Healthcare complaints handling systems: a comparison between Britain,Australia and Taiwan

Abstract

This paper explores the health care complaints handling reforms enacted in Britain, Australia and Taiwan. A documentary search for policy documents, reports and studies related to the reforms of the health care complaints handling system was conducted. A keyword search was performed within PubMed and ProQuest for the period 1985–2009 to identify relevant articles. The study found that the major difference in health care complaints handling systems between countries, is the mechanism for running a complaints system. Both Britain and Australia have attempted to incorporate patient complaints into their national quality systems. Their intention was to set up mechanisms to create an effective bridge, at a national policy level, between the patient complaints management system and the quality management system.

Introduction

There has been an increasing interest in patient complaints and medical negligence.^1–3 Governments in some countries have taken into account public concerns through initiating patient complaints handling policies and systems to improve and regulate the practice of health professionals, for example, Britain and Australia.^4–6

Patient complaints management systems have started to be instituted over the past two decades. Although it has been growing quickly, it is still a young field. Each country has its own unique way of handling health care complaints. It is worth discussing some national complaints management systems in detail, to understand the trends and historical development of the system, as well as knowing the implications so we can learn from these other systems. The aims of the study are to examine modes of reform implementation and the current status of the complaints handling system as well as to compare between Britain, Australia and Taiwan in terms of the health care complaints handing policy.

Methods

A documentary search for policy documents, reports and studies related to the reforms of the health care complaints handling system, was conducted through national policy organizational websites, universities libraries and electronic databases. A keyword search was performed within PubMed and ProQuest for the period 1985–2009 to identify relevant articles. Studies were assessed for quality. Forty-eight articles were selected for inclusion on the basis that they offered the most original account of the health care complaints handling or because they provided useful theoretical concepts. Eligible studies, reports and documents were classified according to nations, periods and main reforms. Reviewed articles were limited to those that included the health care complaints handling and management. A thematic analysis of the selected articles was undertaken.

Results and discussion

Britain

In the United Kingdom, the National Health Service (NHS) was set up to provide publicly funded health care for all citizens, and is managed by the Department of Health (DOH). The Committee on Hospital Complaints Procedure, the government body, reviewed and documented the problems with the NHS hospital complaints procedure in 1973. The Department of Health and Social Security introduced the Health Service Management: Health Service Complaints Procedure in 1981.⁷ Since the revision of this procedure, all NHS hospitals have been required to set up a complaints procedure, based on the Hospital Complaints Procedure Act 1985. Further explanatory guidance was issued in 1988.⁸

Hospitals, community services and family practitioners have different operational complaints procedures.⁹ The Association of Community Health Councils for England and Wales has argued that the procedure is lengthy, not impartial, and in addition, the explanations given for judgements are not sufficiently comprehensive.¹⁰ In particular, inadequate handling complaints by health authorities comprised about one-sixth of the workload of the health service commissioner.¹¹ Although the Patient's Charter has given patients the right to have complaints investigated as well as to receive a prompt investigation, patients need to deal with a maze of procedures for complaints about hospitals, general practitioners and community services.¹²

The Wilson Committee was established in 1993 to review NHS complaints procedures. In 1994, the Committee produced the report Being Heard (i.e. a report of the review committee on NHS complaints) and recommended scrapping the old awkward procedures and replacing them with a simple and faster process.¹³ In Acting on Complaints, the DOH introduced a new NHS complaints procedure in 1995. This new system came into effect on 1 April 1996.¹⁴ It was designed to be easier, quicker for patients to access and more open. The overall approach of the complaints process was intended to be honest and thorough, and the procedure was to operate in broadly the same way, irrespective of which part of the NHS was being complained about. Furthermore, the importance of complaints procedures in clinical management has been argued in the NHS Modern and Dependable. ¹⁵

The system for general practice has been divided into three levels. At the first level, i.e. the ‘Local Resolution’ of complaints, practices are required to have a practice-based complaints system, organized to comply with national criteria so that complaints are resolved locally as quickly as possible. If the complaint cannot be resolved satisfactorily or successfully at the first level, the second level involves arranging for health authorities to undertake an independent review of complaints in the form of an ‘Independent Review Panel’. This panel consists of three members: a lay chairman, a convener and a third lay member to investigate complaints and produce a written report on each complaint. If the complaint still cannot be resolved, it will be referred to the ‘Health Service Commissioner’ (Ombudsman), who is independent of both NHS and the government. He/she has been given new powers to deal with clinical matters and to look at all aspects of NHS care, at the third level.^16,17

