ARTICLES

Less than 1 in 1,000 patients complain about out of hours general practice according to new research from the Health Research Board Centre for Primary Care Research at the Royal College of Surgeons in Ireland.

A new study from the Health Research Board Centre for Primary Care Research at the
Royal College of Surgeons in Ireland on Northdoc – the North Dublin GP Out of Hours service, has discovered that from over 300,000 face-to-face consultations, only 234 patients made complaints. This works out at a rate of 0.61 complaints per 1,000 GP consultations.

The study looked at nearly half a million telephone contacts between patients and NorthDoc Medical Services CLG between 2011 and 2016. Of the complaints made, it found that unmet patient expectations and parental concerns over antibiotic treatment
of children were amongst the most common. While research on patients’ complaints in out of hours general practice is limited, the new research has presented some interesting and positive findings.¹

Common complaints

Common themes seen as a reason to complain in an out of hours practice setting included dissatisfaction with clinical examination and unmet expectations regarding management. An example of this is a parent being unhappy that oral antibiotics were not prescribed to their child who was diagnosed with a viral infection.
Other complaints included:

• clinical problems – including misdiagnosis, prescription errors and inadequate
clinical examination

• communication problems – including the perception of being dismissed or ignored

• concerns about confidentiality breaches

• management problems – including waiting times, staffing levels, problems with facilities provided and issues with fees.

Mitigating complaints

Communication
For GPs working in an out of hours setting, good communication with the patient, and GP colleagues, is key.

Poor communication is well recognised as a contributing factor in complaints² – which is why it’s equally as important that when communicating with patients, doctors listen as much as they talk; thereby leading to a more accurate diagnosis and a reduced risk when it comes to medical errors.

Team communication is also important, and out of hours staff need to work closely together to ensure the service runs smoothly. There also needs to be an efficient system for passing information between healthcare professionals, including the patient’s GP.

The NorthDoc complaints procedure is based largely on a fast verbal response to the patient. It encourages patients to make their complaint in any format that they wish – ranging from a formal contact with the HSE’s complaint procedure online to direct
contact with NorthDoc via an email account. Dr Desmond MacDonell, director of medical
governance at NorthDoc, also encourages all personnel within the service to accept verbal feedback and to communicate it quickly to ensure a quick response to patients.

“Staff can notify me by email following a complaint, advising the patient that I will respond verbally. A relatively small percentage of our complaints are received in writing and in turn, only a very small percentage receive a written response. All complaints are nonetheless closed with a comprehensive written report to the board of NorthDoc.

“I find that verbal responses are very effective in that the matter can be fully discussed with the patient. A 15-minute telephone conversation enables a thorough discussion of the complaint, whereas a written reply tends to be short and somewhat prescriptive, and in my opinion, less likely to result in a complete resolution of the matter.”

Quality standards
High standards and a consistent approach to patient care are key. Employees should all meet agreed criteria and a detailed induction programme should ensure all staff have a thorough understanding of the relevant out of hours systems and processes.

The Royal College of General Practitioners (RCGP) has an Out of Hours Clinical Audit tool that can be used across all staff groups to cover the main aspects of an out of hours service. It’s designed to promote consistency and provide a framework to examine and develop the quality of calls and consultations.³

Risk management within the out of hours team should be an integral part of any meeting, giving staff the opportunity to report and review any complaints or incidents. It is important to ensure action plans are developed as this will ensure the practice is accountable for implementing the changes.It is also good practice to ensure that any changes to the function or running of the practice are communicated effectively to patients.

How to manage complaints

The research states that 85% of patient complaints were managed effectively to the satisfaction of the patient by the out of hours service. This highlights the value of local complaints resolution structures in general practice settings.

The benefits of having a local complaints procedure include:

• obtaining patient feedback, both negative and positive

• highlighting areas of concern

• addressing issues early

• reducing the chance of a medical negligence claim by dealing with the complaint effectively

• diverting the complaint from the Medical Council.

It is important to have a written complaints policy within the practice that details your practice’s approach to managing and handling complaints.

You also need to identify who is the responsible person within the resolution structure for managing/handling complaints – this could be a senior GP.

Some practices find it helpful to have a complaint management checklist which can be retained within the file as a useful aide-memoire, to ensure that none of the steps in the complaints handling process are inadvertently overlooked.

On receiving a complaint, it is important to acknowledge this with the patient – we suggest that you acknowledge receipt of the complaint within three working days.

It is also important to advise the complainant that they will receive a full response and to give an indication as to when they can expect this. Some jurisdictions have introduced time frames for responses in primary care(for example, in Northern Ireland, where the substantive response is expected within ten working days). However, whilst it is important to deal with complaints promptly, the quality of the response must not be sacrificed in favour of meeting a deadline. It might be the case, for example, that a key individual is unavailable for comment (eg due to leave or illness) and it would be more appropriate to await their return. Complainants should be kept advised of any such delays.

In the event that a patient complains verbally to the practice, it is important to establish at this stage if they wish to write formally to particularise their concerns.Where a complainant raises a significant clinical governance issue but declines to submit their concerns in writing, it can be helpful to summarise the issues in the acknowledgement letter, to afford the complainant the opportunity to correct any misunderstandings and/or to expand upon their complaint.

Any acknowledgement with the patient should include a commitment to investigating what has gone wrong.

When responding to a complaint an apology can go a long way, acknowledging with the patient any distress that the situation has caused. In many cases, patients just want to understand the clinical issues. Even in cases where the practice concludes that the service provided was appropriate, empathy with the complainant’s perceptions can be helpful in bringing the matter to a conclusion.

In the letter of response, it is important to provide a chronology of the events in question so that the complainant has a full understanding of what has happened, and to respond to each issue raised in the complaint. Where indicated, the practice should outline the action that it plans to take and an estimate of the timescales for introducing any service improvements –giving clear responses to each issue raised will provide the patient with a full understanding of what has happened. It can also be helpful to offer to write to the complainant with an update in relation to any changes that have or will be introduced.

You may feel it appropriate to invite the complainant to meet with the practice to discuss any unresolved concerns or to explain the response in further detail.

It is also good practice to ensure that all complaints are recorded. Confidentiality must be maintained, as with clinical records. Complaints should be recorded separately from the patient’s medical record. Documentation should be clear and accurate.

References

1. Wallace E, Cronin S, Murphy N et al. Characterising patient complaints in out-of-hours general practice: a retrospective cohort study in Ireland. British Journal of General Practice 2018;68:e860-e868. doi:10.3399/bjgp18x699965
2. Price et al (2007). Emerging risks in out-of-hours primary care services. Clinical Governance: an International Journal 11(4) 289-298
3. Urgent and emergency care clinical audit toolkit. London. RCGP 2010