The Citizens Advice service is a network of community-based advice agencies providing free, impartial, confidential and independent advice and information from over 2000 service outlets across England Wales and Northern Ireland. Advice on health related problems is a significant and growing area of work. In 2002-3 advice was regularly provided in 879 surgeries, health centres and hospitals. Currently bureaux in six regions are responsible for the provision of Independent Complaints and Advocacy Service (ICAS). The evidence from these services provides important indications on where reform is needed if the Government is to achieve its vision of a patient-centred health service.
This briefing focuses on two issues covered in the Health and Social Care Bill, which are of particular concern to CAB clients. These are the reform of the NHS complaints system and the process by which GPs remove patients from their lists.
The proposed new NHS redress scheme for claims potentially up to £30,000 would have four key elements – investigation, explanation, package of remedial care and payments for compensation and further care and treatment not available from the NHS. If such a scheme is introduced the interface between the new scheme the first two complaint tiers will need to be clarified. Issues to be addressed in this context include clarity and openness about the position of ex-gratia payments.
Health Care complaints (Chapter 9 Clauses 109-110)
The report NHS Complaints Procedure National Evaluation showed there are very serious failings in the current complaints procedure, which fail to meet the needs of patients on a number of fronts. The process needs fundamental reform so that it not only meets the requirements of the Human Rights Act but also properly supports the new vision of a patient-centred NHS. In 1999, the Public Law Project (PLP) published a report based on extensive research carried out on the NHS complaints procedure, and made a number of recommendations for reform. (Wallace and Mulcahy, Cause for Complaint? An evaluation of the effectiveness of the NHS complaints procedure); it found that less than a quarter of requests for independent review went forward, patients feeling aggrieved that they have been refused access to an Independent Review Panel, and that procedures were often not compliant with the Human Rights Act.
The main priorities for reform must be to increase the independence of the process and to improve communication with patients. All staff need training in how to deal effectively with complaints; complaints should not be discouraged but treated positively, and, crucially, patients should be assured that making a complaint will not threaten their care or treatment.
Unfortunately this legislation stops short of any such comprehensive approach.
However, the proposal that CHAI should take over responsibility for the second stage of the health complaints procedure does address a number of weaknesses in the existing scheme:
- It secures the independence of the second stage of the complaints procedure
- It provides a mechanism for ensuring that intelligence gained through handling complaints is fed back into the system and used to drive up standards. However many complaints will not progress to the 2nd stage, and it will be important that mechanisms are also in place for the independent Complaints Advocacy service (ICAS) which will be supporting complainants, to feed back its evidence through to its parent body – the Commission for Patient and Public Involvement in Health.
- It provides for a fast track to the ombudsman stage in circumstances where CHAI deems this more appropriate
- It allows for harmonisation between health and social services complaints procedures, which should provide a better system for dealing with complaints, which cover both areas.
In addition we welcome the fact that there will no longer be restrictions on patients’ access to the 2nd stage: the decision whether or not to take the complaint further will rest with the patient.
However, there are a number of issues around how CHAI will work on which further clarification would be helpful. More clarity would also be helpful on the relationship between the first and second complaint tiers. For example
- It is proposed that one option available to CHAI will be make recommendations to the NHS body complained about, to take further action locally to resolve the complaint. It will be important that complaints do not end up being passed and back and forth between CHAI and local resolution. Patients may perceive this as unhelpful if they have decided to refer their complaint to CHAI because they have lost faith in the ability of internal procedures to resolve their problem.
- It is unclear whether patients will always be offered the option of a hearing at which they will be able to attend to put their case. The process is left to Ministerial discretion to produce regulations. As currently drafted it is the Minister who controls the complaints process - for example the Minister could by order exclude continuing care from the scope of NHS complaints. This does not instil confidence in the independence of the complaints system.
- There is no provision for oral hearings at all. Oral Hearings can be particularly helpful for relatives of patients who have died in NHS care; the Bill as currently drafted only allows for a complaints process ‘on the papers', an impersonal bureaucratic process in which the complainant does not get their voice heard. Where appropriate an oral complaints procedure can be helpful in assisting a complainant in coming to tend with their grief.
- In relation to hearings, as CHAI’s functions are primarily audit and inspection, it will be important that the different inquisitorial procedures which will be required to handle complaints, are properly developed. The Council of Tribunals is currently consulting on model rules for the conduct of hearings covering issues such as training for members and meeting disability access requirements. It will be important that these principles are applied where appropriate, to the development of the health complaints system, and that hearings conform to the standards of European Convention of Human Rights jurisprudence.