However, it has been argued that the second level of this new system, i.e. the Independent Review, is unfair or biased. In the NHS Complaints Procedure National Evaluation program,¹⁸ 4000 questionnaires were distributed to those with experience of operating and using the complaints procedure. It revealed that of individuals who requested an independent review, no more than one in 10 was satisfied with the time taken and only 13% were satisfied with the outcome of their complaint. Because of this widespread dissatisfaction, the Health and Social Care (Community Health and Standards) Act 2003 established a legal framework to transfer the delivery of the second stage of the independent review from local NHS bodies to the Commission for Healthcare Audit and Inspection (CHAI^a) on 1 July 2004, also known as the Healthcare Commission.²⁰ CHAI is expected to only receive cases that are either the result of a breakdown in trust between the patient and the service of a serious nature. Moreover, under the NHS complaints procedure, patient complaints relating to private health care cannot be investigated. As the CHAI takes over the registration and inspection functions of the National Care Standards Commission for providers of private and voluntary health care, complaints made by NHS-funded patients treated in private health care will be included in investigations.²¹

In addition, CHAI took over the functions of the complaints system of the Mental Health Act Commission to make the NHS complaints system more integrated and comprehensive.^21–23 This improvement was intended to make the public more confident about its independence and efficiency, and redress complaints to ensure the lessons are learned through dealing with patient complaints. The Healthcare Commission played a vital role to assess whether NHS providers apply quality programmes to attain better patient outcomes.²⁴

Australia

In Australia, each State and Territory has its own statutory body to handle health care complaints and there is no uniform pattern. Thus, we will deal only with the largest of the states – New South Wales (NSW). The Complaints Unit of the New South Wales DOH was initiated in 1984 to formally handle health care complaints. In the beginning, complaints were seen mainly as instruments of consumer redress or for the pursuit and punishment of practitioners who had made errors or engaged in fraudulent practice, e.g. the policeman appointed to the NSW Complaints Unit.²⁵ This body expanded and broadened its functions enormously in subsequent years and in 1994 was upgraded to a statutory authority under the title of the Health Care Complaints Commission (HCCC).

Following the example of New South Wales, the state of Victoria introduced a similar body in 1988, Queensland in 1991, the Australian Capital Territory in 1994, New Zealand in 1994, Western Australia in 1996, Tasmania in 1997 and the Northern Territory in 1998.²⁵ This was in accordance with the 1993–1998 Medicare Agreement, that each state and territory agreed to establish an independent complaints unit to resolve complaints about public hospital services. South Australia is the only state in Australia which did not establish a statutory health complaints body.²⁶ However, the minister for health (South Australia) introduced the Patient Rights Charter in 1996. One objective of this Charter is to deal with complaint handling and access the responsibility of the Ombudsman's Office.²⁷

These bodies have some common features, including conciliation, investigation and consultation with registration boards. Most of them emphasize the alternative dispute resolution process, with conciliation being the key aim. Developments in the State of NSW deserve special attention. This state was unique in its adoption of a ‘prosecutorial model’, with the Commission retaining, investigating and prosecuting serious and systemic complaints, for example, before the Medical Council.²⁶ Complaints are handled in consultation with various professional boards. The HCCC decides whether to carry out the investigation or conciliation, or whether to refer to another appropriate body for follow-up action. If investigation reveals that disciplinary action or prosecution may be warranted, the case will be referred to the respective registration board for investigation. The HCCC takes the prosecution role at such inquiries. For cases that do not warrant investigation or conciliation, HCCC holds informal resolution meetings to discuss issues raised by the complainants, and determines ways to resolve the issues to complainants’ satisfaction. An important role is that of Patient Support Officers, who resolve concerns by providing information, facilitating self-advocacy, and assisting patients to negotiate and communicate, as well as by helping with the resolution of problems. They also clarify issues and identify options for resolution, as the HCCC believes that many problems and concerns can be resolved at the service delivery level directly, without escalating to the Commission.^26,28

The Clinical Excellence Commission (CEC) (commenced in July 2004) and the HCCC have distinct and separate roles. Principally, the HCCC is responsible for investigating individual complaints about any aspects of health care while, by contrast, the new CEC is intended to ensure that any potential system-wide problems identified by the HCCC are dealt with. Moreover, a network of Professional Practice Units (PPUs) were intended to be set up across the state, to manage and investigate patient complaints at a local level, to oversee local protocols relating to complaints handling, to refer serious complaints to the HCCC, to collect data to enable the CEC to gain a systemic overview and to point out potential systemic issues to the CEC.²⁹

This development implies that the NSW Health Department has directed considerable effort to strengthening and improving its patient complaints system, through both learning from other countries’ experiences and by reviewing its own system. The department intends to incorporate the serious issues raised from patient complaints into clinical quality improvement activities, and additionally, to provide a safer health care delivery system to the public. Whether the re-engineering of this structure works out, will depend to a great extent on the implementation of the network of PPUs. These will play a critical role in the linking of the two sections, i.e. HCCC (patient complaints) and CEC (safety and quality of care), working together to effectively use patient complaints to improve safety and quality of care.

