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Abstract |
Objectives: To survey complainants' experience and
the outcome of lodging a complaint about medical treatment.
Design and setting: Random sample survey. A 32-item
questionnaire was sent to 500 complainants by the New South Wales
Health Care Complaints Commission (HCCC), and responses were
returned reply-paid to the university.
Participants: 290 people with complaints finalised by
the HCCC between February 1996 and August 1997.
Outcome measures: Profile of complainants and doctor
involved; type and place of incident; complainants' emotions at the
time of the incident and at the conclusion of the complaints process;
outcome of complaint, and satisfaction with outcome and intention to
take further action.
Results: After excluding non-medical complaints, 290 of
314 questionnaires returned were analysed, giving a response rate of
63% (314/500):
- 64% of complaints were about clinical care, and the
remainder related to rudeness or poor communication (22%), and
unethical or improper behaviour (14%);
- 70% of complainants were women, and 44% of complaints were on behalf
of another person;
- Complainants had a high socioeconomic status, and 60% were
currently in paid employment;
- More than half the incidents occurred in doctors' consulting rooms;
87% of the doctors involved were men, and over half were general
practitioners.
- 37% of complaints were dismissed; 21% of complainants did not know
the outcome of their complaint, and 40% believed that the doctor had
been disciplined.
- Most complainants were dissatisfied with the outcome; a quarter
stated that they would sue, but 70% would do nothing further.
- All but two complainants would never consult the doctor involved
again.
Conclusions: Most of the respondents were not satisfied
with either the process or the outcome. Typically they wanted
stronger measures taken. Only a few wanted compensation; more wanted
acknowledgement of harm done; and most wanted the doctor
punished.
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| Introduction |
Patients may make a formal complaint if they believe that good medical
practice has failed them. The implications of these complaints for
the medical profession in the United Kingdom, the United States and
Australia have been assessed recently.1-5
Although the medical profession has been assiduous in
self-regulation, governments in many countries have responded to
well publicised concerns about the efficacy of professional
self-regulation by establishing complaints handling bodies. For
example, in New South Wales, the highly public failure of the
healthcare system exposed by the Royal Commission into deaths and
injuries as a result of psychiatric treatment at the Chelmsford
Private Psychiatric Hospital6 prompted the NSW Government
to establish a Health Care Complaints Commission (see Box 1). In
Australia, these units have been developed under the auspices of
State health departments, and in some States have been accorded
statutory independence.
The impact of complaints on doctors has been studied;9,10 less
researched are patients' perspectives. One study of
litigants11 explored the views of
patients suing in 227 medical negligence cases. Focusing on
standards of care, the authors argued against proposals for no-fault
compensation and concluded that, while litigation may provide
compensation and possibly some explanation, it does not address
litigants' concerns about standards of care and
accountability.11
Our study takes up such concerns about care, competence and
responsibility as voiced by patients who bring a formal complaint,
but usually do not become litigants -- a somewhat different
population, but one which is likewise disgruntled and distressed
about a medical incident. We examined the experience of healthcare
complainants, and their satisfaction (or otherwise) with the
process and outcome of bringing a formal complaint.
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Methods |
We surveyed people whose complaints were finalised by the NSW Health
Care Complaints Commission (HCCC) during the 18 months February 1996
to August 1997. The HCCC agreed to address our survey package to
complainants at the time of closing each file. This ensured that
complainants' privacy was maintained, and that respondents
answered questions about a process, often lengthy, which had just
concluded.
Questionnaire
The 32-item questionnaire asked for a description of the incident
leading to the complaint; where the incident occurred; the
specialty, sex and approximate age of the practitioner; demographic
details of the complainant (who was not necessarily the patient);
feelings of the complainant at the time of the incident, at the time of
making the complaint and subsequently; their expectations of the
outcome; and whether they intended to take the matter further. The
survey instrument was piloted and revised. The survey packages, 500
in total, were mailed intermittently from the HCCC office, a
procedure which gave us only remote control over the distribution.
Statistical analysis
SPSS software was used for the analysis.12 The results are given as
the percentage of respondents answering particular questions, and
Pearson's  2 tests of independence were
used to determine the significance of the association among reported
(dis)satisfaction, nature of the incident, demographic
characteristics of complainants and practitioners, respondents'
expectations and the outcome of the complaints.
