THE COMPLAINTS PROCEDURE IN GENERAL PRACTICE

 This Information Sheet focuses on the structure of the complaints procedure in general practice - it does not cover the rest of the NHS.  It is copyright free and copies may be made as required. 

The NHS complaints procedure is a mechanism whereby patients can complain if they are dissatisfied with any service or treatment they receive from the NHS.  A new procedure was introduced on 1 April 1996. It emanated from recommendations made in the Wilson Report in 1994¹.   

This new system has two stages - internal investigation and response (also known as “local resolution”) followed by a review panel if necessary.  Matters of discipline are considered separately from the complaints system.

 STAGE 1 

This local resolution stage of the complaints procedure in general practice is known as the “in-house complaints procedure”.  All practices are now obliged to have an in-house procedure though many practice already had such a procedure in place.  Indeed, the Royal College of General Practitioners issued guidelines on how to set up such an informal procedure early in 1995². 

All in-house complaints procedures must conform to a national criteria laid down in guidelines issued by the NHS Executive³.  These guidelines stress that the procedure must suit the particular circumstances of the practice. 

The guidelines state that practices must give the procedure publicity and must give written information about the procedure to any enquirer.  The latter normally takes the form of a practice complaints leaflet.  

The leaflet should include the following information: 

·      how a complaint will be dealt with

·      the purpose of the procedure

·      the anticipated timetable

·      the rules of confidentiality

·      the availability of help from the local community health council (see ‘Definitions’ on page 5)

·      possible outcomes of the procedure so that the person complaining may have realistic expectations

·      the availability of conciliation services through the health authority

·      how to pursue a complaint with the health authority if the person complaining is not satisfied with the practice-based investigation

·      the time limits for making a complaint (within 6 months of the date of the incident that caused the problem, or within 6 months of the date of discovering the problem, provided that is within 12 months of the incident). 

When a patient makes a complaint, be it verbal or in writing, about an aspect of the service provided by a practice the person responsible for the procedure should fill out a complaints form.  This form includes the complainants details and the nature of the complaint.  The patient should then be given a copy of the practice complaints leaflet. 

 A mutually convenient time for the complainant to meet with the complaints administrator (this is often the practice manager) to discuss the complaint in detail should be agreed upon.  This interview should take place in private and detailed notes should be kept (a standard interview form may be preferred).  After the interview the complainant should be sent a note of acknowledgement within two working days. 

 When the investigation of the complaint is complete the complaints administrator normally discusses any ‘findings’ with the overseeing partner in order to decide upon the response.  Often the response will be a written explanation or the offer of a meeting to discuss the findings. 

In straightforward cases, the person complaining should receive this response within 10 working days. 

If patients feel unable to complain directly to the practice they can contact their health authority or community health council. The health authority officer responsible for dealing with complaints may act as intermediary between the practice and the complainant, and may offer conciliation services where appropriate. 

STAGE 2

 If complaints cannot be resolved by the practice based complaints procedure, complainants have the option of asking the health authority for an ‘Independent Review’.  In all health authorities there is a senior member of staff responsible for managing complaints.  This person works closely with a Convenor, a non-executive director of the health authority, who has responsibility for looking at complaints and deciding whether to agree to a request for an Independent Review of the complaint.  At this stage of the procedure the Convenor has several options in deciding what to do and may: 

·      refer the complaint back to the practice for further action under Local Resolution if it appears that the practice-based procedure has not been exhausted;

 ·      arrange conciliation where it appears this might be helpful;

 ·      set up an Independent Review panel to investigate the complaint;

 ·      take no further action where it is clear that everything possible has been done; or

 ·      advise the person complaining of his or her right to approach the Ombudsman.

 In deciding whether to set up an Independent Review panel, the Convenor is assisted by an independent lay Chairperson nominated by the Secretary of State for Health from a list held by the Regional Office of the NHS Executive.  Clinical advice is available from general practitioners nominated by Local Medical Committees (LMCs) (see ‘Definitions’ on  page 5) and based outside the health authority’s area.

If it is decided to establish an Independent Review panel, it will be composed of three members: an independent lay Chairperson, the Convenor, and another independent lay member.  Both lay members are nominated by the Secretary of State for Health from the Regional Office list. 

