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Item 3 is to take evidence as part of our continuing examination of the complaints process for integrated health and social care provision. I welcome Paul McFadden, head of complaints standards at the Scottish Public Services Ombudsman, and Alison Taylor, team leader for integration and reshaping care with the Scottish Government. Both those witnesses have given us evidence previously on the issue. I also welcome Mike Liddle, policy manager for the review of social work complaints procedures, and Professor Craig White, divisional clinical lead with the planning and quality division, both of whom are from the Scottish Government, and Soumen Sengupta, head of strategy, planning and health improvement at West Dunbartonshire health and social care partnership.
I invite Alison Taylor to make an opening statement, after which we will move to questions from members.
I will start with a few words about why we are integrating health and social care. Our aims are quite simple and, frankly, pretty obvious, so this will not take long. We are doing it because we need to improve care and outcomes for the growing numbers of people who have complex conditions and complex support needs. Many but not all of those people are older. I would go so far as to say that many if not all of us are directly affected by integration, probably because we have a loved member of the family who will need integrated care not in five or 10 years but right now. We have an immediate and pressing challenge—certainly, I feel that it is immediate and pressing.
We often say that support for people with complex care requirements—the people who we are focusing on with integration—needs to be person centred. However, that goes alongside the fact that they will get care from a range of professions and from people who work for a range of agencies. Therefore, there is some tension and challenge. The challenge for us—the people who collectively are working to integrate health and social care—is to find ways to improve the processes that govern health and social care and at the same time genuinely enable local flexibility to adapt to the complexity of the situations that people find themselves in.
I feel strongly that, in that context, there is no point in our focusing on big systems alone. We could set out tidy results that might look quite good, but I do not think that they would reflect properly the complexities that people experience or the fact that, frankly, people’s lives can be messy. We need to find ways to ensure that there is congruence and clarity in the systems of health and social care but at the same time ensure that there is local flexibility to adapt appropriately to people’s needs and experience.
With all that in mind, we are reforming the complaints processes under integration to ensure that we achieve that congruence, consistency and clarity. We are legislating to apply the SPSO’s three-stage model process to complaints about health and social work services. The same three-stage process will apply regardless of who the provider of a service is. It might be the health board, the local authority or the third or independent sector that is providing the care, but the same process will apply.
As the committee knows, the Parliament has legislated to bring the strategic planning of health and social care services under the direction of the new legally constituted partnership arrangements between health boards and local authorities that are embodied in the new integration joint boards. As the integration joint boards are new public bodies, albeit that they are not the providers of the care, we will also legislate to ensure that they are subject to the SPSO’s three-stage model process. In the letter that I wrote to the committee a few weeks ago, I set out the timescale and process for those changes and provided an update on recent progress, which I hope was helpful.
To go back to my first point, how does the approach that we are taking relate to our focus on person-centred care? It will mean that it will not matter to the complainant whom their complaint is against, because the process for handling the complaint will be the same—it will be congruent.
That is also the approach that will be taken on the ground as people make complaints. The legislation to integrate health and social care requires people who work in different organisations to work together and take shared responsibility for outcomes, and the position is the same with complaints. Under the legislation, health boards, local authorities and the new integration joint boards are all committed to ensuring that complaints are handled in a joined-up way. To put it simply, that should mean in practice that whichever agency receives a complaint will work together with other agencies as necessary to resolve it and learn from it.
I am delighted to be joined by three colleagues who were not with us at our most recent session with the committee. As members know, Soumen Sengupta is the head of strategy, planning and health improvement at West Dunbartonshire health and social care partnership. He has long experience of complaints handling in what is already a well-integrated health and social care environment. West Dunbartonshire has been at the forefront of integrated arrangements in Scotland for a good number of years, and Mr Sengupta is well placed to describe how those systems work in practice in relation to complaints and how we can build on and improve them.
Professor Craig White is the divisional clinical lead in the planning and quality division in the Scottish Government. He has provided us with valuable clinical advice on integration throughout our development of the policy and the legislation, and he is directly involved in our on-going work to improve complaints processes and standards of clinical care.
Mike Liddle is the policy manager for reforms to social work complaints. He works in the division that works closely with my division in the Scottish Government.
I am pleased that those colleagues are able to join us, and I thank the committee for inviting us to discuss complaints with it.
Thank you, Ms Taylor. Instead of talking about congruent systems, can we just say that the system will be the same regardless of where in the country folk are? What we require in the discussion is simple terms that folk can understand.
For the record, will you outline the timetable for legislating for the three-stage complaint model?
There are different pieces of legislation for different aspects of the system. I will invite colleagues who are leading on the individual pieces of work to contribute as well.
As far as the timescale for the legislative changes in relation to national health service complaints is concerned, the intention is to have those in force by April 2017. There will also be legislative changes in relation to social work complaints, on which my colleague Mike Liddle leads. Both those sets of changes are timetabled to be in force by April 2017.
Further legislative changes are required to bring the integration joint boards within the scope of the three-stage model process. The process for that will involve consulting in the remainder of this calendar year and laying an order in January next year. We expect the parliamentary process for that to be complete around the end of February, although that will depend somewhat on the establishment of the individual integration joint boards.
If it would be acceptable, convener, I suggest that Professor White and Mike Liddle might be able to give more detail on the legislative changes that relate to NHS complaints and social work complaints.
Okay. We will hear from Professor White first.
Good morning. As Alison Taylor mentioned, the work that is being done currently is on developing and refining the existing legislation and guidance on the management of NHS complaints. The Scottish Government has invited Paul McFadden and his team to lead the process and work with complaints handlers across NHS boards to look at how we test, refine and develop the changes that might be required.
