Harnessing the power of language to enhance patient experience of the NHS complaint journey in Northern Ireland: a mixed-methods study

Building rapport

An overriding concern for institutions when interacting with service users is to establish and maintain a good relationship; in social relation terms this is commonly referred to as rapport. 55,67 Institutions clearly have a stake in rapport-building, which ostensibly means better outcomes and thus increased client satisfaction. Rapport is demonstrably useful for service users; as described above, it goes some way to lend credence to their complaint if they can be seen as working with the institution to solve a problem, and not against the institution to create new problems. Rapport is actively sought and tied up with how institutions manage their relationship with their users. 68

Gatekeeping

Gatekeeping is an action accompanying the interactional role of call handling;69–71 call handlers decide whether and how the complaint/request etc. progresses. Whether calls result in a complaint or request does not necessarily result from the actions of individual call handlers, as the institution will have its own frameworks and workflows; they are merely responsible for navigating these procedures and ensuring that the service user fulfils the remit of the service. Though gatekeeping is characterised by decisions made by the institution, it comprises a negotiation wherein service users are tasked with convincing the service provider of the legitimacy of their trouble/request/complaint. Examining gatekeeping thus provides a window into the frameworks, processes and culture of an institution.

Navigating and signposting

Calling an institution often requires some navigation of that institution, whether it be form-filling, answering questions, telling one’s story, etc. Part of the call handler’s role is to support the caller to navigate that system to make their complaint, such as by eliciting details or being empathetic to the complainant’s experience. One method of navigating is signposting. Alexander72 offers a detailed review of signposting as an interactional activity where direction is provided to service users. Interlocutors attend to a preference for helping and providing a service even when the request/complaint cannot be fulfilled. 72,73

Signposting is organised with respect to the goal-orientedness of these approaches to the services. 67 The ‘goal’ is often bound up with how service users make requests to service providers to fulfil a course of action,74 for example, whether a current problem such as the removal of stitches is formulated as a request for help (to remove the stitches) or as a complaint (their non-removal thus far). These constructions have implications for the trajectory and ultimate outcome of the encounter.

Applying the Cultural Theory framework

Our initial discussion of cultural issues focuses on values such as relational justice, norms such as relational morality and practices that promote relational satisfaction. These are fundamental for understanding how institutional cultures preserve cultural values and norms, give them authority and provide a context for the practices of social interaction97,98 that are discussed in microanalytic detail in this study.

If we accept that patterns of social relations shape people’s preferences and justifications so that ‘everything human beings do or want is culturally biased’,99 CT, which distinguishes a limited number of cultural biases, provides a useful mechanism for simplifying system complexity in ways that are congruent with ‘real world’ processes. 100

The Cultural Theory framework and public services

Here we introduce the key elements of CT101–104 as a tool for understanding cultural diversity.

Cultural Theory has its roots in Durkheim’s105,106 two dimensions of social organisation: social regulation (‘grid’) and social integration (‘group’) (Figure 2). ‘High grid’ cultures are heavily constrained by rules and ascribed behaviour; ‘low grid’ cultures much less so. In ‘high group’ cultures, group membership is strong; in ‘low group’ cultures, much weaker. CT thus helps frame institutional analysis of the NHS/HSCNI service environment.

FIGURE 2.

The dimensions and cultural biases of CT.

The four cultural biases of Cultural Theory

Hood107 uses CT to describe four cultural biases describing ideal-typical patterns of relations in public administration:

• Hierarchy (strong social regulation, strong social integration) sums up a bureau-professional relationship in which experts define users’ needs, and services are delivered according to strict rules of eligibility.

• Individualism (weak social regulation, weak social integration) constructs service users as rational, utility-maximising individuals, negotiating the role to support their private needs and wants.

• Egalitarianism (weak social regulation, strong social integration) is represented by ‘mutualistic’ forms of relationship, in which a sense of membership/ownership confers rights (but also responsibilities) on users to co-produce services through more collective processes.

• Fatalism (strong social regulation, weak social integration) sees social relations as imposed by external structures. Fatalists consider the expression of voice as pointless, and therefore tend to feel isolated from the public service system.

Understanding cultural tensions

Cultural Theory includes two further theoretical propositions. First, the ‘requisite variety condition’ states that the four cultural biases need each other to be viable and define themselves against. 104 Elements of all four cultural biases should be expected to be present but exist with one another in a state of permanent disequilibrium, tension and flux. 104,108

Second, the ‘compatibility condition’ states that these different and mutually irreconcilable biases nevertheless need to be accommodated to maintain the viability of the system. 108 Hence, viable patterns arise when social relations and cultural biases are mutually supportive of each other. 104

Achieving ‘relational justice’

These findings display a level of cultural dissonance. As predicted by the ‘requisite variety’ and compatibility’ conditions of CT, the value of the cultural audit lies in showing how action can be taken, to work in a number of complementary ways in the pursuit of greater congruence (or ‘dissonance reduction’).

For this complaints study, where the patient/carer voice is relevant to achieving relational justice, factors in the culture of public service organisations are important in assessing the ‘possibility spaces’ or ‘opportunity structures’ they open up or close off. 109 Survey respondents were therefore asked: ‘Are there are good opportunities available to express your views about the service?’. Yet only 22% said ‘Yes’ – 49% said ‘No’ and 27% said ‘Don’t know’.

Links with service relationships and service performance

The expression of voice could also be cross-tabulated with two further variables (service relationships and service performance), where patients/carers were asked: ‘On balance, how good a service do you think you get?’, and ‘On balance, how positive or negative is your relationship with the people who deliver this NHS service?’. Chi-squared analysis confirmed clear relationships between these variables. Hence, the more likely patients/carers were to say there were ‘good voice opportunities’, the more positive their perceptions of both relational quality and service performance (Table 3). This confirms the findings of previous research and provides an important consideration for NHS/HSCNI service managers and staff.

Tackling fatalism

Finally, we found that the more patients/carers/complainants felt unable to engage effectively in public service relationships, the more likely they were to feel isolated and fatalistic. Those who said ‘no’ to the ‘good opportunities to express your views’ question were significantly more likely to exhibit more fatalistic perceptions (Table 4).

As Hood107 observes, fatalist approaches arise in conditions where co-operation is rejected, distrust widespread, and apathy reigns. In promoting greater relational justice in public services, it is therefore important for greater efforts to be made to listen, engage and respond more carefully with patients/carers. 110

Context of complaining

First, we explore how the cultural predispositions, identified in the cultural audit, are manifested in the qualitative data sources from the longitudinal journeys.

Reasonable complaint/complainant identity

Across our data we find frequent general references to ‘reasonable’, ‘thoughtful’, ‘normal’ person identities, often in descriptions of themselves as patients or carers, for example, ‘I can imagine a lot of people a lot of parents kicking off and like we didn’t kick off’ (RC21). RC23 defends her ‘reasonable patient’ identity in the way she describes her own behaviour (compared to the ‘rude’ doctor) as beyond reproach:

I wouldn’t even lower myself to be cheeky back to him to give him a reason to say anything about me like I don’t drink alcohol or take drugs or anything I’m genuinely sick.

RC23[T]

RC28 constructs herself as a ‘good patient’:118

I am a very independent person as my records the last time will show that at 12 week check up my recovery was brilliant as surgeon couldn’t get over work I had put in.

RC28[D]

Complainants also regularly appeal to membership of the implicit category ‘reasonable complainant’ by distancing from the activity of complaining and stressing that complaining is exceptional or not something the caller usually does (e.g. ‘we’re not really complaining people’; ‘I don’t usually complain’) or through the announcement of explicit membership of particular kinds of ‘reasonable’ identity categories (e.g. ‘I’m not an ignorant man’; ‘I’m sort of the type that doesn’t like to bother anyone’), or through attributes or activities tied to the category ‘reasonable person’ (e.g. ‘don’t want anybody getting into trouble’; ‘it’s not about punishing the system … it’s trying to make a change’).

The moral accountability of complaining sets a threshold of ‘tolerance’ before initiating or progressing complaints. RC23 (a long-term and frequent patient at the hospital) states that her perception of poor staff attitudes began at a much earlier stage but it is only now that she has decided to complain formally: ‘over the course of the twelve years … it’s just getting worse and worse and worse’. Similarly, RC29, calling on behalf of her daughter, emphasises the period of waiting prior to making the complaint; RC21 also implicitly refers to his reasonableness and patience in waiting before ‘taking a stand’:

I’ve let this go on for seven weeks now. And I feel, it’s got to the stage now where I feel like I’m letting my daughter down and I’m neglecting her because I’m her father and I’m letting her suffer. So that’s why I have now taken this stand. I’ve had enough.

RC21[Rc]

Complaining is portrayed as a ‘last resort’, only taken when extraordinary circumstances demand it. Thus, the potential social disapproval associated with the act of complaining might deter some individuals from lodging a complaint at an earlier stage. It also influences how complainants present their motives in the decision and justification to complain.

Preconceptions about the complaints process and motivation to complain

When an individual contacts a complaint line, they generally have an anticipated resolution in mind. Complainants often desire an acknowledgement of fault, an apology and the assurance that steps will be taken to prevent the recurrence of the issue. However, their expectations might also extend to ‘help’, which can be interpreted in a broader sense as any enhancement to their present circumstances or remedies to their issues (this is confirmed by the analysis of complainants’ reasonable motives, which demonstrated that many turn to the complaints process as a last resort). In our sample, 15 participants had ongoing concerns regarding treatment and care at the time of making a complaint. The expectation that their complaint might lead to improvements could have heightened their dissatisfaction when those changes did not occur.

We have a clear illustration of how misrepresentation of functions of the complaints department could lead to an escalation of frustration in the case of RC21. Conversations with the complainant revealed that he expected the complaints department to be independent and to advocate for him:

I put all my trust into the complaints […] I do believe that the complaints will help and they act independently and they will push my side as much as possible.

RC21[TD]

He also did not understand that the complaints team do not carry out the investigation, as is evident from the following quote where he comments on being unexpectedly drawn into a meeting about his complaint without prior notice during a ward visit:

Surely that goes against the whole complaint process because it’s then not allowing the complaint people to effectively investigate the complaint. (emphasis added)

RC21[I]

Unrealistic expectations regarding the role of the complaints department probably exacerbated this complainant’s frustration. Although he had been through the complaints process before with an equivalently complex complaint, that experience did not adequately prepare him for the current one. It indicates that there is a lack of clarity about the complaints department’s function.

Indeed, confusion exists regarding the various entities handling complaints and their responsibilities. For example, two participants believed the only complaint channel was the Ombudsman. RC30 stated, ‘I didn’t know how to complain or who I could complain to’ (RC30D), and turned to the Ombudsman with her previous complaint, but made no progress. RC26 saw the Ombudsman ‘advertised somewhere on the TV’ (RC26[T]), but was unaware of her right to complain, and only learnt about the complaint line after inquiring about her surgery waitlist status.

I think if the public were more aware that they could complain I think there would be a lot more complaints about the NHS.

RC26[I]

Understanding the right to complain does not equate to knowing how to complain, and in one of our cases the NHS staff were equally unaware of the process:

[T]hey told me they don’t know how to do that […] so I’ve actually just googled.

RC20[T]

Although instances of misunderstanding/non-awareness are infrequent in our study, their existence within our limited sample suggests that complainants have varied interpretations of the complaints process.

The tension between complaint and problem-solving becomes evident in those cases where the complaints process did resolve some problems for the complainant. RC17 was a woman who fractured her toe and found her subsequent medical care experience unsatisfactory. While she didn’t initially expect her complaint to lead to a resolution, she has the impression that her complaint contributed to her being seen by a helpful consultant:

[W]hen I phoned up to complain it was really just to complain, it wasn’t, I wasn’t thinking that they would intervene and get me an appointment, but for whatever reason they did.

RC17[I]

Nevertheless, she believes this kind of advocacy shouldn’t be necessary.

Her case also vividly demonstrates how problem-solving could be an underlying motive and expected outcome of the complaint. At the time of complaining its motivation was expressed as getting justice and effecting change for others, but it appears from the interview 7 months later that the complainant’s primary motive was to resolve the issues with her care (‘Well just to get the issue resolved really it was […] I was just hoping somebody would have sorted it out in some way and then they did’). The pressure to be seen as reasonable subsided over time and the complainant’s personal care became more prominent.

Similarly, RC30 and RC24 experienced positive shifts in care after lodging formal complaints. For RC30, it brought about an immediate enhancement in their father’s care, making him ‘treated like a king’. This positive outcome, however, sparked reflections on the privilege inherent in the ability to complain, not afforded to everyone. RC24, stuck in healthcare ‘limbo’ due to an unrecorded referral, reluctantly lodged a complaint. This led to a swift response from the service and an operation date, leading the patient to view the complaint as a direct tool for resolution. Nevertheless, RC24 expresses discomfort over the need to complain for prompt healthcare and concern for the potential system bias favouring assertive complainants. She mirrors RC30’s reflection on the privileged status of those able to voice concerns and effect change.

While RC17, RC24 and RC30 seemed satisfied with the resolution of their grievances, they were not necessarily satisfied with the resolution of the complaint. For example, RC17, in the interview, diaries and e-mail to the research team, expresses ongoing concern about whether the staff member in question who was rude to her was disciplined or addressed. It becomes evident that the complaints process, while often seen as a mechanism for justice and systemic change, frequently serves as a vehicle for problem-solving and individual care improvement. The cases reviewed above highlight this dual role. Yet, these case studies also underscore the complexity and multifaceted nature of satisfaction within the complaints process. Although the complainants saw positive changes in care, questions remained about broader systemic change and accountability.

This suggests that there are broadly two types of motivations to complain: ones directed at systemic issues (justice, change for others in the future) and ones aimed at personal care/treatment (problem-solving). The former is explicitly stated and serves to maintain the reasonable complainant identity while the latter usually stays in the background but nevertheless impacts complainants’ satisfaction.

In sum, misrepresentations and lack of clarity about the complaints process can have a significant impact on the satisfaction of complainants. This implies the necessity for clearer communication strategies and perhaps more widespread education about patients’ rights and avenues for complaint within the NHS.

The power of personal communication

The complaints process starts when the complainant calls a complaint line or submits their concerns in writing. When the complaint is lodged via telephone, the CH is the first point of contact in the journey. The primary contention for the importance of initial interaction lies in the fact that the first conversations with the complaints team significantly impact complainants, a fact supported by the substantial amount of positive feedback received about the complaints staff. Nine out of 13 participants who lodged their complaint via phone expressed appreciation for the call, either during the call itself, or in subsequent interviews.

Personal communication is generally appreciated by our participants, whose stories often report the lifeworld impact of their complaints which calls for the understanding of the background of a unique individual case:

I requested that [a meeting with the complaints team] when I first logged my complaint […]. You know I just thought that was standard because it is such a complex thing to do via email.

RC01[I]

… but somebody maybe just had a discussion about what my complaint is, and find out a bit about the person that they were talking about. I know it’s a big organisation but still, we’re all humans.