Taiwan

At a local level, patients with complaints had four ways of expressing their dissatisfaction, these being (1) Consumer Protection Officials in each city or county government, (2) the Consumers’ Foundation, (3) consumer services centres at each branch of the Bureau of National Health Insurance (BNHI) and (4) the Medical Affairs Deliberation Committee in each local health authority.

1. Consumer protection officials

In order to protect consumers’ rights and to enhance the safety of services or products purchased, the government initiated the Consumer Protection Act and the Consumer Disputes and Mediation Act in 1994. A Consumer Protection Commission was set up at central government level, while Consumer Disputes and Mediation Committees, Consumer Protection Officials^b and Consumer Services Centres^c were established at city or county government level. Consumers with complaints about products or services provided by entrepreneurs, could seek help or consultation from these units and be protected by these regulations and acts.

In the Article 7 of the Consumer Protection Act 1994 (CPA) stated that:

When designing, producing, and manufacturing products or providing services, entrepreneurs should ensure that products and services provided have been no risk of safety or hygiene. While products or services have some potential for threatening a consumers’ life, body, health, and property, entrepreneurs should provide a clearly visible warning, along with its methods of urgently dealing with risks. If entrepreneurs infringe the previous stipulations and this results in injury to consumers or a third person, they will be responsible for any compensation….³⁰

There has been a long-standing and passionate argument about whether health care should be included in the regulations of the Consumer Protection Act 1994. As the essence of medicine has many uncertainties or unpredictable risks, medical professionals have been strongly opposed to the idea of medical care services being included in the concept of services. The attempt to exclude medical care providers from the Article 7 liability, experienced its first defeat on December 1997, when the trial court in Taipei delivered a decision against a hospital. After a year and half of the appeal, the Higher Court affirmed the decision on September 1999 and aroused another wave of policy debate on medical no-fault.³¹ Even though the debate over its appropriateness, this act has legislated for the protection and improvement of patient rights. As a result, medical practice has tended to become much more defensive.

2. The Consumers’ Foundation

If consumers were not satisfied with products or services, they could make a complaint to the Consumers’ Foundation. This was set up as a not-for-profit, non-government organization. Importantly, the activities of this foundation also covered health care. If patients were not satisfied with the care or service provided by a hospital, they could lodge complaints by telephone, letter or email. The foundation investigates the validity of the complaints and attempt to resolve them to the satisfaction of the complainant. For instance, if a hospital failed to respond to a complaint, the foundation might hold a press conference to reveal the detail of the complaint and to apply pressure to the hospital management to work out a plan to resolve the issue.

3. The Bureau of National Health Insurance

Within the NHI scheme, six branches of the BNHI were established in six districts in Taiwan. Each of them saw patient complaints as opportunities for service improvement. Hence, they set up the Consumer Services Centre for providing free consultation and related business, for instance, the issue of cards as proof of a major disease. If patients or consumers had any complaints or comments to make regarding any aspects of services or aspects of the National Health Insurance, they were able to lodge their complaints or ideas through a face-to-face counter service, by telephone including facsimile, through the mail or by email.

To protect the privacy and confidentiality of patients making complaints and to improve the handling of patient complaints, each branch was required to set up its own procedure for handling patient complaints, and then must inform consumers of the results through their webpage/Internet or noticeboard on a regular basis. However, in terms of patient complaints, it was noted that the complaints dealt with by BNHI were more about service issues relating to the NHI scheme than clinical issues.

4. Medical Affairs Deliberation Committee

The DOH set up the Medical Affairs Deliberation Committee (MADC) in 1972 to improve health policies, deliberate new medical technology and clinical trials, appraise cases at the request of judiciary institutions and prosecutors, enhance the system of specialties, promote medical ethics, and review the establishment or expansion of large hospitals.³² The MADC thoroughly investigated 1122 cases between 1987 and 1995. On average, 128 cases are investigated per year. However, the number of cases investigated by the MADC has been increasing since the implementation of the National Health Insurance scheme in 1995. Between 1996 and 2000, 1287 cases were investigated: that is, 257 cases per year. This number is approximately twice that of previous years (1987–1995).³³ However, the MADC only deals with cases referred by judiciary institutions or prosecutors. It does not handle any cases requested or referred by public or other institutions. In other words, the MADC is not specifically designated to deal with patient complaints. If required, it can mediate medical malpractice disputes that have not been resolved at the local level, when referred by judiciary institutions or prosecutors.

