Schools need lessons in complaint handling

When I first became a school governor six years ago, I was taken aback to discover that the thing which the school called its “complaints policy” (when they actually managed to locate a dusty photocopy at the back of a filing cabinet) was something which would barely be worthy of the name in most other public or private sector organisations. 

A leap too far

It told you to complain to the Head, then complain to the Chair of Governors and then escalate your problem to the Secretary of State – definitely a leap too far. This long-winded, defensive document conveyed the clear message to parents that there was no real point in complaining but if they insisted on doing so then they could not expect anyone to make it easy for them. Behind it lay the depressing fact that beyond the governing body there really was nowhere to take their complaint and whatever they did, nothing much was likely to come of it.

No wonder few complain

Under current arrangements local authorities can get involved (if they want) but they don’t actually have any power to require action by the school and no express legal role in considering complaints. The Secretary of State’s hands are tied too and there are very few circumstances in which he or she can intervene. Small wonder few people complain.  We know that many people believe that it would make no difference to anything if they complained about health and social care services. If parents of school children were to be asked the same question I suspect an even higher percentage would give the same answer.

Hip! Hip! Hooray! for DCSF

So it is pleasing to see that finally the Department for Children, Schools and Families has decided to address this issue and issue a consultation document seeking views on its proposals for what looks to be a much improved approach to complaints. It is also pleasing to see that the department explicitly refers to the need to learn lessons from other areas of government such as health and local authorities.

The Children’s Plan  explains what the department is trying to achieve:

“Parents’ complaints will be managed in straightforward and open way and as many issues as possible will be resolved quickly. Parents, particularly those who may not be so readily engaged, will understand the route to follow when they have a complaint. We will review what more can be done to streamline and strengthen these arrangements” (paragraph 3.2).

The first main proposal in the consultation is that efforts should be made to ensure a quick and effective response to complaints within schools supported by an effective system of local mediation if complainants remain unhappy once the issue has gone to the governing body. This sounds like a good idea but the consultation document rather amusingly (and with a terse nod towards those scary teachers’ unions) suggests that this should be done without imposing “any additional burdens on school staff, leaders or governing bodies.” This seems fairly unrealistic.

At the moment schools may be recording complaints (although unlike other sectors they are not formally recorded, analysed or reported anywhere). Good schools will certainly give parents the time of day and have a chat about their concerns but knowing that the complaint is never likely to be escalated and that if it is, it will never get anywhere, means that there is no real incentive for schools to handle complaints properly or provide any effective redress. If they were to start doing it properly there would inevitably be implications in terms of data recording; reviewing and tightening up other areas of school administration; training staff and governors and taking time to talk to people. Not to mention the fact that they might even have to change the way they do things in response to complaints. Real and ongoing input will be required, so schools and governors should not be encouraged to bury their heads in the sand and think they can just get away with ticking a few boxes.

The second major proposal is for an independent complaints review service, probably hosted by the local government ombudsman. We will be taking a longer look at the implications of this – the LGO does not have the same powers as other Ombudsmen such as the Health or the Financial Services Ombudsman  to force compliance and can only name and shame.

Unified Data available to all

One thing which is not mentioned in the consultation document is whether there should be processes for collecting and analysing complaint data at a local or national level. It happens in the health service; the police and utility companies have to do it. But it is a peculiar feature of English and Welsh state schools that they seem to be left to get on with it without taxpayers being given much meaningful information about what is really going on behind the school walls. As we are all perhaps all beginning to realise, SATs don’t tell us much.   “Choice” may be the government’s current mantra for parents but how can parents make informed choices with so little meaningful information available to them?  No wonder they end up relying on school gate gossip.  Ofsted reports can be useful but are often so infrequent as to completely fail to notice when schools nosedive into chaos and there are really very few other measures of their effectiveness or user satisfaction. Other public services such as local government and the health service are inspected and judged year after year and required, as part of this process, to provide copious amounts of data including data about complaints. So maybe this is something that needs to be added in order to provide some real accountablity to parents and taxpayers.

Things may be about to change. It is time for schools to sit up straight and pay attention.

MAC will be drafting a full response to the consultation in time for the 21 November deadline. Meanwhile let us know what you think.