Instead of centralised change being imposed without the benefit of local learning, we have a network of handlers who are working with front-line teams on identifying ways in which the process might need to be changed. There is a much sharper focus on ownership by front-line staff to ensure that, when people who use services are dissatisfied or want to make a complaint, that can be handled early by the healthcare professional who they are in touch with.
The group that is leading the work met on 14 September and it is beginning the work of testing the changes. The idea is that we will capture the learning between now and next year, then we will start to develop that into revised guidance that will, as Alison Taylor said, be reflected through a negative instrument to amend the regulations under the Patient Rights (Scotland) Act 2011.
Over the past several months, we have been working with the SPSO, the Scottish Parliamentary Corporate Body and colleagues in the Care Inspectorate and the Scottish Social Services Council on the proposals that we will make. Yesterday, we received a letter from the Presiding Officer inviting us to bring forward proposals for a draft order in the Parliament to make changes that would allow the SPSO to consider the merits of decisions that are made in relation to social work complaints.
We are therefore looking to bring forward a draft order in the next week or so, which will be laid in the Scottish Parliament and consulted on. The consultation will take place over the remainder of this calendar year and, depending on the consultation responses, the aim will be to introduce an order in Parliament in January next year. It will be a super-affirmative order under the Public Services Reform (Scotland) Act 2010.
The process to get the order through is a particularly lengthy one that requires a 60-day consultation period for the draft order, followed by 42 days in committee—as I am sure the committee will know—and by a plenary vote. We therefore cannot rush it through, and we are also slightly time constrained by the fact that the Parliament will rise at the end of March next year. If we cannot get the order through in that timescale, we will look to bring it forward after the elections in May.
So next year we will have a super-affirmative order to deal with the joint health and social care boards but, if I have picked you up right, other aspects of health and social work complaints will not be dealt with until April 2017.
The super-affirmative order relates to social work complaints, but the order to bring integration joint boards within the SPSO’s scope will be laid earlier than that. That piece of legislation needs to be consulted on as well, and it needs to involve each of the new bodies as they are created, so that will be earlier next year.
Will you clarify what matters will not be done until April 2017?
April 2017 is the date by which we expect to have changes to the NHS complaints and social work complaints processes fully in force. The reason for choosing that date—I am sure that Professor White will also want to speak about it—is that, although the changes are important in themselves and are important for providing the simple landscape that the convener described, what is arguably more important is the staff training and development and the communication that goes around the changes. We need to ensure that we do not simply change the process and legislation but that people fully understand what their new responsibilities are.
Craig White might wish to add to that.
As Alison Taylor mentioned, we have learned from other change and improvement programmes across the country that, if we want to have a sustainable process, staff must feel that they have been able to influence, inform and understand the changes and that they can implement them for every person whenever they are required to do so. We have learned that it is crucial to work with all the teams across the country, with an emphasis on front-line resolution and early and respectful engagement when people are dissatisfied.
We are confident, in working through our networks of learning, that it will not be April 2017 before we start to see the changes. Our work is very much about taking the learning from the revised processes that have been tested across the country and ensuring that the legislation and guidance are updated to reflect that. This is about how we take staff with us and how we respond and listen to what staff—and people who have used the complaints system—have said that they want us to get right.
The previous legislation specified a three-day period for early resolution, and we have learned that that was often not sufficient to enable people to arrange contact with those who were dissatisfied. We have listened and taken on board the feedback that we received, and we are now testing early resolution within a five-day period.
10:15
How does Mr Sengupta feel about all that on the health and social care partnership side?
I am quite encouraged. Some of the issues came up in the discussions that we had with Scottish Government colleagues as we framed our integration scheme some months back.
We have already put in place most of the changes locally. Under our previous community health and care partnership arrangements, any service user or patient who wanted to make a complaint or give feedback about any of the services that they experienced would have their case handled in the same way.
The message to our staff has always been that it does not matter by whom they are employed or which label is traditionally attached to their service area—if someone makes a complaint, they should receive it. If they can resolve it there and then, they should do that, but if it needs to be escalated, they should note it and it will be passed up the management line, where it can be dealt with formally.
It has been important for us to make the process as easy as possible for service users, patients and clients and to provide clarity to our staff so that they are not left wondering which policy to grab hold of in managing a case but are instead applying the principles. Those principles are all the same, irrespective of whether they relate to the NHS or to social work functions and procedures. We want to make it as straightforward as we can for our staff to deal with the process, which we want to be fair.
When there is complexity—I am perhaps overstating the case there—and a decision is required on which policy to use, we handle that by making it a senior management decision that sits with the head of service. To be frank, if any head of service who is responsible for integrated services cannot get their head round which policy to use, they are not worth much in what they are doing.
The substance is the same across all the policies: it is about being fair, proportionate and responsive. That is the approach that we have taken. At the end of the process, whatever the outcome, we have made a point of bringing the learning back.
We previously had a community health and care partnership committee, which was a joint arrangement that involved health board directors, other stakeholders and local authority councillors. As part of our overall performance management, we brought the learning from our complaints processes to the committee regularly—not just the learning from NHS or social work complaints but the learning in totality.
The guidance that is being discussed addresses that complexity. There are only a few differences. One is the timescale for acknowledgement, which the proposed guidance and the change in legislation will harmonise. The removal of the social work complaints committee and its replacement with a direct route to and expanded function for the SPSO will mean that, if someone is dissatisfied and a complaint has to be escalated outwith our arrangements, the complexity is reduced and the process is the same all the way round.
The new legislation and guidance provide an assurance to our integration joint boards that we are applying the policies and procedures; that when we have got it wrong—because we do, as any service and any of you might do—we have properly apologised and taken action; and that, when we have identified learning, we can apply it more systematically and show that we have taken it on board.