RC02[I]

In a system dominated by written correspondence, the complaints process can be perceived as a ‘cosmetic activity’, a ‘tick-box exercise’.

[H]ow can an in depth investigation take place without contact being made and an understanding of the person involved?

RC02[D]

It is just a process for them […], they are like ‘that’s great tick the box’.

RC01[I]

In contrast, in our data the overall impression about the initial calls was that the complainants’ concerns were heard, understood and taken seriously, all actions that validate the complainant’s need to be seen as ‘reasonable’. Moreover, when triangulating different data sources, it becomes noticeable that complainants tend to exaggerate the degree to which the CH sympathises with their perspective. The case of RC26, who has been waiting for a preoperative consultation for over 4 and a half years, vividly illustrates this tendency:

The words that stick in my mind from that conversation were that the lady didn’t believe how long I had waited for an actual first appointment. She said it’s a ridiculous amount of time you’ve had to wait for a first consultation with somebody, from whenever my consultant had sent the letter in. Again, I think she thought it was the system at fault rather than the consultant or the doctor.

RC26[I]

However, the transcript of the call reveals that the CH demonstrated a neutral stance, quickly moving to information gathering and closing phases of the conversation, and that the caller regularly relaunched their narrative to resist the CH’s institutional agenda. Contrary to the complainant’s recollection, the CH’s response did not strongly validate the complainant’s frustration, the only explicit recognition of the long wait time occurring at the very end of the call: ‘that’s far far ahead to see’ (see Chapter 7, Extract 38). Therefore, the complainant’s perception of the initial call appeared to amplify the level of empathy demonstrated by the CH, compared to the more institutional and objective approach taken during the actual call.

A similar pattern is noted in other cases. For example, RC21 in the telephone diary recalls the CH saying that the lack of medical supplies in the hospital was ‘unacceptable’ though the CH did not actually evaluate this. RC17 generalises the sympathetic behaviour of CHs, despite her CH also refraining from making explicit judgements:

[T]hey just say things are unacceptable and, you know, I suppose that’s what you want to hear.

RC17[I]

In addition, conversations with CHs, while being important for the overall experience of complaining, often escape complainants’ deliberate reflection. They were rarely commented on in the diaries, while other encounters, such as calls from the service, holding or response letters, warranted commentary. Participants mentioned initial calls in the interviews only after prompts from the researcher, and some had trouble recalling them (as an extreme case, RC21 did not remember that the initial complaint was lodged with a different CH from subsequent contacts). The inconspicuousness of first encounters arises from the CH’s perceived role as mere intermediary, although our study shows that CHs are fully fledged mediators119 who can modify the content/course of the complaint rather than simply passing it on.

The spoken register thus adds personalisation to the complaints process and makes the complainants feel ‘part of the investigation’ (RC02) and listened to. In contrast, lack of personal communication can lead to a feeling of alienation:

[A]t no stage was I made to feel part of the complaints procedure, other than a letter.

RC02[I]

Chapter 7 presents CA findings on the spoken encounters which reveal the mechanisms behind such positive perceptions.

Balancing formality and humanity in the complaints process

The observations and cultural predispositions revealed through cultural audit and qualitative data mirror findings from a recent study on systems for responding to concerns and complaints in healthcare,117 informed by Habermas’s systems theory. 120 According to Habermas, there are two interconnected levels of society, the lifeworld and the system. The former represents culturally transmitted and linguistically organised shared values, understandings and norms that people use in everyday interactions. The latter, on the other hand, consists of the formal institutions that operate based on a logic of efficiency, money and power. They are autonomous and abstract systems of action that follow their own instrumental logic, separate from the lifeworld.

When a person makes a complaint, their concerns are made sense of in the lifeworld, whereas the drivers for their complaint and desired outcomes are usually systemic issues. Martin et al. 117 use this distinction to explain why their participants expressed frustration with systems and processes (part of the system) which are ill-equipped to deal with lifeworld concerns of people’s everyday lives.

Our study reveals that some people feel that they had already started to express their dissatisfaction with what was going on before they reached the complaints team. This finding highlights an important distinction between complaint and care. In their narratives complainants vacillate between healthcare events leading to the complaint and the complaint process itself. If this distinction is blurred, it may mean that the complaints process is ‘invisible’ for the complainant, and all actions and communications from the healthcare service are treated as inseparable from the complaints journey.

Many participants said that they saw the beginning of their complaint at a moment in time prior to lodging it. Their discontent with the provided services, which eventually compelled them to complain, primarily stemmed from either being shuffled between various departments (RC17, RC20, RC24) or the highlighted chaotic conditions in hospital (RC17, RC29, RC30). These two themes cover almost the whole sample in the Trust B (except RC19 and RC25); therefore we cannot say that they correlate with the blurred boundary between complaint and care. What can be said though is that these factors hindered the ability of the complainants to rectify the issues within the service.

RC20 recasts the distinction between complaint and care as formal and informal complaint:

[I]t was more like an informal sort of complaint to the service and then when I took it to the complaints office that was me sort of, like almost formalising the complaint, outside of the service, because I wasn’t getting anywhere directly with the service then.

RC20[I]

RC21 says almost the same things but feels that the complaint started when it was formalised through the complaints team. The differences between these two accounts stress that, while the formal complaint might become invisible for the complainant, the ‘informal complaint’ tends to be left unattended by the service. Formalisation is a way to make the complaint ‘heard’ by the institution and a tool to have changes implemented. In terms of Habermas’s systems theory, the lifeworld and the system should coexist as systemic change is only possible on the level of formal structures and instrumental action. 120 In the words of RC26, ‘what the public need is for the system to be fixed’.

This complex interrelation between the lifeworld and the system is reflected in our participants’ attitudes to written communication, which they largely find impersonal (as RC02 notes in her interview: ‘I don’t think their complaints system is people orientated, no’). However, they sometimes recognise that the written register is more advantageous when attempting to implement and monitor changes in formal protocols of conduct of service providers.

But you see, that as a case as a learning experience, that means nothing. Really. Unless that’s put in, into part of the protocol or you know it’s put in writing. Him saying that to me doesn’t mean anything.

RC02[I]

I would like all of the assurances provided in the letter to be acted upon and monitored closely until established practice.

RC11[D]

A written register makes words durable and thus accountable for, which is also reflected in re-evaluation of how the complaint is lodged and handled.

I believe my information being relayed to the complaints department was being mis-intro-trued [sic, probably ‘misconstrued’] and maybe noted down slightly differently than what I was saying and just, yes the communication there would have been better if I had of sat down and put it all in writing.

RC21[I]

Yes, well I’ve learned now that people deny things when you talk to them on the phone so that’s why I’ve started learning to send emails because then they can’t deny it, it’s in writing.

RC32[I]

The written register, while being formal and somewhat impersonal, serves a crucial role in the complaints process. It provides a concrete, unalterable record of the complaint, ensuring accuracy and accountability which may not always be guaranteed in oral communication. However, the challenge lies in balancing this formality with the need for a person-centred approach to address and resolve the grievances effectively.

If complaining does not help the complainant to achieve results, next-level options may be considered, such as the Ombudsman, litigation or publicity. The legal path is just a more formalised option to enforce accountability, compel corrective action and ultimately seek resolution to the issues raised in the initial complaint. This escalation is evident in RC23 case study where she initially expresses dissatisfaction with the ‘informal complaint’ to the service (‘I’m fed up trying to complain to them’). This sentiment eventually broadens to the entire complaints process: in the interview the complainant reveals her intent to involve the media and hire a solicitor, feeling she can no longer manage the situation by herself.

Additional case studies also reinforce the perception that legal action is regarded as the most potent strategy for exerting influence over the system, a measure which should be invoked ‘in the right circumstances’ (RC17):

… if something has happened that is sort of negligent, you do need to go down that road [of litigation], otherwise, you know, nothing would ever change.

RC17[I]

… probably that the only way of really changing something when there is obviously gonna be costs involved, dealing with something legally. They tend to sit up and listen when something goes legal.

RC01[I]

In sum, spoken interaction is associated with an informal and thus more ‘human’ register, whereas written discourse is considered formal and thus more impersonal. Ultimately, understanding and improving the complaints journey means effectively bridging the divide between people’s lifeworld concerns and procedural formalities of the system.

In the next section, we examine how the central points of a complaint can evolve and change throughout the course of the complaints process.

Shift over time in complaint focus

When the complaint is lodged, it takes on a life of its own. The complaints journey may comprise multiple instances of communication, both with the complaint-handling staff and with service providers. Each instance forms impressions about the complaints process and expectations of what happens next. A following encounter in a sequence may (in)validate the impressions and expectations created by the previous one. During its lifespan the focus of complaint could shift, due to both the experience of the complaints process and the evolving nature of the underlying issues, alongside the complainant’s changing perceptions and expectations.

Devastating effects of unsuccessful encounters are most evident in the patterns of complainant satisfaction self-reported in their diaries.

The ‘peaks’ indicate that a successful encounter was followed by a communicative failure. If communication fails at the end of the journey, the overall experience will be negative, no matter how many instances of successful communication preceded it. In the patterns observed in Figure 6, two out of three sharp peaks are related to the contrast between impressions and expectations created before and after final response letters were received (Table 6).

FIGURE 6.

Complainant satisfaction throughout complaints journeys, based on diary entries (excluding participants who made fewer than two entries).

Our analysis of participant reactions to the written Trust responses charts how well expectations of complaining map onto their experiences. In a number of case studies, we have encountered instances of contrasting anticipations and actual experiences.

By the end of her complaints journey RC02 was already disappointed with the results of her complaint and wrote a follow-up letter clarifying the main points of complaint, including the expectation of a face-to-face meeting. The offer of a meeting was a positive moment of change for her which was subsequently completely invalidated by the Trust’s reluctance to fulfil their offer (the evaluation of satisfaction rose from 1 to 8 then fell to 0). RC10’s experience is a similar reflection that the complaint journey is often derailed at the point at which the complainant receives their final written response to the complaint. Her second diary entry reveals a marked improvement in her perception of the complaint handling, following a telephone call with the service (scored 9), but this impression was reinterpreted in a negative way after she received a written response from the Trust (scored 2). In the interview RC10 points out that the expectation created in the telephone call with the service manager made the actual receipt of the unsatisfactory written response harder to take. She says ‘I would have been happy to end it at that phone call’, suggesting that the written response has harmed the complaint process. In both cases the dissatisfaction was caused by the fact that preceding communication instances were disregarded, that is, the complaints journeys lacked connectivity.

The dynamics of complainant satisfaction may be also influenced by the evolving nature of the complaint itself. The complaint may encompass a range of concerns, and what is pressing may change over time. The initial lodging of complaints may be affected by emotions which fade away as time passes. For example, RC10 is repeatedly at pains to explain that her initial complaint was made in annoyance and therefore did not make clear what the ‘crux’ of the complaint was. In effect, the complaint appears to evolve over time. The initial e-mail complains about several things: the missed appointment and time lost as well as the consultant’s erroneous claim that she had not picked up the phone when they called. Subsequent communication from the complainant clarifies that it was the fact of being ‘blamed’ for not answering a phone call that never came that made her angry and was the ‘real reason’ for the complaint.

Similarly, RC17 focuses mainly on the rudeness of a single staff member in the initial call. The service manager who resolved the complaint via phone noted that the complainant ‘was just annoyed at the way she was spoken to and would hate to think this person would talk to other patients in the same way’ (emphasis added). In her diaries though the scope of the complaint extends beyond the rudeness. RC17 highlights poor communication, lack of information and an overall lack of interest from the staff in treating minor injuries.

In complex ongoing cases, the focus of complaint tends to shift as circumstances may change and new issues may arise. This is particularly true in long-drawn-out situations like the one faced by RC01. Her case differs from the cases reviewed above as it is the cumulative negative experiences with the complaints process which led to a sharp drop in satisfaction (7 to 2).

RC01’s complaints journey spans a 2-year period and is not fully diarised. Her initial intent to lodge a complaint was primarily to improve her mother’s care and to facilitate her transfer closer to home. However, after a lengthy wait she gained access to additional medical records, following a subject access request. The information she found there fundamentally altered the trajectory of her journey. There were contradictions within the notes, primarily revealing that the hospital had knowledge of her mother’s spinal fracture much earlier than they had communicated.

I did not expect such a complex complaint when I put it in […] did not think two years down the line we’d be talking broken back.

RC01[I]

The peak we have in our data (see Figure 6) reflects the complainant’s call with the representative of the PAS she sought help from after her first unsatisfactory experience of complaining. She reports the PAS adviser as ‘helpful and supportive’ and making ‘the task feel easier’. In the next diary entry, written after receipt of her mother’s medical records, RC01 expresses weariness with the complaints process, indicating reluctance to file another formal complaint to address additional issues due to the anticipated burden of work and a concern that the issues raised may be again ‘brushed off with excuses’. She had expected more help from the complaints-handling team and ends up seeking help from her local MP to expedite the complaint process. Reflecting on her complaints journey more generally RC01 indicates a range of examples of conflicting experiences and expectations:

I didn’t expect to have to keep looking to other external departments for help. Like I rang so many legal departments to do with health … because I couldn’t get basic help from the Trust.

RC01[I]

In this case it was the poor quality of prior experiences combined with the arduousness of the process which led to frustration.

RC03 similarly indicates conflicting expectations and experiences:

Honestly, I think I expected them to hold their hands up and say ‘look we’re sorry and this is what we will change in the future’. And I probably expected too much in that sense erm because as I’ve said it was quite the opposite. They didn’t see any wrongdoing.

RC03[I]

Here the complainant identifies a disparity between the anticipated receipt of an apology and a promise of change in response to their complaint, versus the actual defensive stance and denial of accountability expressed in the response to the complaint.

RC21’s case study exemplifies how the focal point of a complaint can evolve over the course of an ongoing case. The initial grievance was about the complainant’s child being discharged despite being in significant pain. However, subsequent follow-up calls introduced new issues concerning his child’s ongoing care, such as a lack of necessary hospital equipment, exposure to infections and a lack of beds which led to the hospital’s repeated attempt to prematurely discharge the child. Additional issues were not addressed in the response letter, which probably exacerbated dissatisfaction with the complaints journey.

The pattern described, albeit relating to only a small number of observations, showcases that both poor quality of separate interactional encounters and their insufficient connectivity may affect the experience of the complaints journey. Although it is easiest to see from the scores in the diaries, changing levels of satisfaction can also be traced discursively. For example, RC09 reports being happy with the complaints procedure, yet expresses significant dissatisfaction with the final response letter, feeling that it dismisses his concerns and unjustly attributes all blame to him for allegedly violating hospital policy. In a follow-up letter to the research team, he reflects that ‘The Patient Complaints Procedure was actually very good for me – good communication, very quick – it was just the Response that I found unfortunate’.