When the complaint is of a clinical nature, two independent clinical assessors (nominated by organisations representing local general practitioners) are appointed to advise and make a report to the panel.

 Independent Review panels do not have a disciplinary function.  The panel looks at each complaint in the way which best suits the individual circumstances, the aim being to resolve the complaint as constructively as possible. The Panel reports to the person complaining and to the practice and may make comments about service improvements.  It will send a copy of its report to the health authority but will not make recommendations about disciplinary action.  It will be for the health authority to decide if any further action is appropriate.  

HEALTH SERVICE COMMISSIONER (OMBUDSMAN)

 Most complaints are resolved either through the practice-based procedure or Independent Review.  However, if a complainant remains dissatisfied after the Independent Review,  or has been denied an Independent Review, he or she will be able to go the Health Service Commissioner (Ombudsman).  Since April 1996, the Ombudsman has had the authority to consider clinical matters also.

There are three statutory offices of Health Service Commissioner - one each for England, Scotland and Wales - all of which came into being in 1973.  All three posts have so far always been held by the same person.

 The Ombudsman is accountable to Parliament and is completely independent of the NHS and of Government.  His work is overseen by the Select Committee on the Parliamentary Commissioner for Administration.  He is required to present an Annual Report to both Houses of Parliament, and he also produces periodic volumes of selected investigation reports.  These contain summaries which the Health Departments circulate to Health Authorities, Boards and Trusts.  The purpose of this action is to improve standards of service.  He may also make reports on particular cases or issues.

 When a complaint is received it is first screened to see whether it falls within his jurisdiction⁴.  If it does the Ombudsman has discretion whether or not to investigate.  In every case he will need to be satisfied that there are sufficient prima facie grounds for an investigation. 

If he decides that the complaint is outside his jurisdiction, or that he should exercise his discretion not to investigate, he will write to the complainant giving reasons for his decision.  There is no appeal against decisions of the Ombudsman.

 If the Ombudsman decides to investigate he will send the body or person complained against (e.g. a general practitioner or practice) a Statement of Complaint setting out the ‘terms of reference’ for the investigation.  This ensures that the complainant and those complained against know exactly what is being investigated.

 The bodies or persons to be investigated are asked to send the Ombudsman all the documents needed for the purpose of investigation.  It may then be necessary to interview the complainant and any other person who may be able to provide information or evidence pertinent to the investigation.  That can include relevant staff or general practitioners. 

When the Ombudsman has considered all the evidence he then decides whether the complaint should be: 

·      upheld (that is, substantiated);

·      not upheld (that is, unsubstantiated);

·      not made out (where the evidence is not sufficient to warrant an ‘upheld’ finding); or

·      incapable of being resolved either way.

 The Ombudsman then sends a draft of his report to the body investigated in order to (i) check that the facts are correctly stated, and that the evidence has been correctly understood and summarised; and (ii) to secure agreement to any apology and to implementation of any recommended remedial action.

 Where he criticises the actions of a general practitioner, the Ombudsman will request that an apology be conveyed to the complainant through his report.  If he considers that remedial action - such as the review of procedures or measures to enhance skills or competence - is appropriate in order to prevent a recurrence, he will recommend that in the findings. 

The final report is then sent to, among others, the complainant and the body investigated.

 DISCIPLINARY PROCEDURES

 As noted above a feature of the new procedure is the separation of complaints and disciplinary procedures - there is now no direct connection between complaints procedures and disciplinary action.  The investigation of complaints, however, can reveal information about serious matters which indicate a possible need for disciplinary investigation.  If this is the case it is the responsibility of the health authority to act.  It may decide that informal action might be helpful before invoking disciplinary procedures.  For example, the health authority might suggest to the doctor that he or she undergoes training in a specific area or finds help to improve practice procedures.

 If the health authority decides that there is no alternative to a formal disciplinary investigation, members of a disciplinary panel appointed by another health authority will be asked to investigate.  The disciplinary panel consists of a lay chairman and two or three lay members nominated by the Secretary of State for Health from the Regional Office list.  It also has two or three GP members nominated by the LMC. The investigating panel hold a hearing, decide whether there has been a breach of the terms of service and report back to the original health authority who will then fix a penalty, if appropriate. 

