Yes, patients do and Practices like anyone do not like complaints. GP Practices these days are expected to handle and process their own complaints. Practices should have clearly defined procedures to deal with complaints and it should not be too difficult for them to find out how to complain by look at either the Practice Leaflet or Practice web site.

The Trouble is……

Patients these days are quite savvy and they know how to cause problems. They can look at the NHS Web site and add a few choice words anonymously to comment on their experiences at the Practice. They also have access to the Care Quality Commission and can report a Practice with or without grounds.

It’s best not to ignore complaints!

Having said that in over 50 years working in the NHS both as a Complaints officer with an FPC and in general practice. To be honest the number of complaints received each year compared with the number of patient contacts is infinitesimal. In fact, I recall struggling to gather and report annually on complaints dealt with by my surgery let alone find any learning points.

Sorry is not the easiest word to say

Saying sorry is such a way that there is no admission of fault is not easy. Showing empathy band understanding is a start. Giving a clearly worded explanation is the next stage and showing how the Practice might take on board or improve as a result of the complaints might provide some resolution.

Keeping a Register

Keeping a register of complaints for the Practice generally and for each individual GP is a wise move. Complaints might also be split into clinical and non-clinical. The register should show the name of the complainant and or patient. It should show the names of persons complained about. It should then detail the stages of processing the case. It might include acknowledging the complaint, responding formally and receiving further comments. It record the dates of meetings or telephone conversation. There should be a summary of the complaint along with the response or resolution. It might need to record any appeal internally or externally. It might also need to record details of any other bodies or persons involved not associated with the Practice.

A Professional Response

The long and short of it is that it is all time consuming. It needs to be dealt with professionally and in my opinion not just left to a GP to answer his or her own complaints. It is also important to consider whether a complaint is valid. The issues raised may relate to the GP contract and the terms of service contained therein to do with the treatment and care provided for a patient. Was the treatment and care provided within the realms of what might be expected from a GP or was the skill and knowledge that would be required be more appropriate to a fully trained and experienced consultant. Is the GP actually responsible for the treatment and care provided or is someone else. These days the responsibility is not 24 hours.

Another area to check is whether the complaint is timely – when did the event that gave rise to the complaint occur or when did the complainant become aware of its relevance – there are and need to be time limits. In addition if the complainant is not the patient does that person have written consent to complain on behalf of the patient. Clearly anyone can complain when a patient has died although it would normally be a relative.

Practices should have a Practice Complaints Procedure which is available in written form. It is not sufficient to simply say contact our Practice Manager. The procedure should set out all the conditions attached to making a complaint and give a timetable for processing the complaint. Going quiet and not replying is not an option. I fail to understand why some Practices fail to respond to complaints made on the NHS Choices web site. No response does not look good and will be picked up by CQC Inspection.

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It’s now nine years since I formally retired as a full time Practice Manager although even this year I have been drawn back to work in a Practice ‘helping out’. Nowadays I am more of a user of NHS services and start to question even more and more the quality and standards of the services I am offered added to that the expense!

I was referred earlier in the year for a second operation on the same site in two years. The referral and process to a first hospital appointment were prompt only to be let down by ridiculous waiting lists that caused undue distress and major expense. The referral for an ultrasound was efficient and prompt with a 15 mile trip to a remote village surgery where the equipment had been transported in from Blackpool. The results were clear an operation was needed and an E-referral was made on the NHS but to a private hospital. This involved a train journey and long walk to the hospital and an examination which can only be described as cruel and extremely painful. I took an instant dislike to the consultant.

I was invited for a preoperative assessment the following week in late April which I attended (50 mile round trip) after which I received an operation date in June. Considering the pain I was already suffering I was astounded. I could not quite understand the decision to carry out a preoperative assessment over six weeks before the operation. As a layman I did not consider this good practice.

I contacted another private hospital in the same group was was offered a consultation with a consultant the next day and an operation the following Saturday – 11 May. It made a big £4,000 hole in my pocket (and pension) but to me the pain was a deciding factor. The operation was carried out and at the end of the year I am more comfortable and in far less pain but suspect that I will never be in perfect health.

