Dr Gerard Panting discusses the impact on healthcare professionals of patient grievances, how to avoid them happening, and how to cope with the outcomes
One question that regularly crops up at the end of any medico-legal presentation concerns what redress doctors have against patients who make unfounded complaints about them. Why are doctors unable to sue their patients for all the anxiety and inconvenience complaints cause?
The short answer is that allowing doctors to sue or seek other redress from their patients in these circumstances would fly in the face of public policy. If complaints procedures are there to provide patients who feel that things have gone wrong, with an explanation of what happened and why, it would be counterproductive to allow the threat of a financial or other penalty to inhibit would-be complainants from pursuing a complaint. Well-known figures who have used the threat of libel proceedings to silence opponents have never been short of critics.
In addition, complaints can serve a useful purpose as a means of flagging up areas of the service that are not running effectively and that require attention. That does not minimise the stress that receiving complaints can place on practitioners. There are a number of well publicised cases where suicide has been precipitated by a complaint, and many others where doctors have changed career, adopted a much more defensive style of practice afterwards, or just been left with a burning sense of injustice as a result.
There will be few plaudits from those practitioners who believe that the complaints procedure is stacked against them. After all, in civil litigation the losing party pays the winning party’s costs, or at least a substantial proportion of them. Why not adopt a similar model for medical complaints procedures? However, in litigation, the award of costs simply pays part of the legal fees incurred by the winner: it is nothing to do with compensating for loss of time, loss of earnings, or for the distress suffered as a result. In NHS complaints procedures there are no legal costs, so there is no case for demanding reimbursement.
How to avoid complaints
Doctors and other healthcare professionals can take steps to minimise the chance of complaints being made, to prevent complaints from escalating, and to protect themselves from undue stress. In some circumstances, they protest about the way the complaint has been handled, and, infrequently, take action to end their exposure to the complainant and with it the chances of a repeat of the event.
Almost all complaints stem from reality falling short of expectation. This might be in terms of clinical results, perceived attitudes, or the failure of some form of service, such as the provision of a repeat prescription, results not being available when expected, or no-one from the surgery phoning back as promised. These failures might arise from a misinterpretation of what has been said, a simple misunderstanding, a procedural problem, or an error. Whatever the facts, from the patient’s point of view, things have not turned out as expected, and from that perspective it is a very reasonable response to ask ‘why?’. The NHS complaints procedure is designed to provide a framework for such enquiries.
In many instances, avoiding a gap between expectation and reality is down to clear communication, reinforced where appropriate with information leaflets or some other form of aide memoire. Being positive and upbeat has its place but when someone is considering their options, they need to know what can go wrong as well as what happens if all goes well.
When things go wrong
Should something go wrong, the right thing to do in every sense is to explain what has happened and why. Patients are entitled to a clear account of the facts, and to an apology should the problem have arisen from a shortfall in practice procedures or clinical care. Contrary to popular belief, a candid approach prevents many more complaints escalating or becoming negligence claims than a more guarded explanation. The best way to goad someone into taking action, is to stonewall the complainant or to change the account of what happened—the complainant will be forever sceptical and there may never be true resolution.
The General Medical Council (GMC) recommends as follows when talking to patients after adverse events:
‘If a patient under your care has suffered harm or distress, you must act immediately to put matters right, if that is possible. You should offer an apology and explain fully and promptly to the patient what has happened, and the likely short-term and long-term effects.
‘Patients who complain about the care or treatment they have received have a right to expect a prompt, open, constructive and honest response including an explanation and, if appropriate, an apology. You must not allow a patient’s complaint to affect adversely the care or treatment you provide or arrange.’1
Coping with complaints
Complaints are a fact of professional life but even the most stoical of individuals will be unsettled by them, and if they drag on for months or years their impact can be significant. Whether because of embarrassment, shame, or fear of further criticism, doctors tend not to confide in their colleagues, or sometimes not even in family members, denying themselves the support needed and predisposing themselves to stress. Talking to friends and colleagues is helpful, as is seeking professional advice on how best to respond to the complaint and keep the necessary perspective.
Complaints that escalate beyond practice-based procedures can become drawn out. If the practitioner or practice believe that they are the victims of maladministration by another body, they can complain to the Health Service Commissioner in England (the Ombudsman). This rarely happens but perhaps that is a mistake. Unless GPs flag up problems that arise to create some sort of evidence base, it is impossible for policy makers to take them into account.
As a last resort, for example if the patient exhibits violent or threatening behaviour, he or she can be removed from the practice list. First there must be reasonable grounds, unrelated to the applicant’s race, gender, social class, age, religion, sexual orientation, appearance, disability, or medical condition. The PCT must be notified that the practice wishes to remove the patient, who must also be told, in writing where practicable, of the specific reasons for requesting his or her removal from the list. If it is not appropriate to be so specific and there has been an irrevocable breakdown in the doctor–patient relationship, the notice may simply be a statement that the relationship has broken down irretrievably. Removal can only be requested if, during the prior 12 months, the patient has been warned of the risk of removal for the reasons set out.2
Good professional practice
All GPs are expected to follow advice on good professional practice from the General Practitioner Committee of the British Medical Association,2 the Royal College of General Practitioners,3 and from the GMC1 and to explain their decisions to patients. The Ombudsman has also stated that for the complaints system to work properly, it is essential that patients are not deterred from complaining by fear that they might be ‘struck off’ the practice list—the public policy issue referred to at the start of this article.
The GMS contract says that it is good practice to explain to patients the reasons for removal from the list, in line with the recommendations of both the BMA and the RCGP. Removal inevitably follows a breakdown in the practice–patient relationship, but this should not be just because the patient has complained about the practice. There should be a written policy on removing patients from the list. Patients should also be informed about the procedure for registration with another practice and the assistance their primary care organisation (PCO) can provide, as well as the PCO contact details.
However the contract recognises that, in exceptional circumstances, a written response may inflame a difficult situation further. If there are grounds for believing that a written explanation might endanger the safety of practice staff, deciding not to provide a written explanation will be justified.
Complaints are here to stay. They are likely to increase in number and will continue to occupy professional time that those involved might consider to be better spent elsewhere—a feeling made all the more galling if the stress and aggravation could have been avoided or at least mitigated along the way.
- General Medical Council. Good Medical Practice, 2nd edition. London: GMC, 2006.
- GP — removal of patients from their lists. www.bma.org.uk/ap.nsf/Content/GPremoval
- Royal College of General Practitioners. Removal of Patients from GPs’ Lists. Revised Guidance for College Members. London: RCGP, 2004. G