I emphasise again that we have been doing the things that the new guidance—as I understand it—will set out. From our perspective, the process should be much cleaner all round. I repeat that we have been making those kinds of changes locally, which have been in place for some years.
Is Mr McFadden happier from an ombudsman’s point of view with what is now proposed?
Yes—as we outlined in our submission to the committee, we have been pleased with progress since our previous appearance at the committee. A lot of credit must go to Alison Taylor, Mike Liddle, Craig White and other colleagues for moving us forward so far in quite a short space of time.
We have been involved in many discussions about the three key areas of social work, the NHS and the guidance for the integration joint boards. As members know from our previous committee appearance, the key issue has been that the processes, and the complexity and length of some of them, have in some cases been getting in the way of allowing the simple, early and quick resolution that has just been outlined.
Importantly, we now have agreement and consensus on the end point and how we bring everything together. That in itself is a bit of a challenge, but we now have clarity on where we want to get to.
We think that the steps that Alison Taylor described in the timescale for legislation will work. We have been involved in discussions on all of them, and we are content with the proposed legislative approach. We would always want to move much more quickly on such things, and I appreciate Mike Liddle’s comments about bringing things forward when possible—it would be helpful if we could do that. However, we recognise that a lot of work is involved, putting aside the legislative issues.
Craig White’s point about ensuring that we get it right is very important. That was the focus of a lot of our discussions, not just in our recent meetings with the NHS complaints handlers working group but in our work with other sectors. Many of our discussions with local authorities, colleges, universities and other sectors have focused on the need to support staff through the process. It is not just process for process’s sake, but something that has been designed to act as a catalyst for wider cultural change. That requires more than simply launching something and expecting it to be implemented; it involves supporting staff and senior leaders through education, training, raising awareness and providing further detailed guidance.
We are content with progress at the moment, and I think that we have reached agreement on the end point.
At our 10 June meeting, the committee was concerned that there was more emphasis on process than on people. Has that been reversed?
Yes—we have always been clear that the end point is about people and culture, but process is important, particularly when it is a barrier. I do not think that there is any doubt among anyone here today, or in any of the areas of work involved, that the key aim at the end of this work is to focus far better on early resolution and resolving issues quickly for people. The end point is to focus on all the things with which we have managed to have a degree of success in other sectors. I think that we all agree strongly on that, and it fits in well with the patients’ rights agenda and integration more widely.
I listened with interest to the description of the complaints-handling process that will be put in place for local authorities and health boards. There was some mention of staff training in the integration of services.
Ms Taylor, you referred to the independent and third sector involvement in the delivery of services. What discussions have taken place with that sector about some of the issues that have been identified this morning as being crucial for the successful delivery of a complaints-handling procedure?
I am talking about things such as staff training and understanding the processes, and where those elements fit in with the complaints-handling process. It is fine to say that local authorities and health boards have the complaints-handling process in place, with a folder that they can pull out, but how does that tie in with the independent and third sector, particularly at a time when the third sector continually claims that it is underresourced by health boards and local authorities to deliver vital services?
I can speak about that broadly in relation to the independent and third sector’s direct involvement in integration, and to a small degree with regard to the Care Inspectorate’s role in our consideration of how to improve complaints handling. It might also be helpful to hear from Mr Sengupta about local practice in engaging directly with the third and independent sector. The sector contains many very small providers, and they tend to bring the greatest benefits to service users in a local context.
Our independent and third sector colleagues have from the outset been represented in everything that we have done in integration. We had extensive working groups associated with the development of the legislation and the policy, and all the statutory guidance that surrounds that.
The question raises broader issues than those that relate specifically to complaints. It is also about staff development and understanding an outcomes-based approach. In fact, it is often our third and independent sector colleagues who bring the richest insights to conversations. Some of their specific experience has been tremendously useful. We have on-going work on workforce development that closely involves the third and independent sectors.
Obviously, the Care Inspectorate has a role to play with respect to any complaints that are specifically about registered services, which will remain in that context, but with the narrow focus on responding to complaints.
I am happy to do my best to answer the question, but please tell me if you do not think that I am quite getting to the nub of the issue.
In terms of the resource that is available, times are tight all round. If I had a health board hat or a council hat on or if you spoke to colleagues from any part of the sector, we would all say that resources are tight. By the same token, I would expect the committee to say to health boards, councils or any provider that that is no excuse for us not to take on board feedback, especially complaints, about the services that people are responsible for delivering.
Consistency of approach is important in considering the third and independent sectors. We need to recognise that there is a variety of scales. National bodies as well as small local bodies deliver services, and what we expect from them varies quite markedly. Alison Taylor talked about registered services. That is really important. If an organisation is registered to take on social care responsibilities, a series of obligations goes alongside that for the benefit of the service users, not the people who procure the services and whom the contractual relationship is primarily with. The same point applies if we are talking about front-line resolution. It is not about a separate top-down process from a health board, a local authority or an integration joint board. It is about the organisation taking that seriously.
To be honest, I would have thought that, in this day and age, most organisations would get that in principle and that some of them would be further along the journey than others. There will be capacity and training issues. If we are looking at residential care, for example, they would be for Scottish Care to consider. The Scottish Council for Voluntary Organisations has a role in respect of third sector organisations. A range of umbrella bodies out there should take ownership of those issues.