In general practice again I find myself lucky if I speak to a GP on the morning of the request. It’s rarely the same GP and I feel there is much repetition and little continuity. A member of my family was offered a telephone consultation in a weeks time. I find too that there is a drive to change medication and alter repeat medications not always to the benefit of a patients health. I have also witnessed a case of a drug being refused in writing only to find a text message from the pharmacy to collect said refused prescription. Has general practice actually lost the thread. So wrapped up in meeting targets can it no longer see the light at the end of the tunnel.

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There is much debate about the need for and the extent to which Medical Practices develop policies, protocols, procedures and plans.

Perhaps you need to consider whether there is a real useful purpose for a ‘document’. Is it needed for training purposes or is it a legal requirement? Are you just meeting the apparent requirements of the Care Quality Commission. Is it required to meet a legal necessity or is it required because something is not quite right and you need to document your Practices correct approach to a subject. Do all staff need to read the ‘documents’?

All in all it is a bit of a nightmare. Modern management has created almost a duty to document everything that moves and if not produce a risk assessment as to why you have not.

So in the face of all this bureaucracy keep it simple, make it readable, and limit the number of words and pages. One document I found as a model had 60 pages. Stick to key points. Be careful not to use as a model a document prepared by someone else without reading it and making sure it fits the bill.

Here is a list of the sort of documents you might prepare but be careful to choose those that are essential to your Practice and not just desirable.

1. Allergy Protocol 
2. Business Plan 
3. Chaperone Policy
4. Clinical Correspondence Procedure 
5. Confidentiality Policy 
6. Continuity Plan, (Disaster, Contingency)
7. Information Governance Policy
8. Patient Survey Policy (Friends and Family)
9. Patient Participation Group (Constitution)
10. Record Keeping Policy 
11. Practice Leaflet (Content) 
12. Surgery Web Site (Content) 
13. NHS Choices & CQC Web sites (Content)
14. Lifestyle Information Protocol 
15. Significant Events Procedure 
16. New Patient Health Checks Protocol 
17. Patient Care Plans Protocol 
18. Incident Reporting Procedure 
19. Palliative Care Policy  
20. Safety Alerts Procedure  
21. Life Saving Skills Training Policy
22. Dietary Advice Protocol 
23. Quality of Correspondence Policy 
24. Medical Records Transfer Procedure 
25. Carers Policy 
26. Safeguarding – Children and Vulnerable Adults
27. Emergency Plan
28. Criminal Records Check Policy
29. Abuse Leaflet
30. Infection Control Policy (Decontamination)
31. Repeat Prescriptions Policy
32. Access on Line Policy 
33. Controlled Drugs Policy 
34. Access for Disabled Policy
35. Staff (Training) Induction Handbook
36. Employee Handbook
37. Absence Management Policy
38. Breast Feeding Facilities Policy
39. Emergency Equipment Policy
40. Staff Recruitment Policy
41. Personnel Policies 
42. Staffing (levels) Policy 
43. Staff Immunisation Policy
44. Patient Registration Policy
45. Zero Tolerance Policy
46. Practice Complaints Procedure
47. Clinical and Administrative Audits Policy
48. Risk Assessments (various)
49. Sepsis Policy
50. Financial Viability Statement 
51. Standing Financial Instructions
52. Partnership Agreement
53. Model Staff Contract (including Salaried GP, Trainees and Apprenticeship
54. Practice Managers Manual 
55. Practice Managers Handover Manual
56. Death Reporting Procedure 
57. COSSH Manual (Hazard Data Sheets)
58. Practice Drug Formulary
59. Health and Safety Policy

Policy Documents 

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A Child in the 1950s

As a child in the 1950s, I was a regular attender at the sit and wait style of open surgery. There were no appointments. My mother and I sat waiting in the Doctor’s Lounge and we were seen in the Dining Room. The Doctor had a roll top desk, cluttered with paperwork. No computer screens. The receptionist sat in a cubbyhole under the stairs. My bulky record folder was handed to my mother. We would wait at least an hour but I do not remember any complaints. The important thing was to be seen.

Purpose Built Surgeries

The home based style surgery was eventually replaced by a purpose built surgery in the later 60’s around the time I started work in an Executive Council. I worked in a Registration Department writing medical cards and the paper dust from records probably did not do me much good as an asthmatic. My boss at the time once told me that he would never have employed me if he had known I was asthmatic. That wouldn’t happen now would it.

Two whole time staff (equivalents)

I remember that GPs at the time, 1966,  employed only a small compliment of staff, a receptionist, maybe a medical secretary and a nurse. A Practice Manager was a rarity. It was probably well into the 70’s and 80’s that as a senior officer in a Family Practitioner Committee I started to meet and get to know the Practice Managers in my area – Dudley then Wakefield. They were a good solid bunch of folk not put off by considerable change and hard work. We gelled at training events and during my visits to surgeries to discuss premises improvements. Information Technology  was in its infancy. BBC Acorns were used for repeat prescriptions but into the 90’s there were in the region of 60 clinical software systems on the market and today only around three have survived.

Being A Practice Manager

I became a Practice Manager in 1992, after the demise of FPCs and started to see the world quite differently. GPs were not used to managing their own affairs and those that I worked with in five different practices did not always understand their budgets and dare I say the rules of the game. Frustration abounded. The word independent often reared it ugly head and made for difficult relations between Practices and officials from variably named PCGs, PCTs, CCGs and so on.

Fundholding and Practice Budgets

As general Practice Partnerships units merged and grew the number of staff required to run the show also grew. There were ‘funded’ fundholding managers along with data and invoice clerks. But when fundholding ceased did all of these people leave? Then there were new staff entering the affray such as phlebotomists and salaried doctors who had been  paid for out of fundholding monies. But the Personal Medical Services contracts brought another form of fundholding with it’s new so-called Growth money – enough to pay for new staff and more doctors. This is where innovation took hold and more new posts were created from salaried GPs to Nurse Practitioners who could prescribe. I think, however, it also created more rich and more poor practices. It has to be sais that these posts were all funded above and beyond the original Ancillary Staff Scheme and arguably still are or are they?  There were also major issues about Practice Budgets as those Practices that were high earners continued to be so, yet you could argue that those Practices who were low earners and took on budgets lost out even more over the years.  Added to that the Budgets fell short of reflecting the change of Practices to employer status and the new requirement to pay Employers Superannuation contributions.  And then budgets and funding started to be cut. My biggest question is whether the right proportion of funding in Practice Budgets ends up being spent on running the Practice or ends up in Drawings!

Understanding Funding

It is important for the owners of Practices and their Practice Managers fully understand the history and origins of the funding the Practice receives and are able to consider the consequences when these funds are reduced or withdrawn. The Minimum Practice Income Guarantee is no longer reliable. The Quality Framework has changed so much since 2004 and has become harder to achieve. So can you really afford a Health Care Assistant? If you think you can where did the money come from. I suspect the profits of the Practice. Are you actually replacing an expensive member of staff with a cheaper employee. Practices need to be so careful when introducing new ways of working with arguably cheaper staffing costs. One further point is that the Care Quality Commission has added to the pressures on general practice to prove that Practices are achievers and if not the threat of special measures and closure looms alarmingly. It may ask the question – is your Practice financially viable?

Can you really afford it?

I might argue that apart from an adequate quota of GPs, Practice Nurses, and general Practice Staff you cannot actually afford anyone else. You cannot afford a succession of long term Locum doctors. You could swap a doctor for a Nurse Practitioner and you could swap a Practice Nurse for a Health Care Assistant or Phlebotomist. But without guaranteed continuous funding you cannot afford a Practice Pharmacist or a Physicians Assistant.  What would happen today without technology and instead we just sat and waited to be seen.

Is it all Acceptable?

I do wonder whether we have drifted away from the basic contractual requirements of providing treatment and care to patients within a reasonable time. Is it acceptable for patients not to be seen today or be spoken to by a clinician on the same day? Is it acceptable to wait for three weeks for a routine appointment? Has it become more important to please the CQC and the CCG rather than see patients on the same day. What will it take to get back to 1950’s standards. More money or less bureacracy?

Robert Campbell – June 2019

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Spending time training new staff can be difficult in a very busy Practice. Try this Presentation with your staff. Either use it as it is or adapt it.

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