“Engagement” isn’t enough – only “Involvement” can influence commissioning

Have you noticed that PPI is being eased aside by many NHS bodies in favour of PPE?  The “patient and public” (PP) part is unchanged, but in the new rubric  “E is for engagement” and “I for involvement” is falling off the page.  We should be concerned if the “I-word” has been waylaid in the corridors of Whitehall in favour of “engaging people and communities” .   Engagement and Involvement aren’t interchangeable.

However it might be dressed up in the latest policy couture, “engagement” implies a process of enquiry initiated by the NHS when and how it chooses.  “Involvement”, in contrast, implies a sustained, continuous and co-created process.   Picture a gaggle of patients and members of the public hanging around until the NHS decides to engage with some of them for something specific in order to harvest their views for its own uses.  That is a relationship based on dependency, status and power and it won’t do for a user-led NHS.  It doesn’t encourage either health literacy or enthusiasm for doing it again.  You may ask what’s in a word: in the case of ”engagement” vs “involvement” the answer is rather a lot.  If PPE is now DH-approved will we see a rebranding for the NHS Centre for Involvement and the National Library of Health’s PPI specialist section and a host of other respected and established sources using the “I-word”?  I sincerely hope not.

It isn’t that engagement is wrong, just that it is insufficient on its own for the purpose of influencing commissioning decisions. Sustained involvement is the key to this. PCTs needs to develop processes to ensure they listen to patients and the public as they shape ideas for new service delivery models.  Can they be assured that service users, carers and the public are with them on the journey of service re-design as they develop service specifications, consider tenders, and monitor contracts?  If not, they are at risk and cannot demonstrate their accountability to the moral owners of the NHS – that’s you and me.

Here is an excerpt from a PCT policy that does understand the linkeage between involvement, engagement and communications:

Throughout this document we refer to involvement, engagement and communications for patient and public empowerment.  “Involvement for empowerment” is the overall objective; engagement is an aspect for specific purposes, including consultation on specific proposals; and communications is the range of techniques and tools used to interact with people, listen to their views, understand their feelings, communicate them appropriately and feed back to them what they said and what we are able to do with this intelligence.  The result of this is helping people feel that they are continually involved in our business.

Whatever you call it, If “involvement” doesn’t positively influence commissioning then it is a sham.  So why make it harder for ourselves by pretending that “engagement” will do it all?  Achieving sustained involvement is difficult, skilled and resource-intensive work, but it is an investment we cannot do without.   I am reminded of the comment attributed to ”Red” Adair the legendary oilfield firefighter: “If you think hiring an expert is expensive, just wait till you find out how expensive hiring an amateur is.”

Policy Governance® UK Case History: Val Moore hears how it works in Foundation Trusts

It was great to see John Bruce and John Gilham, the Chairman and Chief Executive respectively of Southend University Hospital NHS Foundation Trust demonstrating how Policy Governance® (PG) worked for them as they set out the case history of their experience in launching and managing the UK’s most comprehensive PG-based governance initiative.  Their Hospital Board is implementing Policy Governance in full and their experiences along the way inspired delegate after delegate who said the speakers had brought Policy Governance to life and shown its relevance and application in a modern NHS.

Their presentation was made at a workshop at Birkbeck College London University on 22nd October 2008 when over 30 people came together to hear more about Policy Governance®, the model developed by John and Miriam Carver. Since attending the Policy Governance Academy when it was held in the UK some three years ago, I have been a little frustrated by the lack of examples of UK-based work to put alongside the many implementation case histories from Canada and the States – a need now met with the Southend work.

Those who came to listen and learn were from many different parts of the NHS: Hospital Boards, PCTs, GP surgeries, specialist Councils for health care professionals, health regulators and health charities.  The delegates also heard  from Caroline Oliver Chairman of the UK Policy Governance Board (UKPGA) and a consultant and writer of three books on Policy Governance, Stuart Emslie CEO of the UKPGA and Ray Tooley inventor of OurBoardroom an internet-based tool for implementing Policy Governance.

Hearing first hand about the challenges and the benefits of becoming a Policy Governance Board was fascinating for me as a former non-executive director in a NHS Trust. The UKPGA and the London Centre for Corporate Governance and Ethics at Birkbeck College plan further workshops and the members of UKPGA who are consultants are ready and willing to help individual Trusts or other health organisations test out if Policy Governance could bring them the focus and strategic perspective they so badly need.