The approach that our colleagues have talked about in developing health and social care staff who are employed by health boards and councils is clearly very important, but I have said to colleagues that we should not lose sight of the fact that what our staff at the front line deliver is to do with dealing with people in vulnerable positions. They deal with difficult and complex cases, and they often deal with risk. That is part and parcel of what people with a professional background have been trained to do. By the same token, that is in the business of what third and independent sector organisations that are in the business of care are about, to a greater or lesser extent, so it is not unreasonable for us to expect that they will apply reasonable standards. We absolutely should ensure that we do not have excessive bureaucracy.
From a local perspective, we have as much interest as the integration joint boards—the health board and the council—do in the process not being overly complex. The convener mentioned process for process’s sake. Wherever there are health and social care services in Scotland, people should feel confident that, if they have a complaint, it will be dealt with respectfully and seriously and resolved there and then where possible, and that if they need to have recourse to a more formal process, that will be there for them.
I think that the term “small providers” is used. The issue for me is the availability of small providers to deliver services, as opposed to a health board or a local authority in which a background support team is on hand. Such a team might not be available to a small provider. As we proceed, it is about trying to ensure that we have guarantees in place that those small providers will be able to deal with the complaints-handling process in the same way as a health board or a local authority, for example.
Other bodies, such as care homes and the Care Inspectorate, have been referred to. How do we ensure that, when we talk about the complaints-handling process in the area, the crossover of those organisations is not lost? One problem that we currently have is the myriad of bodies. If someone wants to make a complaint about care services, who should they go to? Some constituents have been passed between different organisations, having been told that it is not the health board or the local authority that deals with that area—it may be the Care Inspectorate or social work services. We need to find a way of ensuring that, when people make a complaint or a member of their family makes a complaint, the matter is dealt with by someone who can act on that complaint. They should not be passed between five or six different organisations when they want to register a complaint.
10:30
It may help the committee to be aware of some guidance that was issued on the clinical and care governance of integrated health and social care services. Alan Baird, the Scottish Government’s chief social work adviser, and I have reviewed all the integration schemes in relation to the specific aspects of clinical and care governance, and the importance of a single point of contact for people who use services is emphasised in that guidance. We also expect the integration joint boards to seek assurance not only that services are being implemented in accordance with the guidance but that, when services are contracted to other organisations such as smaller third sector organisations, the same standards of complaints handling apply.
When Scottish Care was involved in developing the clinical and care governance guidance, it discussed the importance, in agreeing contracts with, for example, the third sector, of addressing ahead of time the issues that you have mentioned, which might subsequently become barriers. It is crucial that the boards seek assurance from those who use the services that they know who to contact, that their issues are being addressed when they are first raised and that complaints are dealt with correctly, irrespective of who provides the service. I am happy to send you that guidance on providing a single point of contact as part of the wider clinical governance arrangements if that would be helpful.
It would be very interesting to see that guidance. If you could send it to the clerks, that would be useful.
I wonder whether Mr McFadden has any comments to make on the issues that are faced by individuals who contact the SPSO, particularly at present but also in the future. In your submission, you say that the SPSO hopes to be geared up to deal with this around April 2017. Are you confident that all the processes will be in place to ensure that that single point of contact will be well advertised and well recognised by individuals who want to raise concerns about the level of care that is being provided?
Yes, we are. The process should make that clear, and it should provide consistency and clarity around whether people should be signposted to other agencies or whether there are joint issues that should be addressed collectively in one response.
There is more to this than just launching a model complaints-handling procedure; it is also about the implementation of it and the availability of all the material. We would like to be able to work a lot more closely with the Care Inspectorate when people come to us with complaints about care provision as well as about care assessment and other elements. Therefore, part of the discussion with Mike Liddle and his team around the social work legislation has been about ensuring that we are able to share information, which might lead to more joint investigation with the Care Inspectorate on some of those issues.
I would like to get an understanding of the extent to which staff have been involved in the consultation process. I am thinking particularly of staff representatives and unions, given the complexity of the situation and the fact that the outcome of a complaint might well lead to disciplinary procedures or other action being taken. What involvement have they had in the process?
The answer is that it depends on the individual piece of legislative work. Staff representative bodies and unions have been very closely involved in the broad project of integration from the outset.
Before I hand over to colleagues, I make the general point that we are not creating a new, split process for anyone; we are refining the NHS complaints process to make it a bit more effective and a bit swifter. We are also refining the social work complaints process to harmonise it with the SPSO three-stage process, so that it is the same as the NHS process and we have one simple mechanism. We are also adding the joint boards to the SPSO three-stage process.
This is about refinement, some improvement and an opportunity to learn. I hope that, as a consequence, it will not be of specific concern to staff representative bodies.
The colleagues who are leading on the legislative work might want to add to that.
On social work complaints, we have been in touch with the Scottish Social Services Council, which is the representative body for social workers in Scotland, and we have shared our draft consultation document with it as well as the draft order that we are going to bring forward. The main change that that will make for the staff is that the SPSO will be able to speak more directly with the SSSC and the Care Inspectorate. The idea behind that is, as Paul McFadden said, to enable joint investigations and to allow the SPSO to share with the appropriate regulator any information that it receives as part of a complaint that relates to either a member of social work staff or a care service, which will enable the regulator to look into the matter. At present, the SPSO is unable to do that unless there is a significant danger to life—I believe that that is the phrase. The change to the social work complaints procedure will just refine the existing system, getting rid of the complaints review committees and bringing it into line with the other models.
Are you saying that there are legislative barriers to co-operation unless there is a danger to life?
Yes, I am.
That will change completely and utterly with the new legislation that you are bringing forward.
It will. That legislation will allow the SPSO to speak to the Care Inspectorate and the SSSC. There will be a much lower baseline for triggering that dialogue.