Since the complaints journey unfolds in time, each next instance of communication has more bearing on the entire experience and may even ‘overwrite’ the effects of a previous encounter (as in RC10: ‘I felt listened to’ → ‘she obviously did not listen’). This insight is explicitly formulated by RC29 commenting on the resolution call from the service: ‘So that was really difficult to deal with and felt, I don’t think patronising is the word, but it just felt like it devalued the positive encounters that we had up to then’ (emphasis added). In the case of RC15, the family explain in their interview that face-to-face encounters with healthcare staff were invariably positive but stalled when the stage of written communication was reached: ‘They are different to your face than they are in how they’re overall dealing with it’.

In sum, the complaints journey is a multifaceted process marked by successive instances of interaction, each having a cumulative effect on the overall satisfaction of the complainant, with one impression potentially overhauled by a succeeding instance. The quality of these interactions, their sequential coherence, and the passage of time significantly impact the perception of the process and may shift the complaint focus.

Written responses, often marking the final stage of the complaints process, have the most significance for the evaluation of the journey as they either meet or not the expectations and match the impressions formed at earlier stages. Due to their paramount importance, we analyse potential challenges involved in providing written responses in Chapter 6.

Navigating the grey area: when is a complaint really resolved?

A complainant’s (dis)satisfaction with the process is not just confined to the formal resolution of the complaint. It extends to the actualisation of pragmatic solutions to their concerns and how their individual care experience improves as a result. This problem-solving aspect can greatly influence the complainant’s overall evaluation of the complaints journey. Thus, dissatisfaction may arise from a perceived lack of concrete action taken to address the issues identified in the complaint.

This is clearly the case of RC01. Her complaints journey, driven by the desire to improve her mother’s care, was marked by a pervasive sense of frustration. She struggled to navigate the system alone, grappling with a lack of proactive support and unfulfilled expectations, including an unresolved data-protection issue and an ignored request for a meeting. RC01 had anticipated more support throughout the complaint journey, but the reality was a challenging process, described by her as ‘really hard to negotiate’. Despite a formal response to her complaint, she did not consider the matter resolved and proceeded to send a second formal complaint letter to the Trust about the inadequacy of the first response:

So I thought that was very sly and inappropriate that they sent a letter saying we are now reopening your complaint … so I know what they did was try to make this look like it was resolved. It wasn’t. It strongly wasn’t resolved. They were, they should be very clear on that.

RC01[I]

RC01’s journey underscores the importance of recognising the difference between a formal resolution and the resolution experienced by complainants. In her case, dissatisfaction arose from a lack of anticipated support and the Trust’s failure to fulfil a problem-solving function. The opposite scenario is more prevalent in our data, where the complaint leads to a problem being resolved, yet the broader issues associated with the complaint, such as the pursuit of justice and systemic change, remain unaddressed. A complaint might feel resolved at the level of personal care but may continue to remain unaddressed in the context of complainables relating to systemic issues and formal procedures. This is fairly common in Trust B, where complaints are often resolved via a telephone resolution call.

As previously touched upon, a fundamental incentive for RC17 was to rectify her personal concerns regarding the care she was receiving. Nevertheless, her motive to get justice and effect change for others went nowhere when the practical problem was solved. Throughout different data sources, the complainant conveys a persistent worry about whether the staff member complained-about was reprimanded or dealt with. In essence, RC17 seems to be less satisfied with the resolution than suggested in the telephone resolution form (TRF):

I believe the last person I spoke to asked did I consider the matter resolved, which I didn’t, but I got the impression they regarded it as resolved! I’d be interested to hear how the member of staff involved was approached about the issue, if it was recorded in her personnel file and what changes would be made, going forward.

RC17[E]

In analysing the cases of RC22 and RC30, we also see a common theme of mismatched understandings between the complainant and the institution regarding complaints resolution.

For RC22, the core complaint originated from a disjointed discharge process for his father with a cast, which left the complainant in an exhausting chase between the ED, fracture clinic and the General Practitioner (GP). Despite the Trust’s view of the complaint as resolved, the complainant did not regard the call from the service as conclusive. The TRF centred merely on the appointment with the fracture clinic, framed the issue narrowly as a ‘poor experience’ in ED and a ‘delay’ in referral, which did not fully encompass the complainant’s frustrations with ‘going round in circles banging my head off the proverbial brick walls’ (initial call) and his father’s follow-up care including physiotherapy. A notable contradiction emerges between the Trust’s perception of a closed complaint and the complainant’s ‘surprise that there’s not been some contact’ (interview) from the CH.

RC30 similarly aimed to address her father’s current health status as well as provide feedback on the accident and emergency (A&E) department. While her complaint immediately led to significant improvement in her father’s care, the absence of a formal response or apology from the Trust left her with the impression that they believed the issue to be resolved once better care was initiated:

What I get a feeling is they’re palming me off, ‘Your father was taken care of so therefore it’s fine’.

RC30[I]

However, she maintains that a formal response is desirable.

The lack of a formal response can not only leave complainants with the impression that their complaint has been neglected (with only their immediate care being addressed), but also create ambiguity about whether their complaint has been officially closed and if they should expect further communication. While RC20 expressed satisfaction with the telephone resolution provided by the service, there was ambiguity as to whether the complaint was officially closed with the complaints team. This points towards a slight disconnection, suggesting the complaints loop was not fully closed.

The complaint and care distinction further illuminates the complex dynamics in our data, where a complaint might lead to a resolved care issue, while broader systemic and justice aspects remain unaddressed. The absence of formal apology or acknowledgement, along with the lack of clarity about the official closure of the complaint, indicates the presence of loose ends. Hence, healthcare institutions should strive to ensure not only the formal resolution of complaints but also the resolution experienced by complainants, addressing their concerns at both the care and systemic levels.

Escalation of the complaint

When the complaint is closed but the complainant is dissatisfied with its resolution, they may consider pursuing it further and escalate via an external third party. The different avenues for this escalation can include the Ombudsman, independent PAS, media, politicians or legal recourse. The choice of a particular path depends on different factors, which necessitates a separate investigation. However, our study identified potential risk factors associated with escalation, which may shed light on why certain external entities are chosen for pursuing unresolved complaints.

The initial factor pertains to the problem-solving aspect of complaining. The complaints process is often seen as a last resort for individuals seeking to resolve issues and improve their or their loved one’s care. However, if it does not yield results, complainants may escalate their concerns to other institutions. The legal path is seen in this regard as a way to enforce accountability and prompt corrective actions, seeking a resolution to the issues originally addressed in the complaint.

A significant role in the escalation is played by the failure to investigate the complaint quickly and effectively. The subject of long delays in the complaints process emerges in some of our case studies:

I was like, three years down the line we still have no answers.

RC15[I]

This particularly characterises RC01’s complaint and her feelings about the process. RC01’s very lengthy waits to receive both her mother’s medical records and a formal response to her complaint (she received nine holding letters during the investigation) cause immense frustration:

I am beyond fed up with the ridiculous delay in responding to my letter with 7 closed questions which can be answered from the medical notes.

RC01[D]

The frustration is arguably compounded by repeated written apologies for the delay which never seem to alter the response rate.

Similarly, RC21 reaches a point of frustration about what he sees as the lack of progress with his complaint:

I got to the stage of so frustration that I had to contact my MP and say, ‘Look, I need you now involved, because I’m not getting anywhere with this’. […] I lodged a complaint [last year] and I’ve only just received on Saturday the response.

RC21[I]

The extensive delays to receiving a formal response have consequences with both complainants considering escalation.

[the complaints service failed] to meet their own timeframe or to communicate with me as to why. I will wait for a bit longer for the trust to make contact. If there is none, ironically, I may decide to complain about the complaints procedure.

RC12[D]

RC01 in particular is minded to ‘email them with a not very polite email stating their incompetence’ and expresses the view that the experience has made her ‘more determined’ and that she has become ‘hell-bent on making them pay’ [RC01(I)]. She elsewhere states her intention to go to the Ombudsman ‘in time’ [RC01(D)] and to ‘go legal’ [RC01(I)].

In her interview, RC01 also expresses the perception that the Trust’s efforts were focused on ‘batting away complaint’ and ‘sweeping under carpet’ rather than diligently attending to the detail and focus of the complaint. She construes these delays as an avoidance strategy:

… feel they don’t care and are hoping I will just give up.

RC01[I]

This is a view shared by RC21 and RC12:

but the two letters were just biding time.

RC21[I]

I would like assurance that they are investigating and not just waiting for me to forget about it.

RC12[D]

RC01 and RC23 (who are also considering escalation) both comment on the contradiction between assurances offered in holding/response letters that the complaint is being treated seriously and lack of any response (hence a perception of insincere communication):

I don’t believe they are looking at the complaint, just kicking the can down the road.

RC01[D]

The attitude to their [previous complaint response] apology was disgusting. If the doctor didn’t do anything wrong, then why did he have to take six months to reflect on what happened?

RC23[I]

Another consequence of the delays and subsequent frustration is the profound cynicism that develops, with many references to ‘no faith’ or ‘zero confidence’ in the complaint process. 121 More work is arguably necessary to reassure complainants when there are repeated delays, but complainants are cynical about expressions of sincerity and commitment as they are perceived to simply ward off any potential inference that the delay may be due to a lack of concern.

Another driver of escalation is the lack of acknowledgement of lifeworld impact. It implies that the complaints process should encompass the wider context of the complainants’ lives instead of concentrating solely on specific points of complaint. This need is most pronounced in serious complaints. In the case of RC02, the failure of the Trust to adequately acknowledge the lifeworld impact in her sister’s care was a prominent factor leading to dissatisfaction. Her sister’s undetected fractured hip, which probably resulted in an inability to walk and rapid deterioration of health, were the focus of the complaint. Despite two formal responses from the Trust, RC02 expressed disappointment with the replies – because they did not acknowledge the sister’s brain damage and dementia (first letter) and her human dignity (second letter). Despite RC02’s dissatisfaction, in the interview she expresses the decision to not proceed with the Ombudsman. However, she plans to pursue a copy of the protocol for treating patients in her sister’s condition, in hope of reopening the complaint, indicating that the acknowledgement of the full context of her sister’s condition and its impact on her quality of life was a crucial missing element in the resolution process:

Nobody has acknowledged the life that they’ve taken away from her, the life they’ve given her now.

RC02[I]

The case of RC02 exemplifies an internal escalation when the complainant seeks to resolve their grievances within the complaints process. In contrast, RC15’s case is emblematic of a situation where the complaints process fails to adequately address the issue at hand, prompting the family to consider more drastic measures such as litigation. The complaint pertains to the hospital’s treatment of the complainant’s mother. The family alleges that the failure to initially consider her alcoholism, which led to a rapid increase in her sodium levels, caused her brain damage. Frustration over the Trust’s lack of acknowledgement of their distress and the current state of the complainant’s mother has deepened the family’s dissatisfaction with the complaints process and led them to consider legal recourse. The interview indicates the family’s feeling of being disregarded and a sentiment that drives the escalation to litigation:

They’re just not acknowledging what we’ve went through and how my mammy is.

RC15[I]

The next risk factor of escalation is the lack of comprehension of the essence of the complaint or acknowledgement of complainant’s reasoning. When the complaint is lodged via telephone, the CH takes on a role of the interpreter who can reformulate the complaint but also has a chance to clarify any ambiguities during the conversation. In contrast, when the complainant puts their issues, concerns or grievances in writing, they have more control over the narrative they present. This written record leaves less room for immediate misinterpretation as it is directly from the complainant’s perspective. However, without the interactive dialogue characteristic of a phone call, there is less opportunity for immediate clarification of misunderstood elements.

In our data, problems with comprehension were more common in written complaints, the reaction to which is exemplified in the following quotes:

not taking into consideration my grievances and missing the objection of the complaint all together.

RC02[D]

Letter outlined reason for the decision made, with no real resolution or new information. It did not address the root cause of my complaint.

RC12[D]

RC02 and RC12 pursued different forms of escalation: RC02 decided to stay within the complaints process, while RC12 arranged the meeting with the Head of Service (suggested in the response letter) and extended it to other service users.

Incomprehension may also be construed as an avoidance strategy to not engage properly with the substance of the complaint. This relates to a perceived contrast between a thorough and substantial investigation and a superficial ‘tick-box’ exercise:

Their response and the procedure to investigate the complaint was a cosmetic activity. The complaint was only superficially read which resulted in my concerns and worries to be disregarded.

RC20[D]

The comprehension of the complaint is closely linked with acknowledging complainants’ reasoning. Misunderstandings may challenge the latter, creating contradictions between complainant and Trust accounts. This conflict is never well received. It can explain the extremely negative reactions of RC03, RC09 and RC10 to the final response letters.

RC03 describes how the response to her complaint was used to dispute the grounds of the complaint and to argue that the complainant had misremembered or was distorting the situation in the hospital. The lack of acknowledgement of the traumatic experience endured by RC03 as well as a lack of accountability ultimately motivates her to seek complaint resolution through the Ombudsman. In RC09’s case, the complainant felt that his complaint about being treated rudely and unfairly by a hospital staff member was overlooked, with the Trust’s response letter placing all the fault with him for acting against hospital policy. Similarly, RC10’s complaint was primarily about the false claim that she had failed to answer the call leading to a missed appointment. The Trust, however, focused its resolution letter on the delay of her appointment, failing to address her chief issue. In all three instances, the complainants perceived that their reasoning was undermined, which created a significant disconnection between their experiences and the Trust’s responses.

Shaken reasoning can contribute to a pessimistic perspective towards the complaints process. In her interview, RC03 for instance says ‘I felt angry with outcome but also expected it’, concluding that the complaint has been a ‘waste of time’. RC02 in a diary entry expresses her ‘disappointment and anger’ that her ‘fears’ around making the complaint have come true. RC10 also reveals a retrospective expectation that the outcome would be disappointing:

[It was] frustrating and it was long and it was ultimately unsatisfactory so it was exactly what I – what I imagined it to be.

RC10[I]

Negative outcomes are often presented as a predisposition to be cynical in advance of the process but it is clear that the experience of the complaint journey itself generates this cynicism since there is an underlying hope for change and improvement:

See I was hoping, even that I would maybe meet somebody with vision and would look at my, look at my complaint and think, ‘God, you know, if we don’t have these, if we don’t have these protocols set in place, right, they have highlighted something to us. We will look at that’.

RC02[I]

As time’s gone on I have become more cynical […] I kind of think it wasn’t a waste of effort because I did feel strongly about it at the time.

RC11[I]

This tendency to present negative outcomes as predispositions sheds new light on the results of the cultural audit, which revealed cultural predispositions as a background for complaining (see Chapter 4). Understanding the complaints process as a journey adds a temporal dimension to it, showing that people navigate cultural landscapes in their evaluations of relational practices and may transition, for example, from egalitarianism to fatalism in their views on service relationships. This conceptualisation therefore allows us to show exactly how culture is constituted through interactions.

The retroactive trajectory of expectations works for supporting reasonable complainant identity: negative outcomes redefine positive expectations as naïve, and people renounce them to construct themselves as knowledgeable:

Realistically I knew what I wanted I wasn’t gonna get because I know how it works. (emphasis added)

RC10[I]

For some complainants, cynicism regarding the complaints process could lead to apathy:

Realistically I knew I was never gonna get that I don’t even know why I bothered it certainly wouldn’t lead me to complain again.

