PSA Board Member Moi Ali reflects on our recent roundtable in Scotland where the topic discussed was "why are there so many barriers to complaining?"

It’s commonly accepted that complaints are a great source of information, highlighting what an organisation is doing wrong, and what needs to be tackled to improve organisational performance. But if organisations generally, and healthcare regulators in particular, really value complaints, why are there so many barriers to complaining? And why is so little focus placed on removing obstacles? That was a topic that the PSA raised in its 2022 report Safer care for all and the focus for the PSA’s stakeholder event in September 2023 in Edinburgh.

I thought I knew a lot about complaints, having held many senior complaints roles over the years – including, currently, being the first Home Office Independent Complaints Examiner, and also undertaking a similar role for the Crown Prosecution Service. Nonetheless, I went away with plenty of food for thought. I’d been of the view that the so-called ‘chattering classes’ (I hate that term!) – namely, the affluent and well-educated middle classes – were well represented amongst complainants, and did not face the same barriers to complaining. I shall have to question my own prejudices following one participant’s insight: some women in that category are what she termed “people pleasers”, who are reluctant to complain because of the social expectations placed on them.

That got me thinking about another awful expression: “Karens”. My own kids introduced me to this undoubtedly pejorative term: “Oh mum, stop being such a Karen,” they exclaimed when I complained about poor service in a restaurant after a family meal. There certainly is pressure on middle class women not to complain, or to be stigmatised for doing so.

It is worth considering the correlation between a willingness to complain/ability to be heard by women and the apparently high volume of patient safety scandals and incidents affecting this group. In Safer care for all the PSA highlighted that, as well as the frequent occurrence of maternity scandals, both the Cumberlege Review and the Paterson Report highlighted harm caused to predominantly female patients and the difficulties faced by those trying to raise the alarm. The Cumberlege Review described a ‘denial’ of women’s concerns.

Another insight at the roundtable in Edinburgh came from Rosemary Agnew, the Scottish Public Services Ombudsman (SPSO), on the need for child-friendly complaints procedures. Research carried out by YouGov on behalf of the Parliamentary and Health Service Ombudsman (PHSO) found that children (and younger people generally), but those from minority ethnic backgrounds, or with disabilities, are most likely to be affected by public service failures, yet least likely to complain.

Talking of the PHSO, a significant barrier to escalating complaints about Government Departments and other public bodies to this final tier of the complaints system is the requirement to have the matter referred by a Member of Parliament (MP). It would be unsurprising if the most disadvantaged (and least likely to complain) found this a deterrent. Although this doesn’t apply to complaints about the NHS which can be made directly to the PHSO (once the matter has been exhausted through other more local routes) or through an MP it still raises an interesting question about the persistence of such obstacles: Are barriers a deliberate part of rationing healthcare complaints? Discuss.

There are many possible reasons why people don’t complain. They may not realise that they can, or be unsure of how to access and navigate the complaints system. The complexity of their issue/concern may be a barrier – both understanding what went wrong and being able to articulate it. This can be magnified if there are literacy difficulties, English is not a first language, or they have special needs. People may be at a very low ebb, without the emotional energy to complain. They might be ill, or made ill by the stress. Then there’s digital exclusion, which may affect some older people, lower socio-economic groups, migrants and homeless groups.

One of the main reasons people don’t complain, even if they can, is that they feel that nothing will change as a result – or worse, they fear that access to the very services upon which they rely, the ones that have failed them, may be adversely affected if they complain. This was a theme which arose from research the PSA recently commissioned into perceptions of discriminatory behaviours in health and care where some participants feared the consequences if they raised concerns about their experiences of discrimination. This too is unsurprising, but the real challenge is how regulators can reach out to under-served communities to encourage legitimate complaints by building trust in the complaints system amongst those groups least likely to complain. It’s a big ask, but a necessary one if the profile of complainants is to change.

And what exactly is the profile of complainants? Monitoring change requires an analysis of who currently complains and, crucially, which groups don’t – and why. As the PSA highlighted in Safer care for all, the data on who does and doesn’t complain is extremely patchy, particularly demographic information, making it difficult to get an accurate picture of who is and isn’t complaining.  Next, an action plan needs to be drawn up and implemented. Performance needs to be measured along the way, and plans amended as necessary. All of this takes time and money – and it takes staff. This, at a time when some of the regulators are struggling to fill fitness to practice vacancies so that complaints can be investigated and, where necessary, put before panels. Perhaps more cross-working across regulators may be part of the solution.

In Safer care for all we recommended that:

• Regulators work with other health and care bodies to gain a better understanding of the demographic profile of complainants and reduce barriers to raising complaints for particular groups.
• Demographic data on complaints made to the health and care services across the UK is recorded and made available for all bodies to use.

There is a role for us at the PSA in pushing for more accessible complaints systems across health and care, and for sharing best practice. As a first step, building on the discussion in Scotland, we will be holding an event with the Parliamentary and Health Service Ombudsman in January 2024. This event will bring together health and care sector stakeholders to look at what we know about the barriers that currently exist and promote practical action and solutions to address these. However, we will need to think about further steps we as an organisation can take to bring about change in this area.    

I for one stand ready to support this worthwhile piece of work, so that we can start to see the demographic widen, as complaints processes recognise and remove barriers and thereby widen the diversity of those complaining.