The inability to share some information relates to the fact that our legislation requires us to work in private and to respect the privacy of people who bring complaints to us. That means that it can be difficult to share some types of information unless a series of tests is met. The draft legislation will ensure that that regime is relaxed a little bit, so that we are able to share information more broadly, particularly when there is a joint interest with the Care Inspectorate, for example.
I have three points to make in response to that question. First, the current NHS Scotland complaints process was subject to a wide consultation process that involved a number of the staff-side organisations. Secondly, there is a national group called the Scottish partnership forum that meets regularly and includes representatives of organisations such as the Royal College of Nursing, Unison, the Scottish Government and the NHS. Recent discussions have focused on the duty of candour provisions in the Health (Tobacco, Nicotine etc and Care) (Scotland) Bill and have related to what Alison Taylor said about complaints investigation and reviews being very much about learning and not about disciplinary, conduct or capability matters. There are discussions within the Scottish partnership forum about how we can ensure that complaints processes focus on systems, process, review and learning and that separate processes are in place for dealing with staff. Thirdly, as I mentioned, a working group has been established to test and review the learning around the changes and improvements that we want to make. After this meeting, I will seek assurances from that working group that it is linked with the Scottish partnership forum.
Good morning. Integration joint boards have not been formed in all 32 local councils, only in Highland and Ayrshire. Are they being formed now? I am interested in the progress that is being made on establishing integration joint boards. Can you please enlighten me?
Absolutely. During 2015-16, each health board and local authority has to submit its integration scheme—the scheme of establishment for its partnership arrangements—to ministers for sign-off. At present, 25 out of 31 schemes have been signed off—some of those 25 are in the process of being established; a parliamentary order establishes the integration joint board—and six are completing their schemes at the moment. That is good progress and we are pleased with it because the deadline to get it all done is March.
Is there any resistance to that or is everybody on board?
It can be quite challenging for people. There is a lot of detail to work through. The schemes work out at about 80 pages. The health boards and local authorities have to go through and agree a lot on finance, functions and other things, and my team has been providing support. However, the process is productive because it genuinely brings the partners closer around the idea of working together to improve outcomes for people. Progress is constructive and good.
Highland has a different system. What do you think of it?
It is interesting. I have been lucky, as I have been able to work in this area for a number of years, so I have had a chance to look at how people do things in other countries as well.
There are two options in our legislation for integration. They both operate on the same principle—according to my philosophy, at least—which is that we need to have a single commissioner and a single budget for planning services for people with complex needs. We can do that in different ways—we can exchange functions or pool them around a joint board—but the key for success in systems that create good outcomes seems to be creating the single commissioner and budget and putting people at the heart of the strategic planning.
As the systems start to evolve and develop in different localities, we will look at outcomes. We will examine who is shifting the balance of care in time and will see what is working and whether we can learn some lessons from whether people have found the Highland arrangement easier or more difficult. We do not know yet.
I want to try to stick to the complaints system, because that is what we are here to deal with.
Good morning. I ask the witnesses to clarify a few points for me.
We are talking about improving care and outcomes in general and the integration process in particular. Are the service providers in the NHS and social work services able to access the complaints process too? It would be a bit naive of us to think that opportunities for service improvement will come only through complaints from clients or service users. There are possibly well over 100,000 people involved in delivering the service in Scotland. What is their role in driving forward the improvement agenda? Can they raise complaints and access the procedure?
The clinical and care governance guidance that I referred to also requires that integrated services have a co-ordinated approach to pooling various sources of information. That relates to complaints made by individuals, but there may also be feedback through reviews of services, reports of adverse events or discussions about risk. The governance requires the integrated health and social care services to consider all that information in the round in the interests of learning and improvement priorities.
Could a member of staff make a complaint about some aspect of service delivery using the process that we are about to legislate for?
That would not be part of the NHS complaints process but it would be part of the clinical and care governance process, in which staff observations on the quality of care are vital to opportunities for learning and improvement.
How does it sit with the vision of integration if the staff who deliver the service cannot access the complaints process that we are putting together?
Professor White, will you explain how a member of staff would complain compared to how a member of the public would complain? It is the latter with whom we are dealing, in the main.
A member of staff could raise a complaint on behalf of a patient or service user, but that would be processed as part of the complaints scheme for the individual’s care. All services have mechanisms to allow staff to raise concerns about the quality of care, such as adverse event or incident reporting systems. If staff have concerns about the quality of the care delivery, they report it through those mechanisms.
Of course, many of our teams also have daily processes whereby they get together to discuss such matters, and that discussion will involve those locally owned processes. For example, someone might say that they have a concern that they could not respond to Mrs Bloggs’s request for information and that the team really needs to discuss that as part of its learning.
In summary, such issues would be dealt with through the adverse event or concerns processes that a board has for reporting such events or through the learning mechanisms that all teams have in place.
10:45
Does that encompass the whistleblowing opportunity that is available across the system? Do issues that arise anonymously through the whistleblowing process go into the complaints process?
The concept of whistleblowing suggests that the mechanisms that are in place have not been effective and that a staff member feels that they have to go outside those. We are beginning to stray into areas that are outside my expertise. However, going back to clinical and care governance, my understanding is that people need to be clear about which process to use for which concern. I expect that, if staff do not feel that they can use the processes that I mentioned, they need to know what mechanism should be used where they work. That is part of good staff governance.
In her opening remarks, Alison Taylor said that the process is the same no matter who makes the complaint. However, it might be different for service deliverers accessing the system. Mr Sengupta said that things can be resolved there and then. To me, that suggests that there is an assessment of whether a complaint is non-complex or complex and that people can have matters resolved quickly without recourse to the full process. Is that correct?
