Harnessing the power of language to enhance patient experience of the NHS complaint journey in Northern Ireland: a mixed-methods study
Authors: Rhys Catrin S , Benwell Bethan , Erofeeva Maria , Simmons Richard 
Published: September 2024

Background
Good communication is consistently recognised as essential for effective complaint handling, while failures in communication correlate with risk of escalation. Nonetheless, communication in National Health Service complaint handling remains underexamined.

Objectives
To examine complainants’ lived experience of the complaints journey through (1) micro-analysis of their communication with National Health Service representatives; (2) their self-reported expectations and experiences throughout the complaints journey; to survey patient perceptions of the culture of the National Health Service; to develop ‘Real Complaints’ – an evidence-based communication training resource.

Design
The project triangulates microlevel conversation analysis and discourse analysis of spoken and written complaints encounters with complainants’ appraisals of those encounters in longitudinal case studies. This is underpinned by an audit of patient views of the cultural–institutional context of the National Health Service.

Setting and participants
Data were gathered in the complaints-handling services of two National Health Service trusts and a Patient Advocacy Service in Northern Ireland. Twenty-three complainants consented to longitudinal data collection and 58 to initial encounter recording; 115 members of the Patient Advocacy Service mailing list completed the cultural audit; 3 trust complaint handlers, 1 Patient Advocacy Service complaint handler and 2 trust complaints managers were interviewed.

Data sources
This yielded 1155 minutes of recorded calls, 113 written encounters, 36 diaries, 6 meetings, 23 interviews and 115 cultural audit responses collected over a period of 24 months.

Results
Our analysis illuminates the dual nature of complaints: as personal expressions of dissatisfaction and as systemic critiques. The complaint experience is a dynamic journey with evolving narratives reflecting complainants’ shifting perceptions, expectations and experiences of the ‘system’, both moment-by-moment and encounter-by-encounter in the overall journey. Key interpersonal priorities for complainants significantly affected complaint outcomes, most important of which was the need to be respected as a ‘reasonable complainant’. Also key is the conversation analytic concept of affiliation, which involves taking a stance towards the event(s) being described that matches the complainant’s stance. Use of affiliation by call handlers supported effective and efficient person-centred complaints handling, while absence of affiliation typically led to escalation of the scope, scale and emotional intensity of the complaint, sometimes to the point of an expressed intention to litigate (particularly in the case of written responses). Viewed holistically, successful complaints communication requires person-centredness, and affiliative interactions framed by shared expectations. These findings were applied in the development of Real Complaints Training and Guidance for spoken and written complaints communication.

Limitations
The COVID pandemic significantly constrained trust participation, particularly the participation of front-line clinical staff, and one trust introduced ‘telephone resolution’ to which we were not given access. Additionally, calls viewed by staff as ‘challenging’ and ethnic minority communities are both under-represented in the final data set.

Conclusions
Addressing the complainant’s desire to be perceived as reasonable was revealed as crucial for fostering a more person-centred approach to handling complaints and addressing the gap between expectations and experience. This finding holds particular significance for recommendations, guidance and training relating to both spoken and written communication.

Future work
Direct extensions of the project include the piloting and evaluation of Real Complaints Training and further primary research involving communication between complainants and front-line service/clinical staff and complaint handling by ombudsman complaints investigators. An emerging question relates to social exclusion and access to complaints procedures.

Study registration
This study is registered as Research Registry: researchregistry5049.

Funding
This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR127367) and is published in full in Health and Social Care Delivery Research Vol. 12, No. 33. See the NIHR Funding and Awards website for further award information.