that patients feel supported and NHS staff in Wales feel empowered, and supported, to deal with concerns at source. The NHS is committed to making sure that this is the case at every level, in every part of the service.


Improving services as a result of complaints

14.   Patients in Wales come into contact with the NHS more than 22 million times each year. Taking this number into account, it is not surprising that there will be times when patients or their families feel dissatisfied with their care. The number of complaints received by the NHS tend to represent less than 0.1 per cent of all activity. However, although these are small percentages, less than 0.1 percent still represents a large number of people.  And for the minority that do experience care that isn’t up to the highest quality, those complaints should be considered and service improved as a result of feedback.


15.   We agree with Keith Evans that complaints should be seen as a ‘gift’. Complaints are an important source of feedback, which can and should be used positively and constructively to improve services. Changing culture and attitudes so that feedback is valued is fundamental to improving services and patients' experiences of care. The seven Health Boards and three NHS Trusts in Wales are committed to improving the way that they handle concerns and to viewing them as an opportunity to improve services. The feedback and experiences, both good and bad, of patients and their families are critical in helping NHS Wales to provide the high standards of care that staff strive to deliver on a daily basis.


16.   The vast majority of people tell us they are happy with the care provided and a positive experience is the norm. However, when things don’t happen as they should, the NHS in Wales must listen, learn and take action. Complaints should be seen as a welcomed opportunity to help the NHS look at ways of doing things differently to continually improve patient safety and give patients and the public greater confidence in the NHS. Complaints should be recognised as a mechanism that is central to an organisation's wider focus on the quality of care and services it provides. It is crucial that organisations encourage patients, their families and carers, and staff to share their comments and for NHS bodies to act on and learn from feedback. We are working to ensure this good practice is better spread throughout the system.


17.   As well as seeing a complaint as a ‘gift’, we must use the information to change the shape of services. Through enabling a greater focus on issues at the macro level it may help the NHS to understand how our system is not always helping people. For example, from complaints received around caring for frail older people, particularly those with cognitive impairment, it is probably more of a challenge in large District General Hospitals. Our focus as NHS Wales on supporting more care at, or close to, home means that fewer older people with cognitive impairment will need to be admitted. Furthermore we need to change the way in which our environments of care operate for those who do need to come into hospital care, and the NHS has started doing this, for example caring for people with cognitive impairment.


18.   In the Welsh NHS Confederation’s discussion document ‘From Rhetoric to Reality - NHS Wales in 10 years’ time’[iii] we referred to building a new understanding of how the NHS should be used, embodied by an agreement with the public that would represent a shared understanding; ‘involving the public is central to realising an NHS where patients and the public are key and valued partners, where they are seen as assets’. The feedback and experiences of patients and families, whether good or bad, are critical so we can make the necessary positive changes in order to continuously improve and develop our services.  The NHS should see complaints as an opportunity to improve the quality of care they provide and support and empower people to raise complaints. Throughout Wales, Health Boards and NHS Trusts are analysing incidents and complaints so that information can be used to improve services.


Transparency and accountability

19.   The NHS in Wales has become more transparent and accountable and is further developing a culture of honesty and openness to enable the NHS to learn from mistakes and improve activities. It is essential we deliver a culture of openness and transparency in the context of the whole system. Everyone in the NHS, from ward level to board level, is responsible for improving NHS culture.


20.   The need to improve the timeliness and accuracy of data collection is well understood by Chief Executives, Chairs and their Boards. The NHS in Wales recognises that using the information gathered from patients and their families is a vital analytical tool in ensuring that the organisation is not pursuing its own cause and direction when it is not bringing satisfaction to patients.  The NHS in Wales agrees with Keith Evans’ recommendations relating to improving the availability and consistency of information on a national basis. Increased transparency is a key driver in improving quality across the NHS as a whole, highlighting both those areas where good practice is in place and those where there is scope for improvement. All Health Boards and Trusts are improving visibility and ease of access to information to ensure that patients and the public are informed.