RC10[I]

I have become a little bit apathetic I suppose and cynical erm about further correspondence on the matter at all […] I have never made a complaint before about any medical treatment I’ve received and this experience – following this I shall never make another one.

RC11[I]

Others, despite disappointment and disillusionment, remain resilient and believe in the necessity of their actions. Thus, cynicism could not only fuel the willingness to escalate, but also contribute to the selection of escalation routes. In RC23 we see the complainant excluding the option to go to the Ombudsman just because the letter from the complaints department advises it:

Well, [the response letter] said about speaking to the Ombudsman but I’m going to the papers and I’m getting a solicitor because I can’t do it anymore.

RC23[I]

Like the proverbial King Midas, for RC23 the complaints process spoils everything that it touches.

Reasonable complainant identity can also influence the choice of escalation route. Because of the awareness of the extreme resource challenges faced by the NHS, it is common for complainants to state explicitly that complaining is not motivated by desire to gain financially. This often deters complainants from escalating to litigation:

No, no, my goodness, they’re under enough pressure, the health service.

RC16[I]

I don’t want money from them. I just want the help and support that I’m supposed to get.

RC23[I]

Money would never pay me for what they’ve taken away from me. And it was never about money.

RC02[I]

While negative experiences may dampen complainants’ optimism, they are also instrumental in shaping their decisions on the escalation route. A strong sense of reasonableness and awareness of the constraints faced by the healthcare system may steer complainants away from financially motivated escalation, such as litigation. Nevertheless, we cannot say if this conviction transfers beyond narratives into action.

In conclusion, our exploration into the reasons for escalated complaints underscores the fundamental importance of person-centredness in the complaints process. While external escalation pathways exist and can be pursued, the goal is to address complaints at their origin effectively and efficiently. Delays and the perceived avoidance of accountability can prompt complainants to escalate their concerns further. A greater focus on the lived experiences of complainants can also significantly improve the perceived legitimacy and efficacy of this process. Equally important is the need for a clear comprehension of the essence of the complaint and the complainant’s reasoning (which does not mean agreeing with the complainant’s perspective). Misinterpretations or a lack of comprehension can shake the complainant’s trust in the system, leading to a negative outlook and potential escalation of the complaint.

Defensiveness of Trust/lack of accountability as a barrier to successfully resolving a complaint

A recurring theme in our participants’ view of the Trust’s written response was that it ultimately evaded or at least mitigated responsibility for the poor experience or poor healthcare.

I think they’re trying to cover up everything that happened. That’s the feeling we get, that they want to cover it up. They don’t want to admit that they’ve done wrong.

RC15[I]

The source of this perception of defensiveness can be identified in the response letters, which adopt a number of strategies to avoid admission of direct responsibility for the complainable – for example, locating responsibility for the events with other actors (including the patients themselves), appealing to factors such as healthcare workers’ ‘experience’, ‘professionalism’ and ‘good intentions’ as well as referring to ‘exceptionality’ in order to avoid or mitigate blame. Sometimes the wording of a complaint response is designed to subtly evade accountability for errors. In the case of RC01, a fracture belatedly detected on an X-ray (following routine review of historic X-ray data) leads to the request for a renewed X-ray, but the mistake is vaguely framed without any overt agent as ‘after the report of L1 was available’, thus obfuscating responsibility for the error. A similar example of obfuscation can be seen in the second response to RC15, ‘the Clinical Biochemist has no record that he was informed of a significant alcohol consumption history’ – a vague and agentless formulation that is speculated about at length in conversations between the family and PAS advisor.

There are some (relatively rare) examples of transparent accountability in our corpus of written responses which admit responsibility for mistakes and explain what should have happened.

Dr Gow adds that if Dr Martin had correctly identified and recorded your son’s blood results this would have had an impact on his formulation of his management plan. He would have sought a second opinion as to the appropriateness of discharge and possible escalation of treatment.

IW01[W]

However, responses that evade or mitigate culpability are more common. For instance, RC10, complaining about a call that a consultant failed to make, focuses on the implication in the response letter that the blame is being shifted to herself.

My main reason for the complaint was the consultant, via his secretary, said he had tried to contact me and couldn’t get me suggesting that it was my fault the appointment did not happen.

RC10[D]

In her interview she reiterates the impression that ‘all these excuses’ have been offered in lieu of a proper apology and that this is ‘bordering on defensive’. Similarly, in the response letter sent to RC02, the trust shifts blame for the complainant’s sister’s fracture remaining undetected to the sister herself: ‘your sister denied having any limb or pelvic pain’, thus implicitly blaming her sister for misleading staff about her pain. This phrasing is explicitly picked up by RC02 in one of her diary entries:

The complaint response refers to my sister having DENIED having any limb or pelvic pain, I find this UNBELIEVABLE. This has little to do with her being reluctant but more to do with her state of mind and brain injury with dementia and old age combined.

RC02[D]

At a later point in this response letter the Trust states that ‘this team is very experienced in managing patients with mobility issues and would have intervened if they suspected any hip injury at this time’. By mentioning the medical delivery team’s ‘experience’ here, an appeal is made to their good intentions, but it also implicitly suggests the injury was not present at this time. The phrase ‘would have intervened’ is epistemically certain and thus casts doubt on the complainants’ view of events. However, the fact that the fracture was later detected and deemed to have most likely dated from this admission presumably means that this handling of the situation needed to be questioned, not just defended. When asked by the interviewer whether RC02 felt that the Trust ever ‘acknowledged or accepted responsibility for what went wrong’, she replies, ‘no no they didn’t. Not when I look at the letters, no’.

In RC01’s case, the mention of good intentions is designed to mitigate the error committed by the doctor.

Dr Crossland believes that the doctor who made the decision to transfer was doing it with the best of intentions but had unfortunately overlooked the statement made in the notes that your mother was unsuitable for surgery.

RC01[W]

Similarly, complaint responses often refer to lack of intentionality as a way of mitigating blame.

[S]taff did not mean to cause any further distress to you at an already distressing time […] It was not Sister Murphy’s intention to cause any upset or distress at the time of this interaction […] I do hope you will be reassured that it was certainly not the intention of any of the staff involved in your care to add to your distress.

RC03[W]

These formulations of lack of intentionality arguably add to an impression that the complainant’s version of events differs from reality and contribute to the sense that their lived experience is being undermined (see Presentation of ‘alternative’ or contradicting narratives of staff).

Blame mitigation is also achieved by appealing to standard practice and what is normally done in such circumstances. 121 In the case of RC01, whose mother had a lengthy stay in hospital during which it was discovered she had sustained a lumbar fracture, RC01 expressed concerns that her mother’s injury may have been made worse by being manoeuvred by staff without knowledge of this fracture and was told that ‘Dr Crossland advised that immobilisation is not standard practice in vertebral fractures’. Moreover, the admission by the Trust that the spinal fracture was missed on an X-ray is mitigated by the information that ‘an abdominal X-ray is not a standard view to look for lumbar spine fractures’. Similarly, the letter states that the decision to transfer the complainant’s mother to another hospital (against the family’s wishes) was due to the spinal surgeon’s wish to assess her and that ‘staff would normally defer to them’. Similarly, in RC21’s response letter the Trust appeals to ‘standard practice’ (‘seeking tertiary opinions from specialist teams in such circumstances would be standard practice’), thus subtly undermining RC21’s account that the doctor had admitted being unable to diagnose his daughter’s condition.

Sometimes fault is implicitly acknowledged but mitigated by reference to challenging circumstances.

Dr Jones recognises that patients who are re-attending because of advice received from the ED should be prioritised for reassessment. We do aim to do this wherever possible, but it can be difficult when the ED is under pressure.

IW03[W]

Here the formulation suggests an ideal procedure (‘should be’) from which the service is exempt when mitigating circumstances arise. Similarly, RC10’s missed phone consultation is explained with reference to ‘unforeseen circumstances’.

Blame evasion can be highly consequential to a complainant’s evaluation of how the complaint has been handled, especially in highly distressing or stressful complaints where it is seen to compromise the Trust’s empathy for the patient and their loved ones. In response to RC03’s complaint (detailing the responses and attitudes of allegedly unsympathetic and unhelpful staff while she was suffering a miscarriage in A&E), the Trust reports, ‘I am unable to identify who this may be and therefore unable further investigate or to comment’. By prioritising a formulation designed to avoid admissions of fault, this becomes a missed opportunity to express regret for the patient’s traumatic experience. RC03 comments on her perception of this stance in her interview, stating that there was ‘no admission of any fault’ and ‘if they’re not going to take responsibility for what happened, how is it going to change for anyone else?’; she goes on to comment cynically that ‘they stick together and look out for each other … remembering events in a way that suits them’. In one of our most complex and lengthy longitudinal cases, involving a very young baby, the response from the Trust contains only one apology: for the delay in responding. The response is otherwise a point-by-point refutation of each element of RC21’s complaint, and while it is possible that the Trust’s response is entirely factually accurate, the absence of any acknowledgement of the complainant’s feelings, perceptions, experiences or the ‘reasonableness’ of his complaint seems likely to exacerbate his sense of grievance and his fatalist view that complaining has been ‘pointless’.

Occasionally this perspective is aligned with the assumption that the relevant Trust is concerned more about legal ramifications than attempting to understand what lies behind the complaint, and this is clearly picked up on by our longitudinal participants. RC01 for instance describes the response letter as demonstrating ‘no accountability for what had gone wrong’. She expresses the view that the Trust should not spend so much time and energy defending their position/avoiding culpability; that she would prefer more admission of culpability and less defensive promotion of ‘here’s what we did right’. Interestingly this is a view shared by staff at the PAS who have been supporting RC01: ‘from my experience of dealing with trust in these complaints y-y- they’re they’re- y’know they don’t want to hold their hands up and admit things’. This perception is shared by other longitudinal participants. RC15, for instance, states, ‘I think they’re trying to cover up everything that happened’ and ‘we feel they just don’t want to admit that they’ve made a mistake’. RC11 similarly comments in her interview that ‘when it was investigated lots of excuses were made’ and when asked by the interviewer if she felt excuses were made says:

[I]sn’t that everybody’s response ((laugh)) to not taking responsibility … try to come up with excuses rather than putting their hands up and saying mea culpa my fault and I’ll have to do something, I have to do more work on this.

Sometimes complainants comment explicitly on their perception that this is linked to fear of legal redress.

[T]hey’re obviously very worried about litigation et cetera erm but – with regards to complaints sometimes the best thing to do in my opinion is just to own up and say ‘we’re wrong, we shouldn’t, we didn’t and we don’t but in the future we’re going to try to do that better’ and that’s all that’s needed as far as I was concerned erm was a genuine – like authentic response.

RC11[I]

RC15’s family comments that for them closure could be achieved if the Trust acknowledged responsibility for what happened to their mother: ‘we will feel better about the whole situation. We’d feel that they’ve took responsibility for what they’ve done’.

The need sometimes exhibited in Trust responses to defend their practices against possible charges of negligence, errors or incompetence arguably takes precedence over the need to make complainants feel ‘listened to’, empathised with, respected and that their complaints are ‘reasonable’ and worth making.

Lack of sincere apology

Apologies are an important component of complaint response letters, especially where blame, error or harm is being acknowledged. Guidance on apologies from the Scottish Public Services Ombudsman (SPSO) reinforces the legislative point that apologies are not an admission of liability and busts the myth that when an organisation issues an apology it is more likely to lead to litigation: ‘Research into the impact of apologies consistently shows that a well-made, timely apology diminishes people’s wish for compensation’. 3,123 Given the clear value of an apology in the context of responding to a complaint, why do we find that so many of our complainants remain dissatisfied following receipt of an apology?

A common theme in complainants’ responses to complaint resolution letters is the sense that the apology was not ‘proper’ or ‘sincere’ (‘an insincere story about the delay’; ‘she kinda brushed over sorry for the delay’; ‘if someone had come on the phone initially with a sincere apology explaining … I would not have complained in the first place’). Since an apology (at the very least for a delay in providing a final response) seems to be an obligatory element of complaint response letters, it is worth analysing why these apologies are seen to be inadequate.

The impression of ‘insincerity’ is likely to be connected to the way in which apologies are worded. In a previous analysis of written responses to complaints122 it was noted that apologies tended to be mitigated by treating complainants’ accounts as subjective and by providing explanations for substandard experiences of care that appealed to unintentionality or exceptionality (see also above). The analysis also noted the common appearance of what has sometimes been described as the ‘fauxpology’ or ‘politician’s apology’ (e.g. ‘I’m sorry you feel that …’) which ‘imputes the cause of distress to the subjective (and possibly misguided) impressions of the complainant’. 122 In this way the complaint responses avoid admission of accountability for the complainable action by ‘implying that the complainants’ feelings do not align with the facts’122 or seeming to ‘question whether the person has actually suffered’. 123 This phenomenon was repeatedly noted in our own data and was also explicitly picked up on by participants in interviews and diary entries. In a written response to RC01’s complaint, the letter states that ‘Sister Morgan would like to sincerely apologise that you felt your mother was treated in a “derogatory” manner’. Here the writer effectively apologises for the subjective and possibly incorrect impression experienced by the complainant (‘that you felt that’), thus rendering the apology insincere. The use of scare quotes for ‘derogatory’ implies distance from the evaluation, mitigating the authority of account and distancing itself from its veracity. Similarly, RC02’s letter states that ‘Dr Dryden is sorry that you and your family were upset about the lack of communication’. In this way, the lack of communication is mediated through the feelings of the family. The letter provides another mitigated apology for the complainant’s sister’s experience using low modality: ‘I wish to support Dr Dryden in making this apology to your sister for the distress she may have suffered as a result of these matters’ (emphasis added). An apology where there is no admission of responsibility, or even an attempt to investigate the cause/timing of the injury the complainant’s sister has sustained more thoroughly, is inadequate and possibly worse than no apology at all.

Interestingly, there is evidence that complaints managers compiling response letters are aware of the nuances of these linguistic choices. In a memo from the doctor asked to respond as part of the investigation into RC03’s complaint, he says: ‘In summary I would like to extend my apologies to Miss Whitehead regarding her experience in the Emergency Department […]. I recognise that this fell below your expectations and has caused distress’. Here the emphasis is on the subjective perception of the patient, ‘your expectations’, which could cast doubt on its objectivity. By contrast, the version that is actually sent to the patient has amended the wording: ‘Dr Carradale is sorry that your experience in the ED … fell below the standard of care that would be expected and for the distress this caused’. Though a subtle change, the amended version suggests that this is a more objective standard of care that would be expected by anyone.

Written responses do often contain direct, unmitigated and ‘model’ forms of apology.

Dr Martin deeply regrets that there appears to have been an error in this case and wishes to advise that he has learned from this and will reflect on this case in the future.

IW01[W]

On behalf of [the Trust] I wish to support Dr Crossland, Dr Richards and Mrs Morgan in making this apology to you for the distress you have suffered.