If it helps, I can give a bit of context about where I sit at the local level. Complaints are only one way in which we get feedback. Our complaints procedure is oriented around the service user, so that is not the mechanism through which staff would raise concerns. We have multiple ways of doing that, but the complaints procedure is very much about the people to whom we provide services.
The way in which we resolve things depends on the nature of the issue and how it feels for the individual client, patient or family member. Many issues that are raised are about communication, for example. If someone is unhappy about something, the matter can often be resolved there and then. That is set out in the policy, so the process is not outwith the policy; however, the machinery—for want of a better term—does not kick in. If an individual says that they are unhappy about something or that they have a concern that is to do with themselves, their mother, their partner or someone whom they care for, the member of staff, whoever they are employed by—currently, this happens in social work and NHS procedures—should take that on board and consider how to address it, make it better and sort it out. If there is a need for an apology there and then, that can be given, too.
However, if the issue is a bit more complicated and requires more consideration, or if the member of the public, patient or client does not feel happy with what the member of staff has said, the issue can be escalated through a more formal process in which we write to the individual to acknowledge the complaint and we investigate. That is all part of the complaints procedure.
The aim of that approach is to put the emphasis on dealing with things as quickly as possible, there and then, to the satisfaction of the client or patient. That is the important point. It is part of the policy to try not to get bogged down in bureaucracy. Again, it is incumbent on us all, including staff, to make that as easy and straightforward as possible. From the feedback that we get, we know that, when an issue comes up, most people, although not all, just want it sorted there and then.
Often, it is small stuff. There are complex issues but, more often than not, the things that we get back are to do with misunderstandings, miscommunication or other things that can be sorted out relatively easily. In many cases, the member of staff in the team was not aware that they were doing something in the first place. A range of issues can be sorted out fairly quickly if the patient, client or carer is made to feel confident enough to raise the issue with the member of staff and the member of staff is not too defensive and just takes the point on board.
To add to Professor White’s answer to Mr Coffey’s earlier question, the local clinical and care governance approach is very important to us and there are multiple ways in which we get feedback from our staff. Issues can be raised through one-to-one supervision and team meetings as well as through critical incident and significant incident reviews. There are multiple mechanisms for that. Staff also have recourse to their union if they have concerns about the way that the service is oriented. In our integration schemes, we have made provision for what is called whistleblowing in the NHS and public interest disclosure in local authorities. Those arrangements are in place, so there are multiple steps.
I return to the earlier point about there being lots of ways in at the local level. The more joined up that we are and the fewer mechanisms that we have, the better, because that means that we can focus resources and get clarity. However, by the same token, if people are unhappy with how process X worked out, for whatever reason, they often want recourse to process Y. There is a balancing act, therefore. If we remove other options, people will feel unhappy about that, because they will feel that their issues have not been properly worked through.
That is a lot clearer.
I have a question about the other end of the process. If a person raises a complaint and is unhappy with the outcome, will it go straight to the ombudsman or is there an appeals mechanism?
I will give some context around the model CHP, which is operating elsewhere and which we have agreed to in all these areas. The difference between complex and non-complex issues is at the heart of the issue.
Our experience ties in with what Soumen Sengupta has outlined in that the majority of issues that people raise or complain about can be resolved quickly and close to the front line. They are probably better resolved by people—staff or managers—as close to the point of service delivery as possible. As the committee knows from previous evidence sessions, about 85 per cent of complaints in local authorities end at that point without progressing. However, some complaints are complex or serious and so are not suitable for five or 10-day resolution at the front line. Those complaints will be escalated straight to the second stage and the 20-day investigation. That is the right approach. It is important that those complaints are taken straight to that stage instead of attempts being made to resolve the issues at the front line.
After the stage 2 investigation is completed, there is a bit of flexibility. If the issue is particularly complex or there is a need to undertake outside investigation, that is the point at which people will be signposted to the ombudsman. At the moment, in each of the different areas, that happens at different points and stages. In the new vision that we are working towards, in every area, after that second stage has been completed, people will be signposted to the SPSO, at which point we will have a remit over all those areas. That is the simplicity in the design of the system.
You are not an appeals body, though. As I understand it, you cannot reverse a decision. If a person is fundamentally unhappy with the outcome that has been arrived at, whom do they appeal to?
In health, we have a role in relation to clinical judgment, which is a standard above maladministration. In our role on maladministration, we can look at how decisions were made rather than at discrete elements of those decisions. The proposal is to give us a similar role in social work to the role that we have in health in relation to professional judgment. Although it may not be accurate to describe us as an appeals body, we will look at discretionary decisions such as how someone’s care needs were assessed and whether that decision was made reasonably. In essence, we will look at whether a good decision was made. The new system will help to provide a good route to administrative justice for people.
On Mr Coffey’s point about referral to the ombudsman, in discussions with NHS colleagues, I have been encouraging people in leadership roles to view a requirement to go to the ombudsman as a failure. As part of our policy emphasis on front-line resolution, we expect more effort to go into consideration of why people feel dissatisfied and of ruptures in the relationship that they might have with those who are involved in reviewing the complaint. We should bear in mind that people will have a continuing relationship with the public service. We really need to get the local organisations to look at that.
It seems to me that the threshold for telling people to go to the ombudsman is too low in some of our NHS boards. I have had quite robust discussions with some staff in boards in which I have asked them to reflect on such matters and to take more local ownership of them. I respect the fact that people will sometimes need the ombudsman and that there are benefits of referral to it, but I am discouraging people from setting that bar too low.
I want to ask about your plans to engage with the public, which can be a complex process. How do you plan to do that? I hope that you do not plan to issue pages and pages of process description that uses very complex language. How do you plan to engage with the public and to simplify the process to make it easy to access and understand?