In terms of the 1986 Medical Treatment Act, each local health authority was obliged to set up a ‘Medical Affairs Deliberation Committee’. The purpose of this committee was to review and deliberate the establishment of health care organizations and the standards of medical fees, to mediate medical disputes and to enhance and promote medical ethics. If patients were not satisfied either with their care or with services provided by health care organizations, or suspected that there are errors with their treatment, they could lodge their complaints with the local health authority. Also, if government organizations received serious complaints, they were immediately able to respond to the local health authority. If required, complaints relating to medical malpractices would be reviewed by the Medical Affairs Deliberation Committee, which could take actions such as investigating the hospital being complained about and interview the relevant health professionals.

An investigation revealed that the local health authority had not been actively involved in monitoring how the hospital handled patient complaints, due to the fact that there were no regulations governing such interactions, except the Article 74 of the Medical Treatment Act. When dealing with medical disputes or malpractice, the hospital would not be required to invite a representative from the local health authority to meetings. The health authority would not be involved in handling a complaint unless it was taken to them first. However, if the complaint went to the hospital first, the hospital would attempt to enter into conciliation with the complainant. On the other hand, if the complaint went to the local health authority first, it would mediate the complaint between the complainant and the hospital. However, the focus of conciliation or mediation was not concerned about any quality improvement issues.

Generally, none of these channels were particularly effective for the resolution of patient complaints. Consumer Protection Officials in each city or county government were rarely utilized by the public, as their services had not been well publicized by the government. Furthermore, consumer services centres at BNHI branches usually dealt with service issues relating to the NHI service. It was most effective at dealing with administrative issues rather than clinical matters. The Consumers’ Foundation was a not-for-profit organization which has less legal power to handle patient complaints; its most effective advocacy channel was through media, which could be used to pressurize the relevant hospital organization to resolve the complaint. Finally, it was found that if a medical malpractice had occurred, the involvement of the Medical Affairs Deliberation Committee at each local health authority, was an important means of mediating the resolution of a complaint between the complainant and the hospital. Notwithstanding, hospitals were accountable to their local health authority in terms of business management rather than a bureaucratic power relationship. Hospitals would be more actively involved in dealing with medical malpractice disputes compared with the previous three approaches.

From the standards of hospital accreditation (i.e. the category of emphasizing patient safety and quality assurance), the item of enhancing the doctor–patient relationship puts stress on certain activities. These activities for medical centre hospitals are the establishment of a reception facility in the hospital, the regular in-house training of volunteers and receptionists, the implementation of patient satisfaction surveys and data collection, the introduction of a channel of communication for patient pleadings, including complaints, and the publication of the hospital's service guidelines. However, in 2007, the DOH introduces new guidelines and standards for Hospital Accreditation. This guideline similarly stresses that the hospital must set up channels for patients to lodge their complaints. The point of difference from previous guidelines is that the document requires the hospital to respond in a concrete way to any reasonable problems.³⁴

Conclusions

Changes in government legislation, e.g. the Consumer Protection Act, resulted in changes in the attitudes and willingness of patients to make a complaint in Taiwan. The occurrence of malpractice suits or medical accidents is gradually increasing. The DOH has been drafting a Medical Disputes Handling Act. Although this Act had not yet been introduced at the time of writing, it does demonstrate that the government has placed the issue of patient complaints or malpractice in the business of health policies at the level of legislation and government policies.

In comparison, both Australia and Britain have attempted to incorporate patient complaints into their national quality systems. Their intention was to set up mechanisms to create an effective bridge, at a national policy level, between the patient complaints management system and the quality management system.

Footnotes

a

CHAI is a non-government body as well as an executive non-departmental public body. It is intended to replace the Commission for Health Improvement (CHI), national NHS value for money work of the Audit Commission.¹⁹

b

The main tasks of the Consumer Protection Officials were to coordinate and handle serious events and to deal with the consumers’ consumption disputes, pleadings and mediations.

c

The functions of the Consumer Services Centre were to provide voluntary services for consumers, for instance, consultation services and workshops for consumer education.

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