RC01[W]

The distress in the latter example is presented as a matter of fact rather than linked to the subjective view of the complainant. It is therefore interesting that the perspective of the longitudinal participant about this response remains negative overall and she still seems to feel that the response and apology is inadequate. One reason may be that the potentially ‘good work’ achieved by sincere apologies is often ‘cancelled out’ by what co-occurs with it. For instance, RC03’s response letter contains the following model apology and efforts at redress (invitation to a meeting) ‘he does acknowledge the distress you have suffered and would therefore like to offer you the opportunity to meet with him’. Unfortunately, this is preceded by ‘On review, whilst Dr Carradale … feels the issues raised in your original complaint have been adequately responded to’. Here the insistence that there is nothing to apologise for does nothing to make the offer of a meeting attractive. In RC09’s complaint (about an ‘aggressive and rude’ doorman) the offer of a ‘sincere apology to you for the experience you encountered’ is arguably undermined by the subsequent text explaining that the complainant was entirely in the wrong for failing to observe hospital health and safety measures around food and COVID. The complainant comments on this in his diary following the response: ‘He basically was more concerned that I was bringing outside food (Takeaway) than how rude and aggressive the Porter was to me’. Similarly, the response to RC11’s complaint ideally states ‘we can only sincerely apologise for the experience that you had’ but this is prefaced by the qualification that ‘all concerns raised appear to be environmental’, suggesting that they were not necessarily linked to staff actions. Such formulations arguably detract from the sense of the trust being accountable for failings or poor healthcare experiences and contribute to RC11’s sense of dissatisfaction with the response.

A detailed and full apology may also seem to be eclipsed or undermined by accompanying ‘excuses’. This can be seen in RC10’s complaint about a call by a consultant that never happened. The letter begins by saying ‘he would like to offer his sincere apologies for the inconvenience caused’ but then proceeds to offer a long and slightly convoluted list of events that led to this omission.

[M]aking excuses in a letter of apology doesn’t make a full apolo- it feels like you’re saying ‘sorry but’ so just say sorry without giving two paragraphs of ….

RC10[I]

A number of our other participants also raise the juxtaposition of apology with excuse: ‘Had hoped for an apology that wasn’t followed by “but”’; ‘it was at least one paragraph anyway of excuses it (tended) to detract from the apology if I’m honest’. Even where a written apology seems to be full and sincere, the appearance of lengthy ‘excuses’ seems to detract from its positive effects. This is an interesting finding that potentially contradicts other research pointing to the value of providing ‘reasons’ to accompany an apology. 123

The following apologies are offered in the response sent to RC03:

Dr Carradale wishes to reiterate his apologies to you for the distress caused to you at an already stressful time […] Ms Murphy [nurse] acknowledges the distress you were in during this time and would like to reiterate her apology that your experience was not made more comfortable with a visible amount of compassion and empathy.

RC03[W]

However, RC03 remains deeply unhappy with the response overall and signals her intention to take her complaint up with the Ombudsman. The letter contains a number of accounts of the events reported by the complainant which contradict her own account and thus cast doubt on her integrity (see also Presentation of ‘alternative’ or contradicting narratives of staff). One can only assume then that these sincere apologies are compromised/cancelled out by other elements of the letter that are defensive and fail to admit fault or accountability. This pattern is also referred to by RC23, describing a previous written response she received and which she remains deeply dissatisfied about:

It took them six months to get back to me and then the fact it says, ‘The doctor has had time to reflect, and he apologises blah blah blah’, and then in the next page it was like, ‘This was correctly done, and this was correctly done’. No, it wasn’t.

RC23[I]

She goes on to describe the response as ‘a half-assed apology. They apologise and then in the next breath they are saying, “This was in order and that was in order”’.

The problem with inadequate, insincere or incorrectly focused apologies was also an observation of the Independent Inquiry mentioned above. The findings point to an institutional preference for apology over a clear analysis of events and admission of accountability where relevant.

Medical jargon

The use of complex terms and a medical and specialised register in written communication is a theme that emerged in some of our case studies. Written responses tend to be constructed using medicalised language and descriptions of conditions which non-specialists may have difficulties understanding.

The urinalysis at this stage showed ketones ++, + blood, + protein, leucocytes ++ and this time nitrates were positive.

IW01[W]

[S]he had a water-soluble contrast enema […]. This revealed a normal recto-sigmoid ratio […] the subsequent results were normal which helped to exclude Hirschsprung’s disease.

RC21[W]

Longitudinal participants comment on the confusing effects of this use of language and the work it creates for them to understand the significance of the terms used.

[W]e found like anything we’ve asked has been avoided then answered in terms that we don’t understand […] all medical, like we don’t understand it at all. I know that we couldn’t understand anything that it meant, so we went back and asked for it in simpler terms.

RC15[I]

The same family reported having to do the work of research themselves to make sense of the communication in written responses.

Aye, it’s like us, as a family, are trying to work it out ourselves, you know, because they’re not explaining it to us properly. And we’re not medically trained. We don’t know what’s what, but you’re just doing a lot of research yourself.

RC15[I]

RC01 also reported finding the written response letter to her complaint about her mother’s care to be ‘longwinded … not really answering anything’. She also finds the volume of her mother’s requested medical records to be overwhelming and intimidating (‘I’m a bit overloaded with all the notes. Hard to understand them’) and expresses the wish that they would be ‘easily understandable, legible and detailed’. She contrasts her encounters with the Trust’s communications with those of the contact at the PAS (who helped her to work through the medical records): ‘He talks normally and makes the task feel easier’. In recorded calls and meetings with the PAS they discuss the use of ‘medical language’ and ‘shorthand terminology’ that excludes the non-expert, and express appreciation of the more ‘plain English’ communications they have received. There are also numerous self-identifying references by the PAS officer to himself as a ‘layman’, ‘not a medical person’, which presents a deliberate contrast to the obscure and medical register of the Trusts.

Another consequence of the use of a medicalised register is that it can detract from the empathy that is needed particularly in cases involving trauma and suffering. RC21’s description of his baby daughter’s pain (‘she was screaming in pain … her whole body was going into spasms … her body was fitting because she was in pain … uncontrollable fits where her knees were swinging about’) is in stark contrast to the more formal and medical register used by the Trust to respond to his complaint and which conveys a kind of downplaying or restraint around the description of the baby’s condition: ‘increased work of breathing … reduced feeding … very unsettled with a high-pitched cry … at times distressed and irritable … any discomfort’. The use of this kind of professional register therefore risks undermining the account provided by the complainant.

Responses which summarise medical care rather than addressing substance of complaint

A common formula adopted by complaint response letters is to methodically detail the stages of care given to the patient/complainant. Often this involves repeating or ‘confirming’ (in more formal, medicalised language) the series of events or treatment already set out by the complainant in their original written complaint and usually comprises the majority of the response. This seems to be a component of the formula prescribed by Trust A, as all their written responses involved a detailed case history of the patient’s care, but it is not part of Trust B’s letter template. This strategy is, however, perceived to be an irrelevance and distraction by complainants:

[…] it was just literally a summary of why she was in hospital and what infection she had. It was a summary of her medical care and I was just like, that’s not what we asked about, so I was very deflated with that […] I cannot believe it has taken 9 months for a 3 page letter to be issued which merely documents my mother’s stay and a high level overview of her care.

RC01[I]

Participant RC03 also comments on this tendency to focus on irrelevant details of care. In the written response she received, the assessment, diagnosis and speed of referral was reiterated and deemed satisfactory (‘I therefore have no concerns regarding the clinical assessment and management made by the doctor at that time’) yet the focus of the complaint was about the attitudes of staff and neglect of her dignity while experiencing a miscarriage while waiting in A&E. In her written response to this, RC03 stresses that the focus is incorrect:

I’m not sure why Ward 21 were brought into this as I had no issues whatsoever once I was handed over to them. The team were fantastic and done everything they could for me. I also had no complaint about having to return to ED as the team were in theatre, that couldn’t be helped.

RC03[RP]

Similarly, in her interview she says, ‘it was a lot of information in the response that I received that was totally irrelevant to my complaint’.

This pattern of spending some time narrating the details of the patient’s care is observed across written responses from both Trusts; in part it seems motivated by desire to show proper healthcare procedures have been observed and could be seen to impart a slightly defensive tone. Significantly, this kind of practice was criticised in the Independent Inquiry report.

Presentation of ‘alternative’ or contradicting narratives of staff

A significant source of dissatisfaction with complaint response letters is the tendency to present alternative narratives to the complainants’ version of events, provided by responses from relevant staff gathered by the investigating officer. 124 Where these narratives contradict those of the complainant they are seen to undermine the complainant’s lived experience and the basis and legitimacy of their complaint and cast doubt on their integrity/truthfulness. While it is obviously sometimes necessary for a complaint response to refute factual inaccuracies in a complaint, this becomes more problematic where the experience is a subjective one involving perspectives on staff attitudes and behaviour for instance.

This is particularly apparent in the case of RC03. In her post-complaint interview she commented that she felt that the response suggested that the grounds for her complaint were dismissed due to the seeking out of accounts which contradicted her experience.

[T]hey said ‘that didn’t happen’. Implied I was lying or too emotionally distressed to realise what was happening. But that wasn’t the case.

RC03[I]

We can see how the letter may have contributed to this impression:

The staff member that has been mentioned does not recall sending you back to the waiting room, and has stated that, when she noticed you were requiring help, she spoke with a staff nurse to arrange a cubicle space, which she then brought you into.

RC03[W]

The letter also makes reference to the possibility of misinterpretation:

Mrs Murphy recognises that this communication may have been misinterpreted as the staff member has intended this to be communicated in a compassionate way and apologises to you sincerely for any hurt caused.

RC03[W]

Despite the inclusion of a ‘sincere’ apology here, the effects are arguably cancelled out by these references to an exonerating lack of intent and misinterpretation on the part of the complainant, and the complainant’s overwhelming impression is that her truthfulness is being brought into question:121

I wouldn’t have gone to the bother of complaining if it hadn’t all been true – wouldn’t just make things up.

RC03[I]

The patient’s reply to this written response (in which she expresses dissatisfaction with the outcome) is dominated by her sense of grievance that her account of what she experienced is being denied and contradicted and leads to a doubling down on her own version of events:

Dr is recalling that night incorrect […]. As for the auxiliary nurses recollection of events, again that is completely incorrect. She called me in for bloods and said quite loudly ‘do you know you’re covered in blood, you’d need to get someone to bring you a change of clothes’ […]. Not once was I offered a gown or anything for that matter to cover myself […]. If what the members of staff are saying were true then there would have been no complaint made or any issues. If given half the chance to preserve my dignity do you not think I would have taken it with both hands? I remember every detail of that night very clearly, it’s a night that will stay with me for the rest of my life.

RC03[DP]

She ends her letter with an expression of intent to escalate her complaint to the Ombudsman’s office: ‘The fact both members of staff are making out I’m lying is just an added insult. I will be forwarding the complaint to the ombudsman’. Finally, her sense of dismay and frustration around the questioning of the veracity of her account leads her to resort to including visual evidence of the events – a kind of counter-empirical evidence to the testimonies provided by the Trust: ‘I have attached pictures to this email of just how I was left in the waiting room’.

A similar pattern of response can be seen in the letter provided to RC21 after a long, complex and protracted complaint about his baby daughter’s care. The written response takes RC21’s issues in turn and refutes or corrects some of his assumptions:

As such, our teams would not be in agreement with your statement that the GI consultant was the first person to do further tests […]. It is generally accepted that Paracetamol and Ibuprofen are not classed as sedative agents.

RC21[W]

It also ‘recasts’ some of the complainant’s perspectives about the team being unable to diagnose his daughter’s condition:

to the best of his knowledge, Dr Li does not feel that he stated that he thought he had missed something.

RC21[W]

The response also points to contradictions between the complainant’s view that his daughter was too sick to be discharged, and his partner’s express wishes that she take the child home. There is some mitigation here with ‘regrets that your opinions had not been communicated to him’, though this could also imply the complainant was not clear. It also refutes the complainant’s perception about the results of a scan, though it does mitigate this with an apology for the possibility that this confusion arose from poor communication: ‘I apologise if this was the case or if there was any misunderstanding in what you were advised, as this is also incorrect’. While it is reasonable for the Trust response to refute points of fact that can be shown to be inaccurate, it seems unfortunate that there is no acknowledgement in the response that any of the complainant’s concerns (especially around his child’s suffering) had any substance to them. The only real apology (and agreement with the complainant) relates to the delay in providing a response.

There is also little acknowledgement of the family’s stressful experience and the pain experienced by the child – rather, the condition and experience is ‘normalised’; ‘in pain’ is recast as ‘distressed and irritable’ and the conclusion of the medical team is that there is nothing really wrong with his child: ‘am pleased to learn and hope that it was some reassurance to you, that GOSH explained that they did not find anything unusual with all the tests they carried out’. There is a stark contrast between this written response and the highly empathic response provided by the front-line call handler in our recording of the initial complaint call. The written complaint response overall is deemed to have addressed all the complainant’s concerns and considers the case ‘closed’. However, in his follow-up interview with the project team, RC21 expresses dissatisfaction with this response and notes its defensive approach. He goes on to comment on his negative view of the whole process as well as his consideration of escalating the complaint.

Well, as I say yes they’ve apologised on one or two points, but I feel like it’s just much covering their tracks and then saying there is nothing more we could have done, like we done everything in our power and so I think to me it was just very much excuses, in a point they actually said that it was my partner’s my fault that it was the mum’s fault […]. Nothing has been addressed. No. I don’t feel anything has come out of it, as I said, you know, the whole process has been a complete waste of time and it’s now in my hands whether, as you say, I want to pursue it and go on to the next level and get somebody else to reinvestigate it.

RC21[I]

This semi-judicial approach to investigation where staff (especially named in a complaint) have a ‘right to reply’ tends to produce responses which are defensive in tone, and are seen to undermine the veracity of the complaint and by extension question the reasonableness and integrity of the complainant. One obvious drawback with this approach (which is ostensibly about fairness and right to reply) is that the version provided by the Trust (through questioning relevant employees) ends up being the definitive one, impossible to question or cross examine as would be the case in the more dialogic context of an actual judicial review. This was also noted by van Dael et al. :

It … positions the provider and patient perspectives as antagonistic, with any inconsistency leading to the dismissal of one account, rather than seeking to understand and explore dissonance and realising its potential to reveal institutional blind spots or failures in communication. 124

Pursuit of the caller’s needs

Meeting the caller’s need to be listened to requires CHs to provide responses that recognise where and how callers’ turns convey more than the recordable ‘facts’. In the absence of this, complainants display their unmet needs by observably pursuing responses that meet their needs. For example, in Extract 15, similar to Extract 14, the caller’s temporal formulation conveys an implicit negative evaluation of the timeline but unlike in Extract 14, the CH’s minimal response provides no recognition of the caller’s stance towards the date. The caller responds by pursuing recognition of their evaluative stance through a form of repetition that makes the evaluative stance explicit. This response thus displays an orientation to the CH’s uptake as insufficient, that is, as ‘not listening’.