Ms Taylor can start—without overusing the word “congruent”.
I agree entirely with Mr Coffey that pages and pages of process would be a very bad approach.
The most important thing is that people know how to complain locally, because the service that is delivered to them or their relative is in the local system. It is enshrined in the integration arrangements and the scheme that has to be produced that the local partners must make it clear to the public how they can make a complaint. We sent the committee some leaflets that NHS Ayshire and Arran uses for that purpose. I am sure that Mr Sengupta would be happy to speak about that.
It comes down to making sure that people know how to make a complaint locally. At its simplest, that is about their being able to speak to whomever they are in contact with and that person being under a professional obligation to respond appropriately. That is what I was trying to get at when I talked about flexibility. You cannot set out rules for everything, because there will be many different situations in which people find themselves wishing to speak to someone.
My comment is about how we are going to improve the system without making it overly bureaucratic. For the planned improvements to the NHS complaints scheme, we are going to encourage people to say what went well in the way that we responded to their complaint, what did not go so well and how we could do better. Using the responses on how we could do better, we will support boards to test and refine the scheme and to continue asking those questions so that, as we work towards the dates that we mentioned earlier, we will have a large body of learning from across the country on what “good” looks like. We will then design that into the system and support implementation at scale across the country.
I am new to this topic as a committee member, but I am not new to it as an MSP and someone who has been a councillor.
We have talked a lot about the way in and the first point of contact. I find that quite often that is me—people come to me to complain. They do not always use that word; they say that they just want to get something “sorted out”. I raise the issue and it gets fixed. My question has partly been answered in the response to Mr Coffey but, having listened to all the discussion this morning, I wonder whether my requests to get something fixed go into the same system of learning, culture change and feedback, or whether it is just a case of, “Phew—tick that one off; we’ve got her off the email.” How does information from people like me come into the system?
Mr Sengupta, you seem keen to answer.
I can answer from a local perspective, as someone who has to deal with MSP and local councillor inquiries. The simple answer is yes—all the learning goes into the system.
The way that it works is that we need to get feedback from as great a range of people as possible, and if there is a tension or a concern, we would rather know about it and look into it. As you all know from your constituency work, many issues can be easily resolved. There are other cases in which we say that we or the services staff have got it wrong and something needs to be addressed so that we do not get it wrong again. In fairness—this relates to what Mr Coffey was talking about—there are also times when people are being unreasonable or vexatious.
A big point is the need to have a fair process, so we take all that stuff in. We make sure that we address it fairly, proportionately and swiftly, as far as we can and whenever we can, and then we take the learning from it. That feeds into how we develop our services. It is really important for the developmental work that we all have to do that it is not just driven by the financial situation or by a range of policies that come out nationally or from professional bodies. Services should be developed in response to the views and experiences of all the people to whom we are providing services.
An important thing for us, which goes back to Professor White’s point about clinical and care governance arrangements, is that we should not put too much onus on one route for that feedback over the other routes. We try to get a balanced view of things, as far as we can. The views that elected councillors, MSPs and others express are as helpful as any formal complaints procedure or any formal or informal consultation that we have with our clients—patients and carers.
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Best practice in this area would usually involve asking what it was about the relationship that our team had with a person that meant that they felt that they were not able to raise an issue with us, or that we were unable to resolve it and that a third party had to be involved. As well as the care episode being looked at, I would certainly expect there to be a mechanism whereby there could be a conversation about or reflection on what the episode said about the culture or the clarity of the single point of contact that we have talked about. If the single point of contact is that clear, why did the person not come through that route? Mechanisms are needed to capture that learning.
Do you want to hear from Mr Liddle, Jayne?
Yes, please.
Sorry—in terms of what?
In terms of social work.
My question was about third-party complaints—complaints that come not from a service user but a third party such as an MSP or a councillor.
Local authorities would take the learning on board in the same way.
In the long term, we will have an extremely effective way of improving service delivery and the customer experience, but in the short term there will have to be a massive culture change and work will have to be done with staff to make them feel okay about being complained about. Being complained about is not comfortable, but it is how we learn. Will there be sufficient space and resource for that to happen in the short term? You have all mentioned training, which there will be a lot of. Will it be possible to backfill staff who go on training courses?
Before I was in my current job, I was assistant director of a health board and I had responsibility for complaints, among other things. I certainly found that that issue came up a lot. Staff need support and they often feel threatened or concerned about the implications of complaints, particularly if the culture is not learning focused—perhaps they are more used to blame. Dealing with that is absolutely crucial.
Every financial year since 2012, the Scottish Government has provided funding to NHS Education for Scotland to support the training and development requirements that are essential to equip staff. I anticipate not only that that funding will continue but that we will need to look at how we sustain and enhance it, given our policy commitment to earlier front-line resolution.
A theme of the evidence that we have been given is not looking at complaints in isolation. We are talking about training and cultural change, not just complaints. We have been on that journey for years. We have quite a long distance to go, and different places to go to.
If we were having a conversation about what happened in Mid Staffordshire or any other place where things have gone badly wrong, we would hear that these issues have come up before. Any reasonable and responsible person in the professional bodies, the employing organisations and the providers is very sighted on that.
The issue of how we can work with our staff to move forward is a live topic, but let us be quite clear: staff do not live in a bubble; they have an interest in this. Often, they are recipients of care and, more often than not, they are responsible and very capable professionals who are developing themselves. In that regard, we all are moving in that direction together.
The really important thing when it comes to how that will work on the ground is how things are practiced. My watchword on this is “fairness”. Staff must feel that it is a fair system and understand that if they invite complaints, they will not get the book thrown at them, that just because the person to whom they respond is not happy with what they have said it will not end in a disciplinary, and that they will be appropriately supported. That is important.