At a time when the word governance is bandied about with innumerable definitions and applications, the workshop was reminded why John Carver’s seminal book Boards that Make a Difference has sold over 1 million copies world wide and why his Policy Governance model is described by Sir Adrian Cadbury ‘father’ of modern day corporate governance, as “….a fully integrated and coherent system of governance, a significant advance in management thinking, as near a universal theory of governance as we at present have.”

Contact Information

For more information on Policy Governance® can help your organisation, please contact me Valerie Moore at M-A-C or you can reach Stuart Emslie at ukpolicygovernance@gmail.com or 07932 376562.
John Bruce, Chairman and John Gilham, Chief Executive of Southend University Hospital NHS Foundation Trust can be contacted at john.bruce@southend.nhs.uk. They prefer emails to phone calls.

Complaint Data – common themes confirmed in different surveys

It gets a little dispiriting if you work with complaints and complainants to see the same old messages emerge in survey after survey as the years go by. If I was a complainant, I would be tempted to be very rude to the next person who wanted me to complete a survey about the experience I had with my complaint. The questionnaires or the questioner have a little spiel along the lines of “your experiences will help us greatly in improving the way we handle complaints”. Really? There seems to be little sign of that.

The National Audit Office has taken a look at complaint handling in both health and social care services in anticipation of the creation of a single complaints system in 2009. Our friends at the Customer Care Alliance and Surveylab have just published their annual look at the complainant experience across a variety of markets and providers based on a survey done during July, August and September 2008. 10,102 responses were received from a random sample of UK consumers and some 230 of them had their most serious problem with health care services.

The findings from the two surveys cannot be compared directly but some interesting common themes emerged – the same reason came top in the list of reasons why many did not bother to complain. Namely, the perception was that nothing would change as a result of voicing that complaint. The NAO survey which focussed exclusively on health and social care services asked more detailed questions about both the informal and formal processes. Young people were especially likely to drop the matter at the mention of a formal process. The people who persisted – this came through with the health care problems – were those who were looking after or complaining on behalf of someone else and there is an interesting suggestion with the social care data that readiness to voice dissatisfaction was linked to whether or not part at least of the service had been paid for. Class and age played their usual part in readiness to voice with ABC1s and 35-54 year olds the more likely to take the problem up.

Social care service problems are most often triggered by a social worker or home help and this personal flavour to the problem explains why people with a problem with for example the bad standard of treatment, worried about the effect of making a complaint, not wanting to damage a continuing relationship with the service provider.

What did complainants want? The CCA survey asked directly whether revenge would be nice. 7% of men said yes to that compared to only 1% of women. That same survey confirmed that what people wanted overwhelmingly was an apology (46%), an explanation (57%), and an assurance that the problem would not be repeated (40%). One of the most telling pieces of data in this study (the NAO did not ask the question) was that 54% of the people who were dissatisfied, shared that experience with friends/ colleagues.

Ministers despair that people do not believe what they are told about the health service. As we have said before, we listen to and more importantly believe our friends more when it comes to service experience. Service reputation lags well behind the public announcements – the speeches, the ads – because private user information (the wisdom of the crowd) discounts these official messages in favour of their word of mouth sources.

We will await the lessons from the early adopters programme for the new combined health and social care complaint handling arrangements and how well local providers put in place their own arrangements within the Making Experiences Count framework. The main pitfall to avoid when building new organisations is to push complaint handling to the back of the process building queue. This overlooks the fact that good complaint handling is an vital resource for users who have been dissatisfied by some aspect of the fledgling organisation’s service delivery. Bad first impression plus bad problem resolution equals poor reputation straight after launch – revisit our thoughts on who gets believed.

In the meantime,  service process designers and commissioners need to look out for the user who is ABC1, 35-54 years old, responsible for someone else’s care. Lives in London and the South East and has lots of friends. Your reputation rests in their hands. Sort them out quickly with an apology and an explanation and just as most of those users do not want revenge, avoid giving any impression that vulnerable users still in the system will suffer for being cheeky and complaining. Worth perhaps repeating that stunning bit of data from the UK Customer Care study showing the rewards of good complaint handling that satisfies your users.

