Harnessing the power of language to enhance patient experience of the NHS complaint journey in Northern Ireland: a mixed-methods study.

ABSTRACT

Background: 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. Objectives: 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. Design: 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. Setting and participants: 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. Data sources 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. Results: 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. Limitations: 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. Conclusions: 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. Future work Direct extensions of the project include the piloting and evaluation of Real Complaints Training and further primary research involving communication between complainants and front-line service/clinical staff and complaint handling by ombudsman complaints investigators. An emerging question relates to social exclusion and access to complaints procedures. Study registration This study is registered as Research Registry researchregistry5049. Funding: This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref NIHR127367) and is published in full in Health and Social Care Delivery Research Vol. 12, No. 33. See the NIHR Funding and Awards website for further award information.

The aim of this project was to make the experience of complaining to the National Health Service better for patients and their families and improve the outcomes for the National Health Service. Complaints can be positive for the National Health Service because they help improve services for other patients. However, if a complaint escalates, it could be costly for the National Health Service and stressful for the patient. We analysed phone calls and letters between the National Health Service and patients or their family. Some patients took part in the study over a long period of time from when their complaint was lodged until it was complete. We also used online diaries and interviews to analyse how this communication affected the hopes and expectations of the patient throughout the complaints journey. Our research found that people making complaints have particular needs to be listened to, to tell their whole story (including how the bad experience has impacted on their lives), to be treated as reasonable and for their complaint to be taken seriously. If they feel that these needs are not being met, the complaint often becomes more serious; the patient may even talk about pursuing legal action. We observed that call handlers can use communication skills to ensure that patients feel listened to and taken seriously when they make a complaint. We also found that receiving written responses to their complaint (often at the end of the complaint journey) is when patients feel most dissatisfied. We identified which responses to a complaint are viewed negatively (avoiding blame, insincere apologies) and which are viewed positively (accepting responsibility, recognising the impact of the events). Our findings were then used to develop training materials using real examples from our data. This will help complaint handlers reflect on how their communication impacts on patients making complaints and will lead to a better experience of the complaints process.