Ethical approval
The Ethics Committee of the Health Care Complaints Commission
requested some minor changes to the questionnaire and then approved
the study in July 1995. At that time, there was no requirement for
ethical approval for such surveys by the University of New South
Wales.
The Results of the analysis of the survey are shown in Box 2.
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Discussion |
Patients who make formal complaint continue to view very seriously
the incident which prompted the complaint. They recall vividly their
negative emotions about the incident, although at the time most were
glad of the opportunity and satisfied with the procedures for lodging
a complaint. Their dissatisfaction mounts, as finalisation of
complaints typically takes many months, even years, and by the time of
our survey, when the file was closed, most were dissatisfied with the
process and the outcome of making a complaint. Almost a third of the
respondents declared that they would take the matter further: 26%
intended to sue, and 4% would inform police, and appeal to the Minister
for Health. Despite the common view that most people who file a
complaint simply want an apology or acknowledgement of
harm,15 such a response would have
satisfied only 16% of complainants.
Complainants' expectations seem to be at odds with the role of the HCCC
and cannot be met by its statutory functions. Its role is protection of
the public, not punishment or restitution.
That only five respondents' complaints (1.7%) had been
successfully conciliated is surprising given the Commission's
vigorous commitment to this course of action. The 1996-97 HCCC report
records successful conciliation in 50 of the 82 complaints in which
this was attempted, and, in 1997-98, 74 complaints were resolved
through conciliation and a further 278 by "direct resolution". These
latter had been judged as important but to "not warrant investigation
or conciliation".16 The complaints of our five
respondents which had been settled by conciliation involved poor
communication on part of a specialist (3 cases) and refusal to attend
by general practitioner (2 cases). Two were satisfied, and three were
dissatisfied, with the process. The numbers were too small for
further analysis.
Our respondents were better educated and of a higher occupational
status than is typical of the population as a whole, perhaps because
people of higher occupational status are more likely to respond to
surveys. However, we found no significant association between
employment status, sex, age or occupation of respondents and their
report of dissatisfaction/satisfaction, expectations of the
outcome, and intention to pursue the matter in the courts. The one
pointer to intention to sue was the nature of the event. Complaints
about clinical incidents are not more likely than those involving
communication or personal ethics to bring disciplinary action, but
they are significantly more likely to lead to litigation.
The health consumer's disappointment, anger or outrage over
inadequacy, incompetence or failed ethics on the part of health
practitioners can find voice through the powers of complaints units
such as the NSW HCCC. Its powers of investigation, referral,
prosecution, conciliation, and accountability to Parliament
protect the public and monitor health service standards. Perhaps the
increase in complaints about health services signals a rising
consumerism and disenchantment with professions generally. Robert
Hughes' diagnosis of "a culture of complaint" that engulfs daily life
is widely accepted.17 The known availability of
effective complaints mechanisms certainly gives legitimate outlet
for discontentment.
Our survey indicates that people are aware of their rights as
consumers and are glad to have ready access to avenues of complaint.
They felt that initiating the complaint was the right thing to do, but
they were often disappointed with the outcome, because their
expectations were at variance with what does, or indeed can, ensue.
Knowing more about what people see as a breakdown in one or other of the
many facets of good medical practice, and understanding what they
expect, as well as what they can feasibly and legitimately expect by
way of resolution, may obviate some of the difficulties and
disappointments revealed by our survey.
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Acknowledgements |
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Our thanks to our UNSW colleague, Ms Frances Lovejoy, who advised on
statistical analysis. The authors are grateful to the NSW Health Care
Complaints Commission for facilitating the survey. This study is
part of a larger project on the regulation of professions funded by a
grant from the Australian Research Council.
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References |
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Vincent CA, Ennis J, Audley RJ, editors. Medical accidents.
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Ingram K, Roy L. Complaints against psychiatrists: a five year
study. Psychiatric Bull 1995; 19: 620-622.
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Nettleon S, Harding G. Protesting patients: a study of complaints
submitted to a family health service authority. Sociol Health
Illness 1995; 16 (1) 38-61.
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The Tito Report. Review of professional indemnity arrangements
for health care professionals. Compensation and professional
indemnity in health care. Final Report. Canberra: AGPS, 1995.
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New South Wales. Report of the Royal Commission into Deep Sleep
Therapy. The Honourable Acting Justice J P Slattery. Sydney: The
Commission, 17 December 1990.
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Workforce Planning Unit, NSW Health Department. Medical Labour
Force Annual Survey New South Wales, 1997.