No Authority? Then No Accountability – the Policy Governance® View on the NHS Constitution

The consultation on the proposed NHS Constitution closed last week. The UK Policy Governance Association (UKPGA) said it all for us in their submission.  M-A-C partners have been big fans of the “policy governance”® approach for public sector boards and Valerie Moore is an accredited PG practitioner. ( See our main website )

The UKPGA submission focused on two key aspects: accountability and local determination of needs. Those have to sorted out first before service users can be clear about what their entitlements to services are.  But the NHS Constitution lacks a statement of accountability – ie there is no answer to the question “to whom is it accountable and for what and how is that accountability to be exercised?”

M-A-C previously tried to interest our (then new) Prime Minister in this when we suggested to Mr Brown back in June 2007 that in his enthusiasm for the NHS, he needed to be clear about what the institution was for. We are glad to see that Ann Keen has assumed the mantel of “Minister for the NHS Constitution”, so we can address our views to her.

As we said to Mr Brown, so we say to Mrs Keen.  The end of the NHS in England – what it is for – should be understood as: “The health of all people in England is maintained as fully as possible for a sustainable tax burden”.

It should be that simple  – and it would be if we were clear that the owners of the NHS are the people who have paid and who do pay for it and who use it.  We also need to be clear that the “p word” we should use more of is “power” not “patients”.   If we were clear about those things, then getting the work done through good management would be a great deal easier.

So we were pleased that the UKPGA’s submission stressed the need for a statement of accountability as

“a central plank of the Constitution which should represent the terms on which the public’s authority is passed to the organisations that, together, comprise the NHS. “

The Statement of Accountability should

“Give guidance to enable NHS boards to deal with the competing demands for accountability from:

1. Parliament as representative of the national public interest
2. Government as the executive of Parliament
3. NHS regulators as monitors of compliance with parliamentary legislation and government policy
4. Local communities as representative of the local public interest
5. Patients as consumers of NHS services
6. Staff as employees of NHS organisations
7. Other stakeholders.

“Whilst it is perfectly right and proper for the NHS to be accountable to the public-as-consumers for any promises it makes to them, it is also vital that it is accountable to the public-as-owners for making only those promises that it can afford to keep if it is to remain a sustainable organisation.” As UKPGA further explained, “No person or institution can be held accountable for something over which they have no authority. Thus NHS organisations cannot be accountable to their local communities if they have no authority to vary their nationally prescribed responsibilities.”

Access to healthcare services cannot be without reasonable limitation if the NHS is going to be accountable. The NHS Constitution should therefore be amended as suggested by the UKPGA: “You have the right to expect your local NHS to assess the health requirements of the local community and to put in place the services to meet those needs as considered necessary.”

The last three words are crucial to accountability because “local NHS boards [must] have the freedom to interpret the phrase “as considered necessary” and [be] able to prioritise and interpret nationally prescribed responsibilities in the light of local community needs.”

The “planned differences” [discussed on our post of 14th October] that result would be evidence that the local NHS was simply doing its job.  Holding it to account for the promises that it could afford to keep would then be much more straightforward for us as the owners.

Contact Stuart Emslie at the UKPGA at either ukpolicygovernance@gmail.com or 07932 376562.

“Local socialism” trumps “post code lottery” in the NHS debate

I’m thinking about starting a list of unhelpful phrases about the NHS and top of the list is going to be “post code lottery”.

“London NHS care is postcode lottery” screamed the Evening Standard recently in response to a study from the Kings Fund showing variations in what London PCTs spend on cancer, heart disease and other things. Cue tabloid shroud waving and health-campaigner handwringing: funding differences  = dreadful unfairness to people in areas where spending does not match the highest levels   =  heartless NHS bureaucrats putting people’s health at risk (shame!).

Simplistic league tables comparing health spending in uncritical ways don’t help public understanding, whether it is between London boroughs or between so called “developed” economies. The US spends more than anyone to achieve often mediocre outcomes and high wastage in their health transactions.

Is there really any significance for the health of their respective populations that Ealing comes “bottom” in England for cancer spending per patient and  Redbridge is the highest spender?   If that level of spending reflects an analysis of health needs and an allocation of resources according to population characteristics and desired outcomes, then the local spend is probably right for each place.  It is the job of PCTs as commissioning bodies to do just this kind of localised analysis and investment to meet health needs and improve health outcomes.  This point is sadly lost on most people and our politicians fear trying to explain it even when it has robust justification. No politician – Town hall or Whitehall – wants to put their neck on the media block for what the public perceives to be “unfair” even when it really is equitable.

