By Dr Ruth Carlyle, Macmillan Cancer Support and Associate Research Fellow, Birkbeck
A very British plea emerged from the House of Commons Public Administration Select Committee in April 2014: ‘More complaints please!’. In the case of British public services, particularly the National Health Service, the Select Committee noted a ‘toxic cocktail’ of reluctance to complain and unwillingness to learn from such complaints as are made (House of Commons Public Administration Select Committee, 2014: p.3)
The Public Administration Select Committee inquiry was triggered by the events at the Mid Staffordshire NHS Foundation Trust. The Francis inquiry identified that the problems at the Stafford hospital should have been apparent earlier, through complaints made by patients and their families. The Select Committee noted that Mid Staffordshire was not alone in its failure to learn from complaints, as a Which? survey of 94 NHS trusts found that only 20 percent reviewed learning from complaints (2014: p. 16). Unless people complain and managers learn from the complaints, services in a near-monopoly are unlikely to improve.
A similarly toxic problem with the Nigerian railways inspired Hirschman’s 1970 monograph on resolving ‘repairable lapses’ in firms, organisations and states. Hirschman identified that in an economic model managers may learn about problems through ‘exit’ from a product or service, but that in political terms consumers may also ‘voice’ concerns (Hirschman, 1970: p. 3). He indicated that customer ‘loyalty’ also needs to be taken into account: in a market, it may discourage early exit by customers who could provide useful feedback; but it might also deter feedback where customers do not have a realistic exit option (1970: p. 55). In the Nigerian railways, Hirschman identified that exit was not an issue for managers, as in a state-supported industry they were not unduly concerned by the loss of customers, and that voice did not operate as the most roused customers were those who transferred their custom to the road network (1970: p. 45).
The lack of a true exit option for users of NHS services creates different pressures from those in the Nigerian railways. For most patients within the NHS, private healthcare is not an alternative and so a choice to ‘exit’ is a choice not to be treated. In these circumstances, voicing concerns is the only option to improve services.
The principal recommendations within the Select Committee report relate to improving how complaints will be managed, rather than increasing the number of complaints:
The title of the report, ‘More complaints please!’, points to the more complex issue of how to enable members of the public to complain. A Which? survey cited by the Select Committee found that just 65% of those with a cause to complain had made a complaint about the NHS; whereas 90% with those for cause to complain had done so in relation to high street retailers. The Select Committee propose that patients and families need to be supported to make complaints about the NHS.
Various attempts have been made to increase the public voice within the NHS, including lay governors in NHS Foundation Trusts, professionally-led engagement and state-funded voluntary schemes. The Select Committee refers to Community Health Councils, a form of state-funded public involvement institution, as having provided support in the past. Local Healthwatch groups, the current successors to Community Health Councils, were granted the right to support complainants as part of the Government’s response to events at Mid Staffordshire (Secretary of State for Health, 2013).
Given the complex loyalty issues for users of NHS services, it is likely to take more than independent support to increase the number of complaints made in the NHS. Hirschman’s 1970 monograph continues to remain relevant, with its warning that having ‘locked in’ customers does not of itself ensure that concerns will be voiced (1970: p. 55).
Hirschman, A.O., 1970. Exit, voice, and loyalty: responses to decline in firms, organizations, and states. Cambridge, Massachusetts: Harvard University Press.
House of Commons Public Administration Select Committee, 2014. More complaints please! Twelfth report of session 2013-14: report together with formal minutes relating to the report. London: The Stationery Office.
Secretary of State for Health, 2013. Hard truths: the journey to putting patients first; volume one of the Government response to the Mid Staffordshire NHS Foundation Trust public inquiry. London: The Stationery Office.