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Health Care Complaints Commission. Annual Report 1996/97: 39, 44,
44-45, 11.
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Marjoribanks T, Delrecchio, Good MJ, et al. Physicians'
discourses on malpractice and meaning of medical malpractice. J
Health Social Behav 1996; 37: 163-178.
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Mulcahy L. From fear to fraternity: doctors' construction of
accounts of complaints. J Social Welfare Fam Law 1996; 18 (4):
397-412.
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Vincent C, Young M, Phillips A. Why do people sue doctors? A study of
patients and relatives taking legal action. Lancet 1994;
343: 1609-1613.
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SPSS (Statistical Package for the Social Sciences) [computer
program], version 4. Chicago, Ill: SPSS Inc, 1990.
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Australian Bureau of Statistics. Educational
attainment in 1997. Canberra: ABS, 1998. (Catalogue No.
4224.0.)
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Daniel A. Power, privilege and prestige: occupations in
Australia. Melbourne: Longman Cheshire, 1983.
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Simanowitz A. Standards, attitudes and accountability in the
medical profession. Lancet 1985; 2: 546.
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Health Care Complaints Commission: 1997-98. Annual Report.
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Hughes R. Culture of complaint: the fraying of America. New York:
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(Received 24 Sep 1998, accepted 14 Apr,1999)
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| Authors' details |
School of Sociology, University of New South Wales, Sydney, NSW.
Ann E Daniel, PhD, BA, Professor of Sociology.
Raymond J Burn, BE, MB BS, LLB, General Practitioner.
Stefan Horarik, BE, MEngSc, BA, Research Assistant.
Reprints will not be available from the authors.
Correspondence:
Professor A Daniel, School of Sociology, University of New South
Wales, NSW 2052.
Email: a.daniel@unsw.edu.au
©MJA 1999
Other articles have cited this article:
 David McD Taylor, Rory S Wolfe and Peter A Cameron. Analysis of complaints lodged by patients attending
Victorian hospitals, 1997–2001 Med J Aust 2004; 181 (1): 31-35. [Research] <http://www.mja.com.au/public/issues/181_01_050704/tay10038_fm.html>
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1: The New South Wales Health Care Complaints Commission
The NSW Health Care Complaints Commission (HCCC) was established in 1994. Its role is to protect the public against incompetent or irresponsible health practitioners, and its work involves monitoring professional standards, advising and conciliating, or invoking sanctions when standards are flouted.
The Commission was established and its powers defined by the Health Care Complaints Act 1993 (NSW). It is required to inform the Medical Board of complaints and of how it intends to proceed. Complaints may be prosecuted before the Medical Tribunal or the Professional Standards Committee, two statutory authorities established under the Medical Practice Act 1992 (NSW). That Act defined the powers of the Medical Board and the two separately constituted disciplinary bodies. The HCCC determines how complaints are to be handled. Complaints may be brought before the statutory Medical Tribunal and Professional Standards Board, but it is not legislatively authorised to be punitive or restitutive of damages. Complainants seeking damages or punishment must approach the Courts.
The Annual Report of the HCCC details the frequencies of each complaint category and of each category of health professional involved. In the past five years complaints about doctors have remained fairly static -- from 971 in 1992-93 to 803 in 1996-97 and 984 in 1997-98. In that period 23 023 medical practitioners7 were registered in New South Wales and the number practising is estimated to be 18 200 (79% of all registrants), suggesting that one doctor in 20 may be the subject of complaint in any one year. Thus, very few services prompt a formal complaint. Nonetheless, although most are dismissed, patients' complaints trigger a disturbing and disruptive experience for the practitioner and diminish the profession's reputation.
The HCCC Report for 1996-97 describes the outcome of all complaints. Some breakdown of completed investigations involving doctors is possible:8 52% of complaints were about doctors; 14% involved other health practitioners; 34% hospitals and other health facilities. The Report does not provide comparable data for the 712 complaints finalised, but it might be assumed that these proportions apply to cases completed in 1996-97. On this basis, 370 investigations specific to doctors were completed in 1996-97.8 Of these the HCCC referred 74 (20% of all medical complaints concluded) to the Medical Board requiring that the practitioner be counselled; it brought 41 (11%) medical matters to the Medical Professional Standards Committee for hearing; and it prosecuted six complaints (< 2%) before the Medical Tribunal. The remaining 249 (67%) medical practice investigations were dismissed, conciliated, or terminated.8
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| 2: Results |
| Characteristics of complainants |
 | | Of the 500 questionnaires, 66 were returned unopened (address not known), leaving 434; responses were received from 314 complainants, giving a response rate of 63% (314/500). Twenty-four forms describing complaints about non-medical health practitioners were discarded, leaving 290 questionnaires for the analysis.