- There is a lack of any timescale for responding to correspondence from complainants after they have received the first NHS response letter. NHS bodies say that they have "resolved" complaints within the current 20 working day timescales, when all they have done is sent off a letter of response. Often there are long delays in responding to follow-up letters from complainants seeking additional information, further investigation or requesting some other reasonable response from the NHS. There is therefore a case for setting up a procedure to fast track certain classes of complaints straight to the independent review panel stage, where they meet certain criteria relating to performance or conduct which threatened patient safety. A mechanism needs to be introduced whereby complaints can go straight to CHAI or the Ombudsman
- The legislation only includes complaints about NHS bodies. There is no clarity here private contractors (doctors, dentists etc) fit in, fir example where a service is contracted out. There is a strong argument that in relation to private GP and hospital services the PCT should have a role in complaint handling.
The development of a comprehensive high quality Independent Complaints Advocacy Service will be essential to the proper functioning of the health complaints system, ensuring that patients are able to use the new system effectively. It will be crucial that the interface between ICAS and the in-house Patient Advocacy Liaison Service is clear and that patients are appropriately referred to ICAS should they wish to make a formal complaint.
To ensure the independence and integrity of the Complaints procedure, Peers may want to consider how the legislation could be amended to provide answers to key questions on the face of the Bill - who is the complainant, what are the issues that can be complained of, what are the rights of advocacy etc. We look forward to addressing these issues at Committee Stage.
Furthermore, the agenda has moved on since the Commons debated this Bill. The NHS Chief Medical Officer has published a report Making Amends, which recommends a plan to integrate complaints procedures with litigation procedures, with the aim of speeding up claims and reducing legal costs. The proposed new NHS redress scheme for claims potentially up to £30,000 would have four key elements – investigation, explanation, package of remedial care and payments for compensation and further care and treatment not available from the NHS. If such a scheme is introduced the interface between the new scheme the first two complaint tiers will need to be clarified. Issues to be addressed in this context include clarity and openness about the position of ex-gratia payments.
Reform of GP contracts - Procedures for removing patients form GPs lists
An issue of longstanding concern to the Citizens Advice service is the inadequacy of the current arrangements, which enable a GP to decide to remove a patient from his/her list at any time, without even the requirement to give reasons and with no means for the patient to challenge the decision. This issue is of key significance to the development of a patient centred health service: for example CABx report that patients are often reluctant to make a complaint about their GP for fear that this might result in them being removed from the GP’s list.
We understand that reform of these procedures is to be dealt with in the new GP contract. Regrettably this has meant that there has been no opportunity for consultation with organisations representing patients’ interests, on this crucial access issue. Indeed it appears that, because of delays in balloting GPs themselves on the new contract, opportunities for Parliament to debate the terms of the contract will also be restricted.
Citizens Advice regularly receives reports from CABx about clients who have been struck off their GPs list, often without a reason being given. In many cases these are patients with serious long-term medical conditions, requiring extensive GP involvement. This is despite guidance form the Royal College of General Practitioners that “an exacting, or highly dependant patient, condition or disability” should never justify removal, and that, reflecting similar BMA guidance, patients should be given a reason for removal.
A de-registration can have serious consequences for a patient’s health care. At best they have lost the continuity of care by having to register with a new GP. At worst they may find themselves in a kind of primary care “limbo” with a succession of temporary registrations if no GP is prepared to take them on permanently.
A CAB in the West Midlands reported a woman who suffers form a number of chronic physical illnesses and disabilities. Over the years she had become experienced in managing her condition, in partnership with her GP with whom she had a good relationship. However on one occasion she became involved in an argument with a junior partner when he refused to prescribe a treatment she needed, in the absence of her GP who was on holiday. As a result, she was told by her GP on his return that she could no longer be a patient at that surgery. Since then, despite the best efforts of the health authority, it has not proved possible to find another practice willing to accept the client on a voluntary basis. Instead, she has had a succession of temporary registrations, changing GP every 3 months. Although none of the GPs have any complaints about the patient, they all have a policy of only keeping unallocated patients for 3 months. The CAB commented that the problem appears to be particularly acute in deprived areas where there are relatively few GPs – precisely the areas where health inequalities are likely to be most acute.
The CAB Service is not alone in voicing these concerns. The issue of inappropriate removals from GPs lists has been a regular feature of the Health Ombudsman’s reports.
We understand that the new contract will require GPs generally to provide a warning before removing a patient, and to give reasons for a removal, and that there should be a transparent process for removal.
Whilst it many now be too late for these conditions to be amended, it would be helpful if Ministers were to provide an undertaking that patients organisations will be given the opportunity to be involved in the development of guidance for GPs on what constitutes a “transparent process”.
Two elements which we believe should be included are:
- Creating a role for the Patient Advocacy Liaison Service (PALS) to intervene. The DoH commissioned research into deregistration found that poor communication between patient and practice was often a major factor. This would suggest that a mediation role at an early stage could prevent the need for many of the deregistrations. The new PALS would appear to be well placed to perform such a role.
- Establishing systems for the local monitoring of levels of deregistration so that remedial action can be taken if required.
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