Extract 15

PI13

Our data show that repetition is a recurring practice that callers use to convey that their need to be listened to has not been met by the CH’s prior turn and to pursue a more relevant response from the CH. Callers use different forms of repetition, from verbatim repetition of the same form (e.g. Extract 16), to repetitions that make explicit unaddressed aspects of the caller’s previous turns (e.g. Extract 15).

Extract 16

IC32

As noted above, repetition may even involve re-launching the complaint narrative in the closing phase of the call to pursue unmet concerns. 130 For example, in the following extract we see that while the CH has already recorded the facts of the complaint (waiting times in A&E), the caller orients to having not been heard and re-launches her complaint story with ‘It’s just …’ and re-tells the story to explain why she took her daughter to A&E and why she was so frustrated by the length of the wait.

Extract 17

IC42

Callers may also escalate the evaluative stance expressed in their repetition. For example, in the following extract, the caller describes herself as ‘terrified’. In the absence of CH uptake, she upgrades her self-description to ‘absolutely petrified’. This escalated description again gets no CH uptake and the caller repeats ‘terrified’ but escalates the scope of their fear with the addition of ‘to go anywhere near them’.

Extract 18

RC23

Following the caller’s third repetition of her escalated state of fear, the CH produces a non-specific expression of regret, ‘I’m sorry to hear that’. This allows the CH to proceed to institutional fact gathering, but does not meet the caller’s need to feel listened to and she later produces a further escalated repetition of her self-description that repeats the frame ‘it’s got to the stage now’ but this time provides a heightened description of the impact of her fear: ‘I’ve started taking pseudo-seizures and everything’:

Extract 19

RC23

This time the CH explicitly acknowledges the caller’s original description of her emotional state, which appears to meet the caller’s need to be listened to as she does not return to this element of her complaint.

Extract 18 also illustrates a second key interactional resource that callers deploy to pursue a CH response, namely silence – the noticeable absence of further talk. CA research has long recognised the interactional significance of moments where talk is expected but absent and hence oriented to as noticeably absent. 137 Key to the significance of noticeably absent talk are the structural, turn-taking features of the environment in which the talk is absent, producing not just an absence of talk but an absence of a particular kind of talk and a particular speaker’s talk.

The structural environment influences the specific turn-taking rule applicable at each transitional relevance place, the moments where change of speakership becomes potentially relevant. In the complaint narrative phase of a complaint call, participants orient to an asymmetry in which callers primarily orient to ‘telling their story’ through extended turns of talk and CHs primarily orient to listenership, displayed through various listening practices. In this phase of the call, there are two positions in which silences are oriented to pursuit of CH uptake. The first is following a caller assertion that displays some kind of heightened evaluative or affective stance. There are two aspects of turn-taking management at stake in this position. On the one hand, it is a storytelling environment so there is a shared orientation to the caller producing multi-unit turns. On the other hand, the caller’s heightened stance makes relevant a response from the call hander that attends to the caller’s stance, so a silence in this position is hearable as an absence of acknowledgement from the CH. This type of silence was seen in Extract 18 above, lines 3–11.

The heightened affect in the caller’s turns make relevant acknowledgement by the CH, so the silences in lines 5, 7 and 10 are hearable as a noticeable absence of empathy and the marked duration can be heard as caller pursuit of affective uptake as the caller delays continuation of their complaint narrative, that is, they delay application of the ‘current speaker continues’ turn-taking rule that applies in the context of multi-unit storytelling turns of talk.

The second position in which silence is oriented to pursuit of CH uptake occurs immediately following CH response turns. As discussed above, minimal responses such as ‘mm hmm’ and ‘yeah’ display listenership while also passing the floor back to the teller. A regular pattern in our data shows lengthy silences following CH minimal responses. Through this noticeable absence of caller continuation, the caller orients to the CH’s minimal uptake as insufficient and pursues a more ‘fitted’ response. This is illustrated in Extract 20 where the caller repeats her complaint that her mental health support worker shouldn’t have contacted her following an agreement that she would be assigned a new support worker because her relationship with the current support worker had broken down:

Extract 20

IC68

The CH responds with a continuer ‘yeah’ (line 3), but the caller does not immediately continue with her complaint. Instead, there is a noticeable absence of talk for 1.7 seconds, following which the caller pursues a more substantive uptake with ‘you know’ (line 5). This gets the same minimal response, ‘yeah’ followed by a further noticeable silence of 1.4 seconds after which the CH moves to the ‘service delivery’ phase of the call. (Note that the caller’s needs remain unmet here and following the procedural talk from the CH, the caller returns to her criticism of the mental health support worker.)

These features of repetition, escalation and silence often, perhaps unsurprisingly, cluster together at moments where the caller’s need to be listened to is not being met. This is clearly illustrated in the following example from earlier in the same call as Extract 20. Here the caller is illustrating why her relationship with her mental health worker has broken down:

Extract 21

IC68

Here we see the caller pursue acknowledgement of what she sees as inappropriate ‘help’ from her support worker in response to the caller’s distress. The caller initially pursues acknowledgement through repetition of the inappropriate help – the advice to ‘join Weight Watchers’. This receives silence and then a minimal response, and the caller escalates her pursuit with an explicit bid for agreement (line 21): ‘Surely that’s not right’. When this receives only minimal uptake, we see escalation in the caller’s criticism of her support worker, imputing deliberately harmful intentions in lines 26 and 32. Alongside these repetitions and escalations, we also see repeated silences displaying noticeable absence of caller continuation following the CH’s minimal responses in lines 11, 19, 23 and 28. These silences are hearable as oriented to pursuit of uptake of the prior complainable, which the CH does not provide and which leads then to the escalation of the complainable.

Repetition, escalation and silence thus serve as observable interactional resources through which callers display that their needs are not being met and pursue alternative responses from the CHs. Close examination of pursuit of particular listening responses also shows that being listened to from the complainant’s perspective includes not just the facts of their complaint experience, but also their subjective, felt experience of the issues and the wider lifeworld impact of their complaint. Where CHs accurately record the point of a complaint but don’t acknowledge these more subjective aspects of a complaint story, callers will resist progress through the call in pursuit of this acknowledgement. These analytical observations translate into very effective training insights to support the development of reflective practice for CHs.

Affiliation to affective stance and overt empathy

There is clearly an affective dimension to complaints communication: complainants are typically emotionally affected by the complaint issue and often also by the complaints process itself. Thus, while callers are telling their story, they usually also convey an affective stance towards their experiences. However, a striking feature of our data is the relative lack of overtly empathic uptake by CHs of complainants’ affectual displays. This observation has also been noted for other institutional settings where there is a tension between expressing empathy and dealing with the institutional task at hand; there is often an orientation on the part of the professionals to prioritising the institutional task and avoiding directly addressing the client’s affective concerns. 147

In our data, the CHs do not generally respond to callers’ displays of emotional stance with overt expressions of empathy/sympathy. This is not to suggest that empathy is not important in complaints communication. Professional guidance to CHs includes the recommendation that complainants should be treated with ‘professional empathy’. Complainants also clearly value empathy and comment, in interview, on whether they felt they were treated with empathy. Moreover, CHs in our corpus are often perceived as highly empathic despite never using overtly empathic expressions. Conversely, as Chapter 6 demonstrates very starkly, communication experiences that include overt expressions of empathy are not always perceived as empathic.

This apparent contradiction relates to the challenges in conceptualising empathy. Empathy is broadly seen as ‘a matter of understanding, of knowing the other person’s experience’. 148 In CA, empathy is conceptualised as an interactional accomplishment, an observable product of how we talk, and prior research in CA has been on examining ‘empathy displays’. However, what constitutes an empathy display and how the boundary is drawn between talk that displays empathy and talk that is perceived as empathic remain somewhat contested. For example, while Hepburn and Potter149 restrict empathic responses to those involving an explicit formulation of the other’s mental state, and a marker of the epistemic contingency of the mental state formulations, others include a broader set of formulations that claim understanding without necessarily constructing mental states. 150 Empathy displays may also be defined as including non-verbal behaviours and prosodic resources that mirror the affective stance of the prior speaker,151,152 although Ford and Hepburn153 argue that the latter, non-semantic, practices are sympathetic rather than empathetic.

For our purposes, we differentiate between CH responses that directly affiliate with the caller’s affective stance and forms of talk that achieve empathy as a perceived impact without overtly addressing the caller’s affective stance. Drawing the distinction in these terms supports the translation of our findings into useful training resources by focusing on the features of the callers’ stance that convey bids for different kinds of affiliation; as our analysis demonstrates, CHs who make effective use of other forms of affiliation are often perceived as highly empathic, but there are moments when affiliation with affective stance appears to be important. Here, we turn to the moments in our data where CHs recurringly affiliate with the affective stance displayed by the caller.

Complaints calls are typically focused on concerns that are recognisably upsetting for callers; there are moments in some calls where the caller moves from talking about distressing details to becoming hearably distressed. CHs need to negotiate this distress sensitively in order to be able to proceed with the institutional tasks of complaint recipiency. These are the moments where CHs respond with empathy and directly address the caller’s emotions. For example, in Extract 36, the caller is reflecting on the care she receives from her doctors in contrast to the mental health support worker who is the focus of her complaint. This triggers her distress, first hearable through her ‘wobbly voice’ which indexes incipient crying and then made more explicit by the hearably tearful ‘give me a wee second’:

Extract 36

IC68

The CH’s responses in this extract focus directly on the caller’s displayed distress with repeated uses of ‘take your time’149 and explicit recognition that the complaints process is difficult for the caller. The latter works as a form of explicit empathy in so far as it formulates the caller’s subjective experience as ‘difficult’ and claims hedged understanding of that experience: ‘I understand this may be difficult’.

As with the evidence from other institutional settings with tension between information gathering and expressions of distress, the CH’s primary orientation here is to the caller’s difficulty in proceeding. 147 Hepburn and Potter149 suggest that ‘take your time’ is deployed in helpline contexts to acknowledge that the caller’s distress is preventing further talk and to license that momentary break in talk. As such, they argue that it is not an overt expression of empathy but is highly affiliative and its absence in contexts of caller distress is perceived as unsympathetic. For our purposes, the consequential observation is that it involves a switch to directly attending to (and affiliating with) the caller’s emotional state rather than the substance of their complaint narrative. Interestingly, a related context in which CHs express similar affiliation with the caller’s affective stance is where the CH formulates the caller’s subjective experience of making the complaint as ‘difficult’ or ‘upsetting’, as a vehicle for accounting for prioritising non-empathic, institutional tasks such as recording personal details.

Comprehending complainability as affiliation

Given the relative lack of overt empathy in our data, along with the importance to participants of feeling that they have been treated with empathy, a priority in our analysis was to understand the CH practices that lead to this sense of having been treated empathically. Careful analysis of calls that were rated by the caller as highly empathic pointed to a set of affiliative practices that can be categorised as displaying comprehension turn-by-turn of the complainability of the details of the caller’s complaint narrative. In contrast to overt empathy (which was infrequent and deployed in specific contexts with an orientation to institutional progressivity), comprehending complainability as a set of practices was evident across our entire corpus; the noticeably empathic calls were differentiated by the high frequency of this type of affiliation within the single call, creating a cumulative empathic impact.

Extract 37 provides a good example of two different practices that achieve this type of affiliative uptake. The caller, at this stage, has provided a lengthy narrative about an X-ray the previous year which led to a diagnosis of a crumbling spine, her subsequent collapse with a broken femur a month later, and issues with her recovery. Here, she is describing a follow-up appointment several weeks later:

Extract 37

PI05

In this extract, the caller narrates the moment where she learns that she had had a hairline fracture in her femur the previous year. The CH’s responses in lines 6 and 8 deploy ‘appendor questions’154 to make explicit two significant, but implicit, elements of this story: firstly, that the hairline fracture had been visible in an X-ray that had been taken before she collapsed with a broken femur and, secondly, that she had not been informed. In The need to be listened to, we described different practices for displaying listenership. This listenership practice doesn’t just receipt the information from the caller but actively displays a ‘candidate understanding’ of the implications of the information – specifically how it contributes to the caller’s complaint. In other words, the responses affiliate with the complainability of the story by displaying on-record understanding of what makes it complainable, while the repair initiation format still orients to the epistemic authority of the complainant by seeking confirmation of that understanding by the caller. 155

The final lines of this extract illustrate a second practice used to affiliate with complainability: a ‘so’-prefaced formulation. These foreground information that has particular contextual salience;156 in complaints handling, they are thus often used to formulate the CH’s candidate understanding of the ‘point of complaint’. 130 In this extract, the caller has confirmed the CH’s candidate understanding of the elements foregrounded by the CH’s appendor questions, then narrates her reaction at the time using direct reported speech. The CH’s ‘so’-prefaced formulation then reformulates the implications of his previous appendor questions as a candidate understanding (‘I guess what you’re asking me today is’) of the point of complaint of the call (‘why wasn’t it picked up in August?’).

An interesting feature of this particular use of a ‘so’-prefaced formulation is that it occurs in response to the caller’s display of affective stance, animated through the use of direct reported speech and marked prosody. The caller’s turn makes relevant both affiliation with the caller’s affective stance but also validation of the complainability of the revelation. By summing up the point of complaint with a formulation, the CH neatly validates the complainability, thus displacing the opportunity to provide affective affiliation. In other words, as noted above, the CH prioritises the institutional focus on formally recording the complaint but does so in a highly affiliative manner.

In Extract 38, the CH demonstrates comprehension of complainability by producing a second assessment that makes explicit the implied negative assessment in the caller’s prior turn. In this extract, the caller is complaining about waiting times:

Extract 38

RC26

In line 5 the caller clarifies the waiting time she has been given. This conveys an implicit negative assessment of the duration of the wait and the CH affiliates with the implicit negative assessment by making it explicit, ‘that’s far far ahead’. By making explicit a caller’s implicit evaluation in this way, the caller affiliates with the complainability of the assessment. Expressions of time are frequently involved in this type of implicit assessment as waiting times are a significant feature of NHS complaints. But other types of complainable negative assessments are also affiliated with in this way. For example, in this next extract the caller is complaining that he was left on his own to get from reception to A&E with a knee injury (in a hospital where porters usually provide wheelchairs from A&E):

Extract 39

PI02

The CH first provides an appendor question that makes explicit the caller’s implied complaint about the lack of help to get to A&E. As in Extract 37, the caller confirms the CH’s candidate understanding with an Extreme Case Formulation that foregrounds the complainability of the concern8 before elaborating on the details of his struggle to get to A&E, including an implied evaluation of distance (‘eventually got within twenty yards or thirty yards’). The CH responds to the implied negative assessment by making it explicit (‘that’s a long walk up there’). This extract provides an interesting comparison with Extract 38 because although it uses the same practice and affiliates with the complainability of the assessment, overall, it is less affiliative in outcome; the issue of distance is not produced as the ‘point of complaint’ so much as an exacerbating factor, whereas in Extract 38 the duration was the point of complaint.