By the same token, our patients and service users need to feel that when something has gone wrong as a result of a member of staff doing something wrong, the organisation will not squirrel away that member of staff somewhere so that nothing happens to them. It needs to feel fair to all parties. That is no different today from how it was yesterday. That is where we are trying to get to so that we can do it better.
I have a follow-up to the last point. What consideration has been given to ensuring the protection of people who make a complaint against an individual care provider or an organisation? Has consideration been given to ensuring that someone who makes a complaint is not unduly penalised in the services that they receive because of that complaint? Mr Sengupta mentioned working with staff to ensure that they understand that, in a good working relationship, there should be a complaints process and that complaints should be handled fairly. However, as we know, complaints are not handled in a fair manner in every circumstance. Some people feel that, because they have raised concern about the care that they have been receiving, they have been unfairly treated, either by individuals or by the organisation charged with delivering that care.
Ms Taylor, I think that we will get you to answer that, as the team leader for integration and reshaping care.
I think that that speaks to the need for strong and effective management. Good leadership and good management will instil the principles that Mr Sengupta and others have spoken about. It is about learning from mistakes and not being threatened by them. It is certainly about not allowing complaints to lead to a diminution in the way in which somebody is looked after, which would obviously be completely inappropriate.
The question also speaks to the professional standards that run through all the professional groups that work in health and social care. It is probably a matter for strong management, leadership and vigilance. I would certainly expect us to reflect that in the guidance that we will develop on complaints under integration. We are working on that now, particularly with our colleagues in the SPSO.
The chief officers in these systems will need to take responsibility for ensuring that there is fairness of the sort that has been described.
Professor White, you look as if you are dying to come in.
I agree with Alison Taylor in relation to professional standards. All the regulated healthcare professions are quite clear that negative feedback complaints are a critical source of learning not only for the organisation but for individual practitioners.
I want to reinforce the point about the importance of including complaints handling in training. People often feel that a complaint was perhaps unjust or can have a negative emotional reaction to a complaint. While I would not wish to play down the impact on individuals, in personal dialogue I would encourage those in leadership positions to explain to the people around them that, ultimately, it is not about them. They are in a public service role and need to develop skills to deal with their reaction to being complained about and focus on how to make things better for the person who has complained.
I agree with what has been said. There is a cultural element to this. Leaders and managers are very important in the development of a value in complaints culture and in moving away from the blame culture. Training is crucial to that. We have supported the NHS Education for Scotland work that Craig White referred to earlier and will continue to do so.
There is also an element of transparency around this. The new model requires all complaints and all elements of feedback to be recorded and reported consistently. That is important to ensure that people are aware of what issues are raised and how they have been dealt with, in order to build confidence in the system. In addition, people should be aware of alternative routes to provide feedback. If they feel that the provision of the care that they receive might be under threat if they made a complaint, they should have alternative routes to raise those issues with the boards or even with the SPSO, as the independent external body.
I have a number of quick-fire questions. The speed of resolution after a complaint can really annoy people. It is sometimes better to say to folk at the very beginning that their complaint is going nowhere than to keep them on the line for ever. How do we ensure speed of resolution in the new systems that we are setting up?
The first thing is to go back to the front-line stage of five days. If we are able to get the majority of complaints in the NHS, for example, resolved within that timescale, that would be a huge achievement. At the moment, all complaints have a target of 20 working days. Speed of resolution is something that we hope to achieve through the new process.
There are challenges in supporting staff to be able to resolve complaints in that timescale, but experience in other sectors is that front-line staff and managers are able to deal with complaints a lot more effectively than is possible when all complaints are sent to a complaints team. Ownership and responsibility as close to the front line as possible is absolutely crucial in ensuring speed of resolution.
Does the SPSO have the resources to deal with the new systems?
That has been at the forefront of the discussions that we have been having with the various Government departments. We and the Scottish Parliamentary Corporate Body need to make sure that we are appropriately resourced. We are in discussions with the various teams, and we have been given assurances, for example in relation to the NHS work, from the cabinet secretary. I understand that the corporate body has sought and received similar assurances.
If all the proposed changes work well at the front line, you might have fewer complaints to deal with.
That would be the ideal end point: to put ourselves out of business.
Finally, Professor White, you said that you saw complaints being referred to the SPSO as a failure. What would you say to the organisations out there—the local authorities and, in particular, the NHS boards—that now say to people at the end of every letter dealing with a complaint that, if they are unhappy, they can contact the SPSO, the details for which are provided?
I would make two points. My understanding is that NHS boards are required to do that under the guidance in relation to the Patient Rights (Scotland) Act 2011. Although there might be a requirement to do that, my advice would be that the boards could also emphasise that people should not feel that they had to go to the ombudsman if they continued to have concerns or feedback about a different way of resolving the complaint. There are some really powerful examples from some boards in which staff have been encouraged to say, “We do not want you to go to the ombudsman, because that would show that we had failed to respect the importance of the feedback. We want to work with you to make the improvements and changes.”
I would expect the group that I mentioned earlier to start testing different ways of putting such information in letters to see whether it can reduce the numbers of complaints that have to go to the ombudsman. The wording of the letters could include additional content that is more focused on respectful, on-going engagement to make improvements.
Thank you very much.
I say to all the witnesses that the committee will undoubtedly keep a close eye on how all the new processes are dealt with, and I hope that our successor committee will do likewise, so I would not be surprised if you are called back.
Thank you for your contributions. I suspend the meeting for five minutes to allow the witnesses to leave.
11:13 Meeting suspended.