Engaging with patient families

21.   We also recognise that the NHS cares not only for the patient but for their family too. Interaction with family members is vital and it is this which the NHS should aim to strengthen further. The lack of information and interaction with families during the care process can, in some circumstances, fuel any issues of general concern and escalate them into a complaint.


22.   It is important that the NHS changes the approach it provides to supporting bereaved family members. If the NHS in Wales analysed all the information available around complaints, it is likely that the more serious complaints in the NHS relate to those where a bereavement has occurred. Understanding this and changing the approach in relation to bereavement is essential. Many family members have questions that they need answering rather than wanting to make a complaint. When family members find it difficult to access the consultant or others to help answer those questions they can translate into difficult complaints, hence the need to ensure that people can access appropriate clinicians and managers for information needs. This could also be relevant for other people, as recognised within the Review: ‘Trust the opportunity to liaise differently with complainants, patients and communities and find ways in which engagement can operate at a different more inclusive level to learn from those who have had difficult experiences, but who wish to ensure that better outcomes can be achieved through learning’.


Staff engagement

23.   Complaints certainly have their place in the system but this is part of a much wider transformation of culture to enable patients, their families and their carers to feel at ease and supported to raise any concerns they may have. The focus should also be on how to support staff to raise concerns and make them feel comfortable having both open and honest conversations with patients and acting on the feedback they receive.


24.   The NHS in Wales is engaging with the public to show that the complaints will be used by all at every level in an organisation to learn and improve services. We need to do all we can to allow patients who feel they have a grievance to be able to put forward their concerns effectively and simply. At the same time we must not create a climate where staff feel under siege, as this Review has found. When staff see poor practice, they must take action and must be supported to do so. Health Boards/ Trusts must reflect on and respond to what their staff tell them and staff must be supported throughout this process. As the Review highlighted: ‘Organisations need to carefully develop an environment built on trust with their own staff.  It is important to ensure that your staff members are working in the manner in which you would wish to know that your clients, business partners or users are being treated’.


Committed to delivering high-quality, patient centred care

25.   The NHS in Wales is committed to delivering high quality, patient-centred care. Evidence from healthcare organisations across the world demonstrates that Boards in high performing NHS organisations take this responsibility seriously and continually strive to achieve this, regularly reviewing and examining their performance. By creating a positive organisational culture, they create the right environment to support and enable individual staff (clinical, managerial and support) to do the ‘right’ thing for patients, their families and carers. High performing organisations:[iv]

·         create a positive, open and transparent culture;

·         embed desired values and behaviours across the organisation;

·         prioritise delivery of high-quality patient care, setting quality objectives;

·         have appropriate, integrated governance systems, processes and procedures, including robust clinical and financial governance arrangements, and implement them;

·         identify key risks early and work to mitigate them;

·         encourage, value and act on feedback from patients and staff;

·         understand and track performance, including learning from complaints, concerns and serious incidents to improve the quality of care; and

·         know their limitations and understand other organisations may be better equipped to provide some services.



26.   We wholeheartedly welcome this important Review by Keith Evans into how concerns and complaints are handled within NHS Wales. While it is important to highlight that the majority of people who receive care and treatment from the NHS in Wales have a positive experience, it is also vital that we recognise this is not always the case for everyone. When care does not meet the high standards which patients and their family deserve and expect, the health service must hold its hands up and make sure action is taken to put things right. In order to do this, the complaints system must be clear, consistent and easy to navigate for patients and their families, who must be reassured that they are being listened to.


27.   A good complaints system is vital for accountability and gives the public greater confidence in the NHS. Patients need to be put at the heart of this and not feel sidelined by procedures that have been designed to help them, especially when they in turn are helping to improve the NHS.

[i] Welsh Government, June 2014, Fundamentals of Care audit.

[ii] Healthwatch, November 2013, Improving the health and social care complaints systems.

[iii] The Welsh NHS Confederation, January 2014, From Rhetoric to Reality – NHS Wales in 10 years’ time.

[iv] The NHS Confederation, February 2013, Making it better? Assuring high-quality care in the NHS.