What we have shown is that CH practices demonstrating an understanding of the complainability of the details of the caller’s experience provide a vehicle for affiliative uptake that meets the caller’s need to feel listened to. These practices involve moment-by-moment negotiated sense-making, often offering candidate understandings of the caller’s perspective for the caller to accept or reject as well as making explicit aspects that were implicit in the complainant’s narrative. This perhaps accounts for why these calls are perceived as highly empathic despite the lack of overt empathy. While some authors argue that empathy involves explicit orientation to another’s emotional state,149,157 others158 refer more widely to displays of understanding of the other’s perspective. Affiliation that demonstrates comprehension of the caller’s stance towards the complainability of their story can thus be understood as achieving empathy by negotiating shared understanding of the complainant’s perspective on their complaint story. These practices for displayed understanding of the caller’s perspective have been incorporated into Real Complaints Training as a detailed approach to meeting the requirements for active listening to ensure that complainants feel listened to.

Affiliation to reason

The final type of affiliation revealed as important for complaint handling is affiliation to reason. This type of affiliation is obviously closely tied to the complainant’s need to be acknowledged as reasonable which, as our longitudinal case analysis has shown, permeates the entire complaint journey, influencing how complainants talk (and feel) about their complaint at every stage. Previously we discussed the practices callers use to pursue acknowledgement of their identity as a reasonable complainant. In this section, our focus turns to the practices CHs use to validate callers as reasonable without being heard as agreeing with the caller’s complaint. Some of these practices relate directly to callers’ practices for pursuing recognition as reasonable, while others relate to the reasoning explicitly or implicitly conveyed in the callers’ complaint narratives. One striking feature of CH turns oriented to affiliating with reason is that they usually involve combining multiple forms of affiliation.

One set of practices for affiliating with reason focuses on directly affiliating with the caller’s self-presentation as a ‘reasonable complainant’ by validating either their decision to complain or their motivations for complaining.

In Extract 40, the CH validates the caller’s decision to complain, with ‘you’re right to come to us’:

Extract 40

IC40

Note, the CH first demonstrates comprehension affiliation in a ‘light touch’ form with the anticipatory completion in line 8 of the caller’s turn in line 7. 159 The CH thus first displays understanding of the complainability of the caller’s concerns before validating the decision to make the complaint.

In Extract 26 above, the CH also validates the decision to complain but does so implicitly first through aligning and affiliating with the caller’s assessment that they are ‘not malicious or anything like that’ and then through a formulation that presents the caller’s motivation for complaining as reasonable (‘you just want yourself to get sorted’). The CH’s formulation directly affiliates with the caller’s reasoning motivating their complaint and emphasises the reasonableness with ‘just’ which frames the motivation as proportional and restrained. Again the CH deploys a form of anticipatory completion that is maximally affiliative in that it demonstrates anticipatory understanding of the motivation that the caller was formulating.

Callers often construct their reasonable complainant identity through accounts that frame their decision to complain as a last resort or driven by extreme circumstances. In Extract 41, the caller has been describing his ‘horrendous experience’ of having a heart attack and waiting in A&E in one hospital before being transferred to a different hospital where he had another heart attack. Although his complaint centres on the duration of his wait to be seen in the first hospital and the damage to his heart caused by that wait, his narrative leading up to this point focuses on his extreme pain and distress during the whole experience.

Extract 41

PI16

The caller formulates his complaint with an extreme case formulation, ‘an absolute disgrace’, before pursuing recognition of a reasonable complainant identity. The CH responds to this appeal with a reformulation of the caller’s ‘awful experience’ as a reasonable account for making the complaint. This affiliates both with the caller’s affective stance and with the caller’s appeal to reasonableness, while avoiding affiliation with the caller’s negative stance towards his wait in the first hospital. This pattern repeats throughout this call: the caller handler recurringly affiliates with the caller’s heightened affective stance (she is unusually empathic) and with his multiple bids to be acknowledged as reasonable, whereas her uptake of the core part of the complaint, which she summarises for him three times during the call, remains entirely oriented on a neutral recording of the complaint, for example, ‘so basically we’re focusing on why did it take so long to be seen in the out of hours (.) at Barlett, that’s kinda the (.) the crux of the (.) the problem’. Interestingly, the caller is highly complimentary at the end of the call, commenting that ‘it has been smashing talking to you, smashing manner’, providing strong support for the claim that these forms of affiliation matter to the caller experience of complaints interaction.

While the previous set of extracts involved affiliating directly with caller’s bids to be acknowledged as a reasonable complainant, Extracts 33 and 30 show how CHs can validate the caller as reasonable by validating the caller’s reasoning in their complaint narrative.

In Extract 33, the caller makes a clear appeal to reason by invoking common-sense reasoning and general knowledge160 The use of the adverbial obviously frames the turn as presenting common-sense reasoning and the switch to generic, non-specific somebody combined with the present tense (‘when somebody waits’) indexes a generalisation. Thus, although what she describes in this turn is her personal experience that has led to her complaint, these linguistic features frame it not as personal but as an obvious (and therefore reasonable) generalisation. The CH’s response, on the other hand, first claims understanding and then demonstrates understanding by switching back to invoking the caller’s first-hand experience to affiliate with the complainability before explicitly claiming affiliation with the caller’s reasoning with ‘I understand where you’re coming from’.

In Extract 30, lines 9–12, we see a concise example of affiliation to reason in response to the caller’s use of the concession structure ‘I know X (concession), but Y (complaint)’. What is interesting in this extract is the CH’s orientation to the recognisability of this reasoning structure as a practice for emphasising reasonableness, as revealed by the position of the CH’s affiliative response which comes in overlap with but and affiliates with reasonableness by denying the need for the concession. Note that again, this affiliation to reason is combined with comprehension affiliation that underscores the affiliation to reason by providing a formulation of the ‘main point’ of the caller’s complaint.

Negotiating blame and criticism

Complaining involves not just an expression of ‘feelings of discontent about some state of affairs’ but also attribution of responsibility for the state of affairs causing the discontent. Pino’s analysis146 of third-party complaints in an institutional setting labels these two components of complaining as ‘hurt’ and ‘blame’ and argues that they are constituent components of the action formation of complaining. Blame, however, may be quite implicit and diffused or non-specific. For example, complaints are sometimes expressed with passive voice or with non-specific ‘they’:

Extract 42

RC22

Here the caller uses multiple linguistic devices to leave the agent of his father’s poor treatment, that is the blame, unspecified: passives (‘unbelievably let down’), non-specific they (‘they said he’s still showing as an in-patient’) and noun phrases that avoid specifying agency (‘nothing, no medication, no referral letter, no doctor’s letter’).

In the context of the NHS, blame is often left implicit161 or, as our longitudinal findings show, generalised to failings of the wider NHS ‘system’. Sometimes, however, blame is explicit, personalised and directed at a specific individual. This presents obvious challenges for CHs who need to accurately (and affiliatively) record the complaint without appearing to agree with or uphold the caller’s still-uninvestigated blaming of a particular individual. We investigated this particular interactional challenge to identify CH practices that either escalate or de-escalate individual blame and to understand how CHs avoid agreeing with explicit blaming without appearing to undermine, disbelieve or disagree with the caller’s account of their complaint.

Extract 43

IC68

The complainant is ringing to complain about the breakdown in her relationship with her mental health support worker and to make sure that she is allocated to a different support worker. At this point in the call, the caller makes an explicit criticism of her support worker: namely that she patronises her by addressing her as ‘pet’. The CH responds with a continuer and the caller pursues a more substantive response with a more specific and somewhat escalated illustration of this criticism. Further lack of uptake from the CH leads to more explicit stance-taking from the caller along with escalation of the blame to explicitly impute negative intentions to the support worker. This extract illustrates how receipting explicit blame as if it were neutral information leads to the patterns of pursuit previously discussed. This is unsurprising as complaining makes affiliation relevant, so each of the CH’s neutral responses represents a noticeable absence of affiliation leading to pursuit of affiliation.

Pino’s analysis146 of the negotiation of blame demonstrates very persuasively that complaint recipients can ‘decouple’ hurt and blame and affiliate just with the affective stance embodied in the hurt. Pino’s data, however, come from a therapeutic setting. In our complaints data, CHs also decouple hurt and blame but deploy particular forms of comprehension affiliation and of affiliation to reason as effective resources for the negotiation of blame. These forms of affiliation directly or indirectly validate the caller as a reasonable complainant without agreeing with the blame or the assessment of the complained-about person.

The first set of practices directly validates the caller either by affiliating with the caller’s decision to make a complaint or by acknowledging the seriousness of the complaint issues. For example, in Extract 44 the caller has made extended allegations of abuse by staff in a mental health ward. The CH validates the caller by labelling the accusations as serious and focusing on the procedural implications:

Extract 44

IC15

In this second extract, the CH validates the caller by focusing on their decision to complain:

Extract 45

IC30

Here we see that the CH responds to the caller’s accusation (repeated from earlier in the call) that ‘the guy’s actions were outrageous’ by validating the caller’s decision to make a complaint and making extended generalised assertions about welcoming feedback (though it should be noted that the downgrading of the call to ‘feedback’ rather than a complaint would not be seen as good practice). These response strategies that treat the caller as a ‘reasonable complainant’ help to move the focus of the call away from the individual blaming, and we see in both examples that the caller accepts the response and the call moves swiftly to call closure.

The shift to speaking in general terms noted in this last extract is another practice for providing affiliative uptake in contexts of blame. For example, in Extract 46 the caller has been criticising her social worker and the CH switches to ‘what usually happens’:

Extract 46

IC68

We see a slightly different application of this generalising type of response in the next extract from the call seen in Extract 44. Here, we see the caller make multiple allegations of different kinds of abuse and then list their belongings that have been taken, ending with their mobile phone:

Extract 47

IC15

The caller handler responds to this series of allegations by generalising about the process for ‘some patients’ in mental health wards. This frames the caller not having their mobile phone as a ‘normal’ part of being in hospital and provides a resource to raise the potential of face-to-face contact, which the caller accepts as a positive offer.

Each of these applications of the idea of generalisation is context-specific but, in each case, it serves to treat some aspect of the caller’s experience as ‘normal’ and ‘expectable’ and thus indirectly treats the caller as a ‘normal’ ‘reasonable’ person going through a ‘normal’ and ‘reasonable’ process. In each case, we see that the move to generalisation facilitates progressivity through the call, supporting the claim that it is perceived as affiliative by the caller.

The first set of practices for negotiating blame was, to varying degrees, oriented to affiliation to reason. Our data also show that caller handlers may negotiate blame with comprehension affiliation through reformulating what the caller has said in ways that help to mitigate or diffuse the blame. For example, in Extract 48 the caller is complaining about a rude receptionist. The caller had asked the receptionist whether they could take pain relief while waiting for triage and complains that the receptionist was very rude to them and accused them of trying to ‘jump the queue’. In the extract, we see the CH reformulate the issue as ‘a wee bit of a communication issue’:

Extract 48

RC16

Notice that while this practice of reformulating addresses the explicit criticism of the receptionist, it is combined with other forms of affiliation oriented to validation of the caller. The CH displays comprehension of the complainable, showing comprehension of the caller’s perspective of her own behaviour as reasonable, as well as affiliating with reason through the practice of validating the caller’s decision to complain by valuing the complaint as feedback to improve the service. This practice of combining reformulation with other forms of affiliation seems to work to mitigate the risk that it might otherwise be seen as distorting or undermining the version of events presented by the caller.

Our final set of practices for negotiating blame demonstrate taking the caller’s concerns seriously through the practices used for receipting and recording those concerns. This is sometimes done by paraphrasing, and sometimes by what we call ‘typing aloud’ –citing back the caller’s own words to them as a form of record-taking. We see both these practices in Extract 49, which is from a complaint about a social worker who blocked the caller’s contact visits with his children on the grounds that he ‘smelled of drink’ (the caller is adamant that he does not drink):

Extract 49

IC23

In line 1, we see the CH overtly preface typing aloud with a reference to his task of recording the complaint (‘I’m gonna say’). Prefacing it in this way provides an anticipatory account of the extra time it takes, which is often more explicitly referenced with phrases like ‘bear with me a wee second’. The typing aloud follows and is prosodically highly distinctive, marked with multiple silences and continuing intonation. Note the caller collaborates with this very overt display of getting the complaint ‘on record’. The CH’s turn of typing aloud in lines 10–12 also illustrates the practice of paraphrasing as he types aloud ‘her comments regarding his hygiene’ rather than the caller’s words (‘she called me scruffy and smelly’).

Sometimes the typing aloud, as an audible form of the act of writing the caller’s words, is further signalled through the use of the first-person pronoun as a way of marking the text as the caller’s own words. We see this in Extract 50, which is a continuation from Extract 47:

Extract 50

IC15

As with the previous example, we see here the typing aloud prefacing and the explicit reference to what has been recorded (‘I’ve taken a note …’). This last set of practices that focus on explicitly orienting to recording the caller’s own words might be seen as a strategy of last resort. It works very effectively in some calls, where CH and caller collaborate on the recording of the details, but we also see in many of our calls that callers orient to ‘mere’ recording of their complaint as insufficiently affiliative and pursue a more affiliative response from the CH through repetition and escalation.

Our analysis thus shows that affiliation provides effective resources for the negotiation of blame. It also reinforces our claim that orientations to the reasonable complainant identity are a key driver in these conversations. These particular forms of affiliation directly or indirectly validate the caller as a reasonable complainant without agreeing with the blame or the assessment of the complained-about person. We again saw that the various practices are often most effectively used in combination, particularly with more risky practices such as reformulation which otherwise might be heard as undermining the complaint. Our data also show that in some cases, individual blaming may be an effect of anger and frustration rather than the key point of the complaint. A significant task for CHs is thus to deploy comprehension affiliation effectively to determine where this is the case.

Module 1: focusing on listening

This section of the training establishes the Real Complaints CA framework for reflecting on communication in terms of the moment-by-moment experience of a conversation and the context-dependent nature meaning. The module provides training on listening skills that draws on core conversation analytic insights about the relationship between turn-taking and listening, as well as on our research on how particular call handler choices of listening response influence whether (or not) callers feel ‘heard’. This framework-setting module works as a standalone module to stimulate reflection on foundational communication skills but is primarily designed as introductory resources for the other modules in the training package.

Module 2: listening to callers’ needs

Our research revealed three key communication priorities for callers with implications for the listening practices of CHs, who need to listen for what matters to a caller both in the moment and overall in a call and to take that into account when replying. The module focuses on developing CHs’ awareness of the cues that callers display to convey that their interactional needs are not yet being met. Our findings indicate that this is a key training objective as not meeting callers’ needs causes delays and disruption to a call and may lead to escalation of the complaint. These cues provide an early indicator of potential problems as they emerge in a call. Sensitivity to these cues thus helps avoid escalation. This module encourages reflective practice for even the most experienced of call handlers because of the microlevel focus on callers’ cues which supports the development of CHs’ ‘conscious competence’.

Module 3: using affiliation to meet callers’ needs

This module stimulates reflections on best practice in responding to complaints, focusing on how the skill of affiliation supports active listening and professional empathy. The module applies our findings relating to how affiliation needs are interactionally signalled and met, as well as how different types of affiliation interact and intersect and the impact of not meeting affiliation needs. The module provides exercises relating to each of the relevant categories of affiliation in turn, as each is significant to complaint handling in a different way. A central objective is supporting trainees to recognise different patterns of interactional behaviours relating to the different categories of affiliation but also to develop a critical awareness of the inherent context sensitivity of the different forms of affiliative response and how they interact. This is fundamental to appreciating that affiliation cannot be understood simply as a decontextualised set of response options. The module also includes data sets that demonstrate how affiliation needs evolve over the trajectory of an encounter, building on our analysis of the significant impact of timing on the outcomes of the use of affiliation.

Module 4: affiliation in challenging contexts

This module focuses on the interactional challenges of negotiating explicit, personalised blaming. The module reflects on the contexts in which explicit blaming emerges and the affiliative strategies that are used to successfully negotiate blaming without either agreeing with the blame or undermining the complaint/complainant. The workbook tasks also extend the critical reflections on context sensitivity and timing that were introduced in module three.

Module 5: affiliation-focused reflective practice

This final module offers opportunities to practise applying the take-away checklists from the previous modules to case-study calls, either from participants’ own practice or from the Real Complaints corpus of calls.

Round-table event

The first event was a round-table discussion of the communication challenges in complaint handling and associated training needs. Seventeen people signed up to attend, including CHs and managers from across all six HCSNI Trusts as well as a representative from the PAS. It included a presentation from NIPSO’s Complaints Standards Manager on the recently approved Statement of Principles for complaints handling by public bodies. A key insight from this session related to the challenge of combining empathy with professional neutrality. This became an important theme in the development of our training.

Stakeholder training design workshops

During the training design phase, a co-design workshop was held to seek stakeholder perspectives on the training focus and data sets as well as guidance on preferred formats. The workshop was attended by five people, including complaints managers and PAS representatives, and led to invaluable feedback which was incorporated into the training.

Stakeholder training evaluation workshops

Lastly, we hosted three ‘taster’ sessions at which draft versions of the training resources were presented. These were delivered to the SPSO (11 attendees), the NIPSO (22 attendees), and the Parliamentary and Health Service Ombudsman (3 attendees), as ‘critical friends’ with expertise, experience and insight to feed into the training development. Attendees ranged from senior leadership to managers responsible for training design and CHs dealing directly with the public. They engaged with interactive exercises to experience working with real complaint data and reflect on their own interactions. Time was provided for discussion and comments; the feedback received was then reflected in the design of new versions of the resources. Feedback was overwhelmingly positive, with many participants expressing the view that such training, particularly the use of transcripts of real recorded data, was useful to their reflective practice and professional development.

Reasonableness as a driving force in the complaints experience

A key finding from both our interactional and qualitative data streams is the pervasiveness of the discursive work by complainants to present themselves as both ‘reasonable patients’ (during the complainable events) and ‘reasonable complainants’ (in the decision to complain and manner by which they raise a complaint). Crucially we have shown the extent to which complainants pursue recognition of their reasonableness in their interactions with complaints staff and the impact this has on the progress and outcomes of a call, as well as the significant benefits of language choices that validate the complainant as reasonable. This finding is central to the unique contribution of Real Complaints Training for CHs.

The emergence of the reasonable complainant identity as significant demonstrates the value of discursive research in revealing and evidencing tacit priorities that nonetheless have a profound influence on experience. More conventional methodologies recognise complainants’ explicit priorities such as the desire for an apology162 and empathic treatment163 or values such as fairness, transparency and timeliness. 164 Our findings demonstrate the importance of understanding how the need to be seen as reasonable interacts and intersects with these more explicit priorities in ways that are consequential for the overall experience of the complaint journey.

This finding is highly significant for recommendations, guidance and training around communication (both spoken and written) as our data show that meeting the complainant’s need to be seen as reasonable is fundamental to achieving a more person-centred approach to complaint handling, but to date has not been discussed in previous research, guidance or policy documents.

The complaint experience as a dynamic journey

Our multiple data sources in our longitudinal case studies reveal the complaint experience as a dynamic journey with evolving narratives reflecting complainants’ shifting perceptions, expectations and experiences of the ‘system’, both moment by moment and encounter-by-encounter. Each interaction within the journey moulds these perceptions and future expectations; hence the paramount importance lies in improving individual instances and enhancing connectivity throughout the complaint journey as each next encounter can ‘overwrite’ the effects of the previous. Our study shows that written responses, which are typically the final stage of the journey, have the most significance for the overall evaluation of the experience. Written responses often miss the mark by not acknowledging accountability, providing insincere apologies, using obscure medical jargon, and detailing irrelevant patient histories. Such issues can propel complainants to escalate their complaint, emphasising the need for more nuanced written communication.

More broadly, our analysis illuminates the dual nature of complaints: as personal expressions of dissatisfaction with care and as systemic critiques, reflected in the motivations to complain. 117 Attitudes towards communication methods manifest themselves in a preference for more personal, ‘human’ spoken interactions to address individual concerns, contrasted with a reliance on formal, written responses to ensure accountability and effect systemic changes. Understanding this duality – complaint and care – is vital to improving the complaint-resolution process by ensuring both the validation of individual lived experiences and effective systemic response. This suggests that scrutinising communication within the service sector is as important as examining process in any investigation into complaints.

Finally, the cornerstone of a successful complaints process is a person-centred approach. It should include: understanding the complainant’s broader life context and recognising the ‘lifeworld impact’ of the complaint and respecting the complainant as reasonable in making the complaint. Inadequacies in addressing these factors, coupled with misunderstandings, misrepresentations and ambiguity, can jeopardise the complaints process, fostering dissatisfaction, mistrust and escalation. This finding mirrors the CA finding about the significance of affiliation in complaints interactions. Therefore, our study revealed complainants’ priorities which are fundamentally important on different levels of communication processes.

Transforming experience through affiliation, person-centredness and congruence

Collectively, our findings show that resolving the dissonance in complainants’ experience stemming from unmet expectations and concerns requires:

1. affiliative interactions with Trust staff in which complainants feel heard and respected as a reasonable complainant

2. person-centred complaints journeys in which both individual and systemic concerns are recognisably understood and addressed

3. congruence in the cultural context to support patterns of service relationships within which patients see themselves as having a legitimate voice.

Our research considers each of these aspects to be mutually supportive within healthcare settings. Indeed, weaknesses in one of these aspects can undermine good work in each of the other two. We therefore see this as a ‘chain’, in which each link needs to be made as strong as possible if overall complaint outcomes are to be strengthened (Figure 7).

FIGURE 7.

The relational complaint chain.

The chain metaphor emphasises the importance of the links being connected up effectively. For instance, it is insufficient to train people in affiliative skills, unless appropriately person-centred contexts and opportunities are going to be provided to use those skills. Similarly, it is insufficient to argue for a person-centred approach when the cultural context is insufficiently congruent with the values and norms of complainants or when complaint-handling staff lack the affiliative skills for person-centred interaction. The links in the chain need to be joined together, in a co-ordinated way, if complaints processes are to be strengthened.

In sum, different factors working at different levels of the ‘relational complaint chain’ have a role to play in whether or not complaints are resolved effectively. Our focus at the microlevel of affiliation was broadened to include other influencing factors. This approach reveals complaint handling as fragile, with numerous potential points of failure. Employing the relational complaint chain framework, we show that effective complaint management involves predictable, plannable and actionable strategies.

Opening of letter

• Thanks for raising concerns and expression of commitment to resolving complaint.

• Any apology for delay in responding.

• Summary of complaint as the Trust understands it.

Acknowledge responsibility

A study by Lewicki et al. 126 found that ‘Acknowledgement of Responsibility’ is seen as the most important component in an apology. Where the investigation concludes that an error has been found to be made or behaviour found to be wanting, it is most effective to admit this in clear and transparent terms. The following, from a Trust response, is an example of good practice since it clearly and honestly states that the outcome would have been different if the mistake had not been made:

Avoid explicit ‘blame evasion’

Obvious defensiveness or an unwillingness to acknowledge responsibility where it is due is one of the most salient expressions of dissatisfaction about complaint response letters made by longitudinal participants in follow up diaries and interviews.

We feel they just don’t want to admit that they’ve made a mistake, like that’s just how it feels.

Blame evasion can be very explicit or more subtle, perhaps pointing to blame mitigation, though it is striking that participants pick up negatively on even the most subtle forms of mitigation. Blame evasion can be realised through:

• blaming others

• using obfuscatory formulations that make the agency of the actions unclear (who does what)

• excuses and mitigating circumstances (multiple excuses or excuses that seem designed to exonerate the complained-about subject from the need to apologise are most negatively received)

• good intentions/no intentionality to cause harm.

Sometimes it is valid and effective for a response letter to offer explanations about what events occurred as they did, but it is important that these are not seen to undermine the accountability of the Trust or to obviate any need to apologise. An example of a good-practice response is as follows:

Acknowledge the lifeworld and emotional impact of the complained-about event on the complainant (‘Be Affiliative’)

In the SPSO’s guidance on apologies, they recommend that complaint responses include ‘an acknowledgement of the effect the problems have had for the other person’, for example, ‘you experienced significant delays and were left not knowing what was happening’.

The kinds of lessons about the importance of affiliation described in the interactional analysis section also apply to written complaints. Complainants have explicitly constructed their complaints in a way that stresses the evidentiality of the right and need to complain and also in ways that constructs their own identities as ‘reasonable complainants’. These constructions need to be recognised and affiliated with in the written responses. Sometimes this kind of affiliation can involve an expression of overt empathy: ‘I was sorry to hear about the difficulties you encountered and understand that this was an upsetting experience’. However, possibly of even more value is a complaint response that acknowledges the impact the complainable has had on the complainant (or their loved one). Where this kind of acknowledgement is lacking, we find this reflected in post-complaint evaluations by study participants:

• Nobody has acknowledged the life that they’ve taken away from her, the life they’ve given her now.

• There’s been no acknowledgement of how her life has changed or how it’s affected her and us as a family […].

• [In the context of considering engaging a solicitor] They’re just not acknowledging what we’ve went through and how my mammy is.

In contrast, the quotation below from a Trust response is an example of good practice:

Avoid introducing ‘alternative’ narratives that undermine the complainant’s account of events

Complainants report feeling particularly aggrieved when a response includes alternative accounts of events which seem to directly contradict those presented by the complainant.

The staff member that has been mentioned does not recall sending you back to the waiting room.

These are felt to be particularly grievous when the experience being contradicted is an emotional, traumatic and necessarily subjective one. While the purpose of an investigation is to establish the ‘facts’ of the complaint, and to allow a ‘right of reply’ by individuals named in the complaint, the presentation of these conflicting perspectives as the substance of a response to the complaint risks framing the complaint response as a ‘defence’ by the Trust and is better avoided. Such responses are then construed as partial and ‘one-sided’ rather than being an even-handed investigation of all perspectives. This is an observation remarked on by family members in one case complaining about a serious adverse event experienced by their mother.

We were happy to leave the investigation with the Trust, as we believed it would be impartial and comprehensive. Unfortunately, we feel that the response so far has been one-sided, and we are very disappointed about this.

While it is important for a complainant to understand that concerns have been raised with relevant staff about their behaviour, a simple account that this conversation has taken place and an apology or expression of empathy would be more effective, as we see in the following good-practice formulation in the response to a participant’s complaint:

Make a clear commitment to change/reform

The most valuable outcome of a complaint for many complainants is the promise of future change and a guarantee that the complained-about event will not affect future patients. Evidence of practical steps to institute permanent changes (‘offer of repair’, ‘indication of future intention’, ‘remedy’) is a crucial key to the success and effectiveness of complaint handling.

Complaint responses should give concrete details of the changes that were made as a result of the complaint, as in the following good-practice example:

Apologies

Where a complaint investigation reveals the need for an apology, it is important that this is delivered effectively.

An apology should be personal, written for the specific occasion and be sensitive to the context in which the apology is being made.

SPSO guidance

The composition of an apology matters.

Lewicki et al. 2016126

In the SPSO’s guiding document, they point out that written apologies can be less effective than face-to-face apologies: ‘When we speak to another person directly we come over as fellow humans and not a faceless organisation’. For this reason, the composition of an apology in written communication is really important to get right.

Writers should avoid the ‘faux/politician’s apology’ (see also McCreaddie et al. ). 122 In other words, avoid framing the apology in terms of the patient’s feelings (and thus implicitly reducing the experience to something merely subjective): ‘I am sorry that/if you felt’. Acknowledge the reality of the experience for the patient. Also avoid expressions that suggest the patient’s experience may be in doubt, for example, ‘I wish to apologise for the distress she may have suffered’, ‘I apologise if this was the case’. Apologies that minimise the ‘hurt’ of the complaint (e.g. by suggesting ‘someone else is worse off than you’: ‘Mrs Khan acknowledges that at present you have been waiting 71 weeks and Mr Wright’s longest waiting knee replacement is currently waiting 247 weeks’) undermine the complaint and the complainant’s sense that they are being reasonable.

Where apologies are offered, avoid mitigating with appeals to exceptional circumstances, good intentions or standard practice. The following are good-practice examples that acknowledge and accept responsibility for the error without mitigation and apologise for it:

How to conclude

Our analysis demonstrated that complainants may be uncertain if the complaints process has concluded if they feel their concerns remain unmet. Therefore, it is important to communicate clearly that the complaints process has come to an end, so they can decide on their next actions if unsatisfied with the outcome (rather than waiting for some other actions from the Trust). An example of good practice is as follows:

Written responses and the complaint journey

As it is impossible to take into account every detail, it may be a good general practice to offer calls/appointments to complainants to make them feel heard, a part of the process, to express what are their actual concerns during the investigation (not after), at least for more serious cases.

It is important to take very brief notes of each point of communication with the complainant. In this way the trajectory of the complaint is uninterruptible. Complainants get very annoyed when they are told something, for example, via a phone call, and there are no traces this information was acknowledged in the response letter. Notes should be brief so they may be retrieved quite easily by the staff member who will be the next point of communication.

Finally, the overwhelming evidence of our analysis of longitudinal journeys points to the value of face-to-face conversations between complaint handlers and complainants. While written responses are an important record of the investigation and any reparations being offered, they are often deemed to fall short in terms of presenting complainants with a satisfactory outcome to their complaint. While the guidance above points to ways in which written responses can be improved, our recommendation would be that face-to-face meetings (especially in the more serious cases) are offered to discuss the outcome of a complaint alongside the written response.

References

Lewicki R, Polin B, Lount R. An exploration of the structure of effective apologies. Negot Confl Manag Res 2016;9:177–196. https://doi.org/10.34891/9awp-8644122

McCreaddie M, Benwell B, Gritti A. A qualitative study of National Health Service (NHS) complaint-responses. BMC Health Serv Res 2021;21:696. https://doi.org/10.1186/s12913-021-06733-5

Scottish Public Services Ombudsman. How to Make a Good Apology. www.spso.org.uk/sites/spso/files/csa/ApologyGuide.pdf (accessed 3 July 2023).