On very rare occasions, and where the circumstances fall outside the terms of service, the health authority may at the outset refer cases directly to the police, for example, in cases of alleged fraud, or to the General Medical Council (see GMC disciplinary procedures below), for example, if there is an alleged breach of confidentiality. 

 After the disciplinary panel has considered a case the health authority may decide that, rather than imposing a financial penalty, they would prefer to work with the practitioner to help him or her overcome any problems.  Such help my include, for example, suggestions for further training or support for improving premises, where this was the problem.  But if the health authority feels a penalty is needed, they will only be able to impose those which are currently available - a withholding from remuneration with, where appropriate, a warning to comply more closely in future with the terms of service.

 The health authority has no right of appeal against the decision of a disciplinary panel because it is the health authority with which a GP has a contract which brings the action in a disciplinary case.  The practitioner, however, can appeal against a disciplinary panel’s decision and against any penalty imposed by his or her own health authority, to the Family Health Service Appeal Special Health Authority.

 GENERAL MEDICAL COUNCIL DISCIPLINARY PROCEDURES

 There is no direct link between the complaints/disciplinary procedures outlined above and that operated by the General Medical Council (GMC).  Health authorities and the Health Service Commissioner will, however, both refer complaints to the GMC where there is evidence that a doctor’s general professional performance is seriously deficient, or where it is apparent that a doctor’s fitness to practise is seriously impaired by ill health, or if allegations of serious professional misconduct are made.

 The General Medical Council (GMC) is a self-regulating and self-financing body that regulates the medical profession.  The GMC has the supreme powers of registration of a doctor and of removing his or her name from the Medical Register.  Doctors who are not listed in the Medical Register cannot practise in UK.  For further details on these procedures contact the GMC at the address below.

 REASONS FOR AND OUTCOMES OF COMPLAINTS

 The Medical Defence Union recently published a study⁵ of all complaints notified to the MDU during the last complete year of the ‘old’ complaints procedure.  A total of 737 complaints were analysed.  The reasons for these complaints are listed below.

The five most common reasons for complaint were:

Over 90% of the complaints in the study were dismissed or resolved.  Only 6.5% progressed to an adverse outcome for the GP i.e. the GP was found to have breached the terms of service.  The reasons for a breach finding were as follows:

Of the complaints which received a formal hearing, 2.5% resulted in a referral to the General Medical Council and 4% progressed to a claim of alleged medical negligence.

  REFERENCES

 1. The Report of a Review Committee on NHS Complaints Procedures.  (1994).  Being Heard.  Department of Health. 

2. Royal College of General Practitioners Northern Ireland Faculty.  (1995).  Guidelines on In-house Complaints Procedures.  London: RCGP.

 3.  NHS Executive.  (1996).  Practice-based Complaints Procedures: Guidance for General Practices.  Leeds: NHSE.

 4.  Health Service Ombudsman.  (1996).  A Guide to the Work of the Health Service Ombudsman.  Section B.  London: Office of The Health Service Commissioner.

 5.  Medical  Defence Union.  (1996).  Problems in General Practice: Complaints and how to avoid them.  Manchester: MDU.

 FURTHER READING

 General Medical Council (1995).  Duties of a Doctor.  London: GMC.

 General Medical Council (1996).  Performance Procedures:  a summary of current proposals.  London: GMC.

 Medical Protection Society.  (1992).  General Practice Complaints Procedure.  London: MPS. 

Pietroni PC and Uray-Ura S. DE.  Informal complaints procedure in general practice: first year’s experience.  British Medical Journal 1994.  308: 1546-1548.

 Pulse and the Medical Defence Union.  (1993).  Coping with patient complaints in general practice.  London: Pulse.

 Royal College of General Practitioners.  (1994).  Wilson Report: Complaints Procedure.  Being Heard: Report of the NHS Complaints Review Committee.  Response by the Royal College of General Practitioners.  London: RCGP.

 Royal College of  General Practitioners Information Services Section.  (1996).  Summary of the Guidelines Produced by the NHSE  on Practice-based Complaints Procedures.  London: RCGP.