Authors' objectives: Good communication is consistently recognised as essential for effective complaint handling, while failures in communication correlate with risk of escalation. Nonetheless, communication in National Health Service complaint handling remains underexamined. To examine complainants’ lived experience of the complaints journey through (1) micro-analysis of their communication with National Health Service representatives; (2) their self-reported expectations and experiences throughout the complaints journey; to survey patient perceptions of the culture of the National Health Service; to develop ‘Real Complaints’ – an evidence-based communication training resource. Effective complaint handling is vital to a safe, high-quality healthcare system, yet recent reports still highlight major failings with the current complaints system in the NHS. While effective complaint handling is recognised as contributing to quality improvement and patient safety, poor complaint outcomes lead to litigation, at significant cost to the individual complainant, the complained-about healthcare staff and the NHS as an organisation. The strongest predictor of litigation, however, is not medical error or patient demographics but dissatisfaction with communication, either within the clinical encounter or subsequently in the complaint-handling process. A challenge in addressing litigation rates is therefore to develop effective communication interventions for healthcare complaints handling. NHS complaints policies, however, focus mostly on systems and procedures and prioritise administrative and quantitative key performance indicators over qualitative outcomes relating to complainant experience and quality improvement. A recent systematic review points to a recognised need for patient-centric ways of responding to complaints in order to improve complainant satisfaction, in relation to both the formal written response and the spoken communication skills of complaint handlers (CHs), and to a lack of training resources to meet this need. However, although relevant communication goals for improved complaint handling are frequently identified (e.g. apology, empathy, understanding), they are often not met because there is insufficient understanding of how to achieve those goals when responding to a complaint. Observational analysis of moments of interactional contact has been neglected in previous attempts to reform the complaints process and is likely to improve our understanding of the components of good and poor communicative practice. The primary aim of this study was thus to focus the analytical lens on the lived experience of complainants going through NHS complaints procedures, using the observational methods of conversation analysis (CA) and discourse analysis (DA) to examine in detail the language used in encounters (both spoken and written) between complainants and NHS staff in order to understand how to meet the recognised need for patient-centric, comprehensive and bespoke ways of responding. Our study thus aimed to address the following research question: How can the power of language be harnessed to transform complainants’ experience of complaining in the NHS and reduce their recourse to litigation? This was addressed through six research objectives: to examine complainants’ lived experience of interacting with the ‘system’ through detailed micro-analysis of direct communications, both spoken and written, with NHS representatives to audit patients’ perceptions of cultural bias in NHS contexts and show how this may create patterns of social relations that can help or hinder effective complaint resolution to record self-reported expectations and experiences of the complaints journey and its timeline, focusing on evolving perceptions of the complaints experience and the complained-about issue, and the impact of the process on complainant well-being and satisfaction to identify and cross-reference moments of change and key drivers of change in complainants’ responses and intentions (including intentions to litigate) throughout their complaints journey to develop an evidence-based ‘Real Complaints’ communication training resource to provide effective, evidence-based intervention that addresses the specific interactional and interpersonal challenges of NHS complaints handling to disseminate good-practice recommendations to service users, NHS staff, local and national policy-makers and ombudsmen that will improve NHS complaint-handling processes and experiences.