Self-styled health campaigners and quite a few politicians wallow in emotive  “death sentence” language claiming differential spending always means differential quality of care.  On the contrary, it could just mean that all areas are not the same. We don’t have homogenous, equal-sized populations with identical needs.  The fact is that uniformity of spending would be inequitable because it would smother action to meet local needs and reflect local views.

Local decision making - reflecting what patients and the public want and what public health intelligence says is needed and effective  -  is incompatible with national uniformity of spending.  I don’t want Whitehall dictating how  Wandsworth PCT should spend its resources on meeting the health needs of our population.  I want local people to have an informed say about it and for clinicians, public health specialists and managers close to the issues who know the data and the effectiveness of the interventions to inform the PCT’s decisions for investment.

With this in mind, I was cheered this week to see well known South London GP Brian Fisher tackle this politically charged subject head on in a succinct letter in Health Services Journal on “local socialism” – certainly an attention grabbing title on a very serious topic.

“Unplanned and irrational differences in provision may be unacceptable”, but Ministers need to get over their fear of “planned differences” as Dr Fisher terms them.  Rational and robust “differences” show that the NHS commissioners are doing their job, not the reverse.  We need the health literacy and political maturity to understand and welcome that.  And the thing that would make it much better is when local communities get involved in decisions about levels of health and social care funding.  The participatory budgeting pilots reported in a recent issue of the HSJ point the way to greater local decision making, not less.

So here is my “Memo to Ministers”: stop taking your cue from the tabloid sub-editors and the self-interested campaigners. Get the facts first and then support the people taking the tough decisions at the front line.

As Brian Fisher sums it up: “We need to reassure Ministers and the Department of Health that localisation is usually the result of good practice.”

Paying for Participation

We have talked before about the role of cash incentives in getting people engaged with their Health Service. So when we saw this on the BBC News site, we wondered who else was using this or other cash-type rewards? It opens the intriguing concept of cash-based competition between public bodies – many now with statutory duties to consult – to access the views of us fish in the pool of public opinion. Whoever has the biggest feeding bucket with the most fish food gets the most opinions? See the story below:

Vouchers offered for NHS opinions
http://news.bbc.co.uk/1/hi/england/london/7658352.stm

Residents in east London are being offered vouchers by the NHS as incentive to get involved in improving their health service.

NHS Waltham Forest said it would give vouchers worth £25 to the first 500 people who turn up to the public event to discuss local healthcare.

Residents who attend the event at Walthamstow Town Hall can redeem the vouchers at local shops.

The NHS insisted spending £12,500 as an incentive was “good value for money”.

Public engagement requires corporate endeavour

So says Healthcare for London (the Capital’s own Darzi “vision for better healthcare”) in a refreshingly short and to the point discussion from a recent workshop on patient, user and public engagement and – wait for it – empowerment.   In governance terms, we certainly endorse HfL’s view that “public engagement has to be a board-level corporate endeavour”. Without this everything else is just process, however well executed, and vulnerable to the first whiff of financial necessity.  And there are plenty of signs of that around in the real world at the moment.

The importance of branding and reputation building are also wound into the report and it is good to see those fundmental points acknowledged.  Too many in the NHS still squirm when brand and reputation language are used.  They need to grow up and acknowledge that service users understand this already.  It is much more than the PCT changing its note paper to be “Anywhere NHS” and then having hurt feelings when it is pilloried in the local press for “wasting our money” instead of doing more hips and knees.

But for my money the phrase to blow up, print out, frame and stick up on the wall of every NHS office, practice, clinic and canteen across the land is this one: “staff need to put themselves in patients’ shoes. Just the physical act of lying down physically disempowers a patient”. If only this happened, it would change everything.  Language mirrors reality” I seem to recall from a bygone philosophy lecture.  So let’s stop talking about “patients” as a first step to empowering all of us and especially the service users and carers who should really be partners in planning and delivering their own care.  Collectively we are the ones who have paid and are paying for it after all.  I for one don’t want to take it lying down.  And I want to be sure they understand that in the Boardroom.