Patient expectations about what can be achieved in an NHS struggling to balance its books (Hawkes & Charter 2006) are today perhaps a tad unrealistic and a programme of re-education needs to take place. As we have seen, government policy has been directed towards making the NHS revolve around the interests of the patient; perhaps it is now time for a new strategy – a strategy directed towards viewing patients as equal or equity partners in a common enterprise. Partners have responsibilities and cannot simply function, as some patients do, just as vitriolic recipients of care. The NHS is becoming a safer place as a developed patient safety infrastructure is being slotted into place, although it must be acknowledged that we are still a long way off from developing an ingrained patient safety culture. Only incremental progress is being made. The National Audit Office state (NAO 2005):
Powers (2004) brings an interesting perspective to risk management and the audit regulatory focus of organisations and his comments can equally apply to the NHS:
To avoid developing an NHS culture that could be termed ‘ossified’ and ‘risk-obsessed’, and to allow organisations and professions to exercise at least some degree of professional autonomy, we may need to try and educate the public to accept that failure is possible and that nurses and doctors cannot always guarantee a perfect treatment outcome. Patient expectations may have to be adjusted downwards.

As Powers (2004) states:
The NHS may need to think less about regulation and audit and try to guard against its seemingly natural reactive tendency to create new organisations whenever a new major crisis happens. As Powers (2004) argues: ‘the test of good governance would not necessarily be the speed of their reaction to failure; on the contrary, it might be their ability, in Peter Senge’s phrase, “to take two aspirin and wait”.’

The political policy drivers who control and manage the NHS may not yet be ready for ‘Politics of Uncertainty’ (Powers 2004), but thought should be given to the concept, particularly in the consent to treatment process and in communication with patients generally. NHS policy makers also need to think more proactively and guard against their natural centralist regulatory tendencies.

A patient may wish to complain and asks a nurse about appropriate channels. To function effectively as a patient advocate, the nurse must have a reason-able working knowledge and understanding of the complaints system and protocols (Tingle 1990), in particular his/her own local hospital complaints procedure. Minor complaints can often be handled by the nurse as they arise, and this is encouraged by Department of Health guidance. More significant complaints should be referred to the nurse’s line manager.

A rise in complaints or clinical negligence claims may not necessarily be directly attributable to a general deterioration in the quality of the health service, but rather to a much more informed, consumer orientated and less deferential public which maintains high expectations, (albeit perhaps unrealistic expectations) of the health service and what can be achieved. It is clear that a more vocal public is increasingly holding all types of professionals to account. Initiatives such as the Patient’s Charter (Department of Health 1995) and the Government’s health quality reforms (Department of Health, 1997 and Department of Health, 2000), which are intended to forge a quality-driven NHS, have raised patient expectations and helped draw attention to the patient’s right to complain. Government health policy has been in recent years to put the patient firmly at the centre of the NHS (The NHS Plan, Department of Health 2000) The NHS Plan worked from a pure patient focussed premise:
The Shipman case (Beecham 2000) and the Wisehart Bristol heart surgery scandal (Dyer 1999), widely reported by the media, have also kept medical and nursing matters well in the public eye, have inevitably driven up care expectations and, along with other medical scandals, have caused the government to reflect on complaint systems and other matters. Berrington & Barnwell (1995) discuss the Central Statistical Office publication Social Trends (vol. 25) and note: ‘Britons have become healthier, sometimes wealthier and more likely to own their own homes; higher expectations mean we are also increasingly dissatisfied’.

Health complaints and litigation can be seen in a much broader and more generalised context: we live now in a much more complaining and litigation-conscious society. The mantle of infallibility exuded by many health carers seems to have been largely eroded in the minds of many patients today. We hold our health carers to account, like any other professionals involved in providing professional services. Health professionals may in some respects be at a disadvantage in that complaints made against them are more likely to attract media attention because of the ‘human interest’ factor. Finally, it must be remembered that, where a complaint is made in the context of health care, it is not simply a matter of ensuring that a fault is remedied. There is an important issue of public accountability in the context of the NHS (Simanowitz 1985).

Health-care provision is a matter of public funding and of public concern. There is an expectation that health-care providers should be accountable. Nurses need to be aware of the complaints process and the fact that they may be the subject of complaints made, whether at informal or formal level. It is also important that the nurse is aware of what rights patients have in this area regarding his/her role as patient advocate. Nurses also need to be aware of the mechanisms that have been developed to enhance patient safety as this is also an aspect of professional accountability.

Hill (1991) of the Medical Defence Union also offers some useful guidance on complaint handling: ‘When dealing with patients’ complaints remember the four S’s: complaints should be handled SPEEDILY, with SYMPATHY, to the patient’s SATISFACTION, and (if indicated) with an expression of SORROW. Conciliation, not confrontation should be the goal’.

It is important to remember that a complaint could result in litigation.

Complaints should be analysed for trends.

Frequently a patient’s complaint, or the commencement of a legal claim, may arise from his/her confusion, anxiety and frustration at not receiving a satisfactory explanation of why something has gone wrong; frustration that may result in anger and trigger off a complaint (Medical Defence Union 1993). Litigation or a formal complaint might never have taken place had the patient been given an understandable explanation of what had gone wrong and the steps being taken to remedy matters. Vincent and colleagues (1994) surveyed 227 patients and relatives who were taking legal action through five firms of plaintiff solicitors. They found that the decision to take legal action was determined not only by the original injury but also by insensitive handling and poor communication after the original incident. The following four main factors were identified in the analysis of reasons for litigation:

• Accountability

• Explanation

• Standards of care

• Compensation and admission of negligence

Patients and relatives wished to see staff disciplined and called to account. They wanted an explanation and felt ignored or neglected after the incident. They also wanted to make sure that the same problem did not happen to anybody else.

Complaints may or may not have a reasonable basis. Truelove (1985) states: