Last reviewed 23 January 2018
Jef Smith looks at the recent report from the Competition and Markets Authority (CMA) on complaints in social care which makes the rather serious criticism: “many residents and their representatives find it difficult to make complaints and seek redress”.
The first CMA cause for concern was that people in care who wish to complain about how they are being treated need considerable protection. There are barriers to obtaining redress and fears of reprisals against complainants. Many complainants feel themselves exposed and vulnerable. Good complaints systems are praised, but good practice in this area is by no means uniform. The report’s recommendations included that regulators should “embed an assessment of complaints systems within their inspections” and that there should be a statutory requirement for homes to signpost the ombudsman service.
The ombudsman referred to in that paragraph covers all local government activities, but last summer it formally inserted “social care” into its title. This is not merely to recognise our sector as a significant source of complaints, but also to draw attention to the fact that all care clients, including self-funders who are not financed by a local authority, lie within its remit. The service has long provided template complaints procedures and other documentation which providers can easily adapt to their own situation, along with a range of information and guidance. As Martin Green, Chief Executive of Care England said in November, “It is right and proper that the sector works with the Ombudsman to create a more robust system where there is more confidence in care providers.”
The Ombudsman’s review
Professor Green’s comment came in response to the ombudsman’s annual Review of Adult Social Care Complaints. This report revealed a 3% increase in care complaints overall compared with the previous year, but a 16% increase in complaints and enquiries about care arranged privately with independent providers. Both figures are worrying, but such statistics require careful analysis. Does a surge in complaining indicate a commensurate increase in poor practice — which would indeed be alarming, but is out of step with other indicators such as those presented by Care Quality Commission (CQC) inspections — or does it, more positively, suggest that providers are getting better at encouraging feedback and consumers more confident in asserting their rights? The report draws attention to this ancient dilemma but without resolving it.
It certainly is a matter of concern that as many as 62% of investigations about independent care providers were upheld. For the ombudsman’s office to become involved in a complaint, it must first have been thoroughly considered, but not resolved, locally, so these 202 cases represent real failures of providers to sort out legitimate complaints within their own resources. One is bound to ask how many other dissatisfied customers gave up on their complaint because, having been rebuffed by a home or home care agency, they lacked the energy or courage to take it further?
Some of the examples the ombudsman quotes demonstrate how much pain and effort could have been avoided if a provider had reacted to reasonable criticism more promptly. Presented with the ombudsman’s report, a home — well after it should have done, one might think — instituted better procedures for making an inventory of new residents’ possessions. In another home, all residents are now provided with a written statement of fees and costs. Another provider agreed to train staff to distinguish informed and uninformed decisions, the dispute following a resident’s refusing food. Should it really have required the full force of the ombudsman to get managers to a point of recognising the need for improvements in such obvious areas?
Launching the report, Michael King, the Local Government and Social Care Ombudsman, praised those organisations which encourage and react promptly to client feedback: “Good leaders will empower their staff to respond quickly and with confidence to customer concerns.” Poor leaders, he might have added, ignore informal criticism and set the tone for the front-line staff to do so too. Social care service users are among the most vulnerable people in our society, which means that, even if they are supported by resourceful carers or advocates, they are often reluctant to pursue a complaint through all its stages. The imbalance of power is a central factor of which care practitioners should constantly remind themselves.
Mr King also highlighted “the power that one person speaking up can have in changing services for the better for everyone”, and it is encouraging to learn that a single investigation may lead the ombudsman to uncover injustices suffered by many others who have not themselves come forward. In one instance, changes to a council’s charging procedures eventually benefitted more than 60 people; in another, criticism of a blanket policy of reducing care to a couple led to nearly 70 others having their care reviewed. There can surely be no greater reward for a complainant than to learn that their action has not only obtained justice for themselves but has also benefitted a number of their fellow citizens.
Other social care research
Despite the ombudsman’s good work, not only in processing complaints but also in publishing aggregated data and analysing trends, complaining in social care is a poorly researched area. The Social Care Institute for Excellence (SCIE) has publicly bemoaned the lack of data, and its own information on the subject illustrates that much of what does exist is up to a decade old. A National Audit Office (NAO) survey in 2008, for example, found that “the social care complaints system has a number of shortcomings”. It drew attention particularly to the paucity of evidence on whether lessons are learned and services improved as a result of complaints, to the need for more information on complainants’ satisfaction or otherwise about how their complaint was handled and what subsequently happened, and to the fact that few complainants receive advocacy services. All of these criticisms seem still valid.
The NAO study made an attempt to cost complaint handling and again its findings, though dated, remain apposite. The average cost of dealing with a social care complaint at the first stage, it revealed — at 2008 prices — was £570, but costs for all concerned escalated significantly for later stage processes. Early resolution certainly pays off, particularly when the reputational damage arising from a badly handled complaint is taken into account.
A repeated finding of such research as exists is that many people are reluctant to complain. The reasons are legion, but they certainly include fear of the personal consequences, a factor highlighted by the Francis enquiry into the infamous Mid-Staffordshire Hospital and picked up by just about every other report on the issue. Other factors may include ignorance of procedures, limited communication ability arising from poor command of English or cognitive impairment, and perhaps most sadly of all a lack of belief that anything can be achieved.
On this last point, a survey by the Alzheimer’s Society of over 1000 carers found that only 7% were happy with the outcome of their complaint, with 44% seriously dissatisfied and 45% only partly content. This study related to the NHS and again is eight years old. Would the scores be better for contemporary social care complainants? Unfortunately, there is no evidence to answer that question.
As the CMA pointed out in their report, it is odd, even reprehensible, that the CQC does not collate statistics on the complaints dealt with by providers, though its inspectors could fairly easily produce at least some of the relevant material. This situation reflects the historic reluctance of both the CQC and its regulatory predecessors to get themselves into the complex business of investigating complaints; even SCIE acknowledges that “Handling formal complaints can be time-consuming and costly,” and CQC, perhaps understandably, constantly seeks to reinforce the fact that the responsibility for maintaining quality and dealing with lapses lies first and foremost with providers. Nevertheless, the fact that the Health and Social Care Information Centre collects data on NHS but not social care complaints demonstrates a clear gap in the system. To be taking sensible decisions about complaints in adult social care, we need much more information. Academic researchers, public bodies and professional associations share the responsibility for this dearth of evidence.
Finally, a cautionary story illustrating how things should not happen. I complained recently about a health service clinic appointment which was cancelled without notice or apology. It took three letters before I received even an acknowledgment, the excuse eventually offered being that the person who handles complaints was away on holiday. That person turned out to be the administrator at the centre of my dissatisfaction and after a further delay she offered a weak oral apology — plus some compensation, which I had not sought and which in the circumstances felt like an attempt at buy-off. Only a threat to report the whole matter to the CQC brought at last a written response from the head of the service. I should add that the professional treatment I regularly get from that particular department is excellent; how sad that their administration and complaint handling let them down.