- The complainants ranged in age from early 20s to over 70 years; the median category was the 30-39 year olds; 153 respondents (54%) were in their 30s or 40s.
- 70% of complainants were women.
- The respondents were well educated: 85% had completed high school, 26% had a university degree and 34% held an occupational certificate or diploma. This profile is significantly different from that for all Australians of workforce age in 1997 (58% had completed high school; 14% had a university degree; and 26% held an occupational certificate or diploma13) (P < 0.001, df = 2)
- Sixty per cent were in paid employment. Their higher than average socioeconomic status is reflected in their occupational distribution (according to the Daniel Scale of Occupational Prestige).14 Very few respondents identified as Aboriginal (5; 1.7%) and only 13 (4.5%) reported speaking a language other than English at home.
- Almost half of all complaints (128; 44%) were brought on behalf of someone else. Of these, 42 concerned the complainant's child or ward; 31 complaints were on behalf of a spouse or partner; 43 for a parent or other relative; and in 12 cases a complaint was brought by another practitioner. In the remaining 162 cases (56%) patients complained on their own behalf.
- Very few respondents (10; 3.4%) had ever complained formally about a medical practitioner before this occasion.
| | Incidents prompting a complaint |
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Respondents described the treatment or behaviour which led to a formal complaint. The incident was classified under one or, if necessary, two categories (eg, complainants might say the doctor failed to diagnosis their illness and was also rude to them.)
- Most complaints (64%) were about clinical care, with incompetence/
negligence being the most frequent. This agrees with HCCC statistics for 1996-97, with clinical care complaints making up 61% of the total.11
- The next most frequent complaints involved failure of communication and lack of courtesy. The comparative HCCC figure is 13%.
- More than half the incidents occurred in doctors' consulting rooms, more than half the doctors involved were general practitioners, and 87% were men.
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| Emotions triggered by the incident of complaint |
 | | Respondents wrote passionately of their emotional responses to the incident. The questionnaire listed 12 possible emotional responses, with the opportunity to add to the list. The percentage of all respondents recalling each emotion is shown in the Box.
- In recalling the incident complainants described a mean of 4.1 emotional responses each. The most frequent were anger, shock, and a sense of betrayal.
- At the beginning of the complaints process two-thirds (63%) of the 290 respondents had felt satisfied that they had done the right thing; some recalled being worried (19%), confused (10%), or cynical and angry (8%) about the process itself.
- By the time the complaint file was closed (the median time to finalise a complaint was 18 months, range one month to 6 years), initial satisfaction had faded, and the majority (61%) were dissatisfied; 23% remained satisfied and 16% were unsure about their feelings.
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| Outcome of complaints |
 | - Over a third of complaints were dismissed; in 40% the doctor had been disciplined, and the result was not known in 21%.
- After excluding complaints with outcome unknown, there was no significant association between category of complaint as described by respondents and the outcome; nor was there any significant association between demographic characteristics of respondents
and outcome or respondents' intentions to take further action.
- Heightened levels of dissatisfaction at the conclusion of the process were significantly associated with the outcome (P = 0.001; 2 = 70.02, df = 8). Satisfaction was much more likely if strong action had been taken against the doctor. With disciplinary measures or counselling of the doctor, 42% of complainants were satisfied, 43% dissatisfied and 15% undecided. With complaint dismissal, 6% were satisfied, 90% dissatisfied and 4% undecided.
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| Further action and outcomes complainants wanted |
 | - Asked whether they were contemplating further action, 70% said no; 26.2% declared they would sue in the civil courts; and 4% would inform police, appeal to the Minister of Health or publicise their complaint. The intention to take the matter further was not related to respondents' sex, age, education or occupation.
- Respondents were much more likely to take further action (usually litigation) when the complaint involved clinical issues. Complaints about practitioners' rude or inadequate communication or personal ethics were significantly less likely to lead to intention to sue (P < 0.001; 2 = 10.03, df = 2).
- At closure of their complaint file, many respondents remained angry and most wanted stern measures taken.
- All but two people would never consult the doctor involved again.
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