Authors' results and conclusions: Our analysis illuminates the dual nature of complaints: as personal expressions of dissatisfaction and as systemic critiques. The complaint experience is a dynamic journey with evolving narratives reflecting complainants’ shifting perceptions, expectations and experiences of the ‘system’, both moment-by-moment and encounter-by-encounter in the overall journey. Key interpersonal priorities for complainants significantly affected complaint outcomes, most important of which was the need to be respected as a ‘reasonable complainant’. Also key is the conversation analytic concept of affiliation, which involves taking a stance towards the event(s) being described that matches the complainant’s stance. Use of affiliation by call handlers supported effective and efficient person-centred complaints handling, while absence of affiliation typically led to escalation of the scope, scale and emotional intensity of the complaint, sometimes to the point of an expressed intention to litigate (particularly in the case of written responses). Viewed holistically, successful complaints communication requires person-centredness, and affiliative interactions framed by shared expectations. These findings were applied in the development of Real Complaints Training and Guidance for spoken and written complaints communication. Addressing the complainant’s desire to be perceived as reasonable was revealed as crucial for fostering a more person-centred approach to handling complaints and addressing the gap between expectations and experience. This finding holds particular significance for recommendations, guidance and training relating to both spoken and written communication. Our longitudinal analysis illuminates the dual nature of complaints: as personal expressions of dissatisfaction with care experiences and as systemic critiques. Understanding this duality – complaint and care – is vital to improving the complaint-resolution process by ensuring both the validation of individual lived experiences and effective systemic response. Complaining is experienced as a dynamic journey with evolving narratives reflecting complainants’ shifting perceptions, expectations and experiences of the ‘system’. Each interaction within the journey moulds these perceptions and future expectations, hence the paramount importance lies in improving individual instances and enhancing connectivity throughout the complaint journey, as each next encounter can ‘overwrite’ the effects of the previous. Written responses, in particular, were often noted to have the greatest negative impact on the overall evaluation of the journey by not acknowledging accountability, providing insincere apologies, using obscure medical jargon, undermining complainants’ accounts of events and detailing irrelevant patient histories. These longitudinal findings were also reflected in the analysis of the cultural-institutional context (cultural audit), which found significant gaps between patient expectations and experience around assessment of the ‘system’ as overly hierarchical and insufficiently egalitarian, as well as lacking in recognition of individuality, leading to expressions of fatalism in patient expectations. Across all data sets, complainants convey three key interrelated interpersonal priorities which are evident in how they communicate their complaint and the expectations they place on call-handler responses. Complainants want to tell their story in full; they present their complaints not as a collection of facts, but as a detailed narrative which stresses the impact of their story on their daily lives. Relatedly, complainants want to feel that they have been listened to and that their perspective (including the lifeworld impact of the complained-about event) has been fully recognised. Finally and most significantly, complainants seek ratification of the reasonableness of their complaint and/or of their identity as a reasonable complainant. The CA concept of affiliation (designing responses to display recognition and validation of the stance expressed by the other speaker) was identified as a key conversational skill required to meet complainants’ interpersonal priorities in the moment-by-moment communication of a complaints encounter. Specific forms of affiliation and cues for affiliation emerged as important for effective and efficient complaints handling. A key finding, for example, was that affiliation specifically to the ‘reasonableness’ of a complainant could be deployed to negotiate explicit blaming without agreeing or disagreeing with the blame. Crucially, our interactional analysis also showed that the absence of relevant forms of affiliation typically led to escalation of the scope, scale and emotional intensity of the complaint. Similarly, the absence of affiliation and ratification in written responses was found to lead to dissatisfaction with the complaint and, in some cases, escalation to the Ombudsman or to legal redress. The Real Complaints Training package was developed around the research findings relating to the significant role of specific forms of affiliation for healthcare complaints handling. The training package is composed of a number of modules which address a series of skills: ways of listening, identifying complainant cues, using affiliation to meet complainants’ needs and negotiating the expression of explicit blame. Several training design workshops and evaluation workshops were held with complaint-handling teams to refine the training design and ensure useability and accessibility. A key outcome of those workshops was the flexible modular design of the training resources that ensures that the materials can be adjusted to meet training needs and accommodate practical constraints on delivery. The design also ensures that the training can be adapted to complement existing training approaches. Additionally, guidance on how to compose written responses to complaints, what to include, what to avoid, and ideal ways of ensuring that the complainant feels their complaint has been listened to and taken seriously are included in this report. Our study found that the highest priority for complainants is to be seen as reasonable complainants and for their complaint to be seen as ‘reasonable’ and legitimate. At a more systemic level, complainants seek concrete and measurable change and reform as validation of the reasonableness of their complaint. Addressing the gaps between complainants’ expectation and experience requires a more person-centred approach in which the complainant’s perspective and reasoning are reflected and the lifeworld impact of their complaint is demonstrably understood. Current practice is variable but where dissatisfaction with the complaint process is expressed, it is usually related to a perception that the complaint has not been adequately affiliated to. Affiliation in various forms (affiliation to emotion, to complainability and to reason) demonstrates that the CH is aligned with the objectives of the complainant and willing to address the complaint’s detail and complexity. Our research has led to the development of guidance and training that will assist complaint-handling staff in navigating these interactions. This offers strategies to validate the complainant’s experiences and emotions, while also maintaining professionalism and fairness throughout the process. By adopting a person-centred approach that acknowledges and supports the complainant’s need to be seen as reasonable, organisations can enhance complainant satisfaction, contributing to a more constructive and collaborative relationship between NHS and patient.

Authors' methods: The project triangulates microlevel conversation analysis and discourse analysis of spoken and written complaints encounters with complainants’ appraisals of those encounters in longitudinal case studies. This is underpinned by an audit of patient views of the cultural–institutional context of the National Health Service. Data were gathered in the complaints-handling services of two National Health Service trusts and a Patient Advocacy Service in Northern Ireland. Twenty-three complainants consented to longitudinal data collection and 58 to initial encounter recording; 115 members of the Patient Advocacy Service mailing list completed the cultural audit; 3 trust complaint handlers, 1 Patient Advocacy Service complaint handler and 2 trust complaints managers were interviewed. This yielded 1155 minutes of recorded calls, 113 written encounters, 36 diaries, 6 meetings, 23 interviews and 115 cultural audit responses collected over a period of 24 months. The COVID pandemic significantly constrained trust participation, particularly the participation of front-line clinical staff, and one trust introduced ‘telephone resolution’ to which we were not given access. Additionally, calls viewed by staff as ‘challenging’ and ethnic minority communities are both under-represented in the final data set. Our study developed an innovative mixed-methods design with multiple data sets. The wider institutional culture of the NHS was examined using a cultural audit tool to assess service-user perceptions of the institutional context within which complaints take place. The core of the project was the microanalysis of language-in-use in both spoken and written communication between complainants and the NHS Trusts and a parallel analysis of participants’ subjective reflections on their complaint journey, both during and after that journey. This mixed data approach constitutes a detailed, contextualised examination of the relationship between complainants’ observable complaint-handling experiences and their personal, evolving perspective on both the complaint issue(s) and the complaints process.

Project Status: Completed

URL for project: https://www.journalslibrary.nihr.ac.uk/programmes/hsdr/NIHR127367

Year Published: 2024

URL for published report: https://www.journalslibrary.nihr.ac.uk/hsdr/NRGA3207

URL for additional information: English

English language abstract: An English language summary is available

Publication Type: Full HTA

Country: United Kingdom

DOI: 10.3310/NRGA3207

Organisation Name: NIHR Health and Social Care Delivery Program

Contact Name: Rhiannon Miller

Contact Email: rhiannon.m@prepress-projects.co.uk