A partnership model is needed to break down NHS defensiveness

Quality of care

When I attended the All-Party Parliamentary Health Group Meeting entitled ‘Patient complaint: a duty to listen and learn’ on 24th June, I was reminded of the old joke,

“How many psychiatrists does it take to change a light bulb?”  “Only one but the light bulb has to want to change.” 

As one meeting on the poor state of complaint handling merges into another and yet another, it struck me that you could ask a similar question;

“How many meetings does it take to change the NHS complaint process?”   

The primary problem is one of insidious defensiveness and this particular ‘elephant in the room’ was not mentioned by any of the panel consisting of;   Anna Bradley, Chair of Healthwatch England,  Dame Julie Mellor, Ombudsman PHSO, Michael King, CE for Local Government Ombudsman and Paul Hodgkin, Founder of Patient Opinion.

How entrenched is defensiveness within the NHS?  There was a time when no one would question, let alone criticise care given by a clinical professional.  Nowadays we are more confident to ask the questions, we just don’t get any answers.  It is only human to rebuke criticism, but fear of litigation adds a whole new dimension to the problems of accepting fault within the NHS.  There should be a simple model of complaint handling as outlined by Roy Lilley, from NHS Managers;

“Dealing with complaints isn’t that difficult. Listen, sympathise, don’t justify, make notes, agree a course of action and follow through. Six simple steps I’ve been banging on about for ages. Equip and empower the patient-facing front-line of care to handle complaints and say ‘sorry’ is a simple way to make sure they don’t become grievances.” 

If only it were that simple, but the NHS has a history of scapegoating those who fail to protect the system (whistle blowers) and woe betide any member of staff who slips up.

Who does defensiveness serve?  Generally speaking it serves the people at the top, who can put forward neat data charts with sound bite summaries to prove they are worth their salaries without any messy ‘reality’ getting in the way.  The Francis reportconfirmed that one of the primary issues in the Mid Staffs scandal was a desire to keep bad news from the Minister.  It serves those in leadership to cover up the holes in funding, staffing and training rather than expose the fact that patients will suffer when the system is overstretched and underfunded.  Which begs the question;

If the leaders are served by a cover up culture then who is to lead the reform? 

How do you begin to change a culture of defensiveness which is embedded within every aspect of NHS practice like the letters in a stick of rock?

You could start at the top and give a big stick to Jeremy Hunt so that he can hold Chief Executives and managers to account for poor complaint handling.  You could beef up the Care Quality Commission inspections and name and shame NHS Trusts and individuals.  However, this would most likely drive the culture of cover up even deeper, as people fear for their livelihoods and reputations.  Cover up thrives in a culture of fear.

Or you could start at the bottom and get local complaint handling right.  Anna Bradley from Healthwatch England informed us that there were currently 152 local healthwatch groups monitoring complaint handling and service delivery.  This independent body is also busy making close links with MPs to enable them to better support their constituents and no doubt to promote their plan that a properly funded advocacy service is provided to all complainants under the Healthwatch banner. (Point 2 of  7 point action plan delivered to Jeremy Hunt in June 2015)

Most complainants shouldn’t need advocacy if the process is simple, timely and honest. 

Or you could rearrange the regulatory bodies to make a more efficient, single portal which speeds the complainant through to the appropriate body in a ‘no wrong door’ approach. A recent Cabinet Office review has proposed that a new  ‘Public Service Ombudsman’ post is created with a Chief Ombudsman overseeing a number of other services such as LGO, Health Service and Housing.  This proposal is most likely to get the go ahead and will require a whole raft of meetings, consultations and written papers; but will it deliver any improvement?

People change the culture and the people have to want to change.  

The NHS is a massive, top down, control and command bureaucracy.  You only get whistle blowers in a Kafkaesque environment; anywhere else they are just staff members giving feedback.  The system has become a self-serving machine which uses its legal teams to close down complaint; internal or external.  Just reorganising the regulators isn’t going to impact on such deep rooted protectiveness.  This recent article from James Titcombe published in HSJ (1st July) shows how far the NHS has to go before the staff share the same kind of open culture enjoyed by the aviation or nuclear industries.  He describes an anecdote repeated by some clinicians he met of staff members using disclosure of incidents as a threat.

“A very common IT system used to report safety concerns in the NHS is Datix. I was told that a phrase which has now emerged is “I’ll Datix you”, used as a kind of threat in argumentative situations where there is some disagreement or heated discussion.”

Lord Philip Hunt was the only person in the room who highlighted the pervasive issue of defensiveness when he asked the panel;

When are we going to have the discussion on the culture of defensiveness?  We have to stop beating people up and create an open culture.  It’s led by ministers from the centre and we need to move away from the blame culture. 

In response to this Paul Hodgkin, founder and former Chair of Patient Opinion replied that he did not believe that cultural change would come from parliament or from any of the reforms on offer.  He said that it was impossible for bureaucracies to deliver good complaint handling and that change would come from the public as they used technology to gain a ‘web-based voice’ which could not be ignored.  He had spoken earlier of citizen power gaining strength through technology and that this would forge an alternative complaint handling mechanism which cut through the layers of processing to deliver the feedback directly to the people who could effectively use it.  For this purpose he had developed the website ‘Patient Opinion’ which works like an NHS Trip Advisor, giving feedback directly to those responsible, who are able to reply on-line and deal with a grievance before it becomes a full blown complaint.

A step in the right direction, as is a similar scheme to use technology to take control of your own medical information.  mynotesmedical a start up idea presently looking for funding.

No real progress will be made until we move away from the top down delivery model of the NHS and introduce a proper partnership with the patient and their family.  This requires mutual trust and the best way to achieve this is to invite more complainants to the endless meetings so that the voice of the patient is heard and we can work together for all our sakes.  We know what we want, what works and what doesn’t work, but far too often we are not part of the reform process.

Just like the elephant in the room, we too are invisible.