I’ve had my first complaint

DSC00763Yesterday I received the first complaint of my 35 year career through the Health Services Comp
laints Commission. It was submitted on behalf of a patient by my local MP’s office. I spent a few hours yesterday coming to terms with it and again today responding. It has made me realise that we have a problem. I have written to my local MP requesting the chance to spend some time with him to explain the implications of formal complaints through the HSCC after determination of my complaint. I am experienced enough to take this on the chin, but a less experienced doctor will undoubtedly find such a process daunting and is likely to see the community as hostile.

There is no doubt that there is a very great need for a clear and powerful pathway to complain as a citizen about the health care we receive. It is also fundamentally important that this process is geared to deal with complaints at different levels. If the person has been harmed or suffered in a major way, it is important that this goes to APHRA and into a legal process where appropriate. If the person has been harmed in a temporary way, caused to suffer unnecessarily or does not feel that they received adequate care or information, this should lead to a local and careful process. Any claim of offense should be taken very seriously.

However, if the person has been inconvenienced or communication has been poor but has had reasonable care, or the complaint is vexatious, then the professional should not be required to respond in a lengthy manner and should not suffer unduly. If this happens frequently the community will receive more and more defensive care of dubious value. There are already many GPs who largely do what patients request for fear of complaint. Interestingly, a US study has shown that doctors who have very high levels of patient satisfaction have poor outcomes, even in terms of mortality. Patients don’t always know best.

We also need to acknowledge that there are the normal checks and balances that operate in terms of patient experience were no harm results. Patients are free in Australia to seek health care elsewhere or complain to the provider, even publicise the problem (now common on social media). I believe this should be the accepted pathway when no harm has been caused. Accredited general practices have to demonstrate that they act reasonably in such situations and keep a register of complaints.

Such unsatisfactory experiences are universal in all service settings including healthcare settings and some providers and some patients find it difficult at times to understand the situation of the other person. Regulation and heavy handed approaches will not solve this very human situation.

How can we ensure that these increasingly common formal complaint processes do not cause more harm than good? First, a professional who has received a complaint should be able to discuss the complaint with a qualified professional within the complaints environment. This could resolve situations where there are clearly no grounds for complaint and where a conciliatory process is inappropriate. While this might appear to be more costly it would forego the costs to many professionals of the hours spent dealing with a complaint, the demoralising effect of receiving notice from a statutory body and the loss of face with colleagues.

 Second, there needs to be some formal redress for vexatious complaints or minor complaints that have used this heavy handed approach to be heard rather than seeking conciliation through the provider. This requires responsibility of those managing the process to ensure maximum general good and not just meeting the complainant’s wishes. It also requires an apology from the statutory body to professionals when processed complaints are found to be inappropriate or vexatious. Again, while there is no professional input within the complaints environment prior to passing the complaint to the professional this is likely to be frequent.

I fear formal complaints will become all the rage, encouraged by social media and politicians standing up for a fair go. At present the professional has to respond according to legislation – no doubt for our own good. Don’t mistake me, I do believe conciliation is the best approach and practice this avidly in our setting. However, at times it is not helpful to seek conciliation and it is most appropriate to separate and for the patient to seek health care elsewhere. I think a practitioner should have the right to ignore the complaint with the understanding that legal approaches may costly and perhaps not covered by medical defense insurance. Sometimes we know there is absolutely no cause for complaint and absolutely no chance that reconciliation will change anything. What should we do?

Facing complexity

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The wonderful Jan Radford (you should follow her on twitter)  drew my attention to Garth et al’s excellent study on repeat prescription management in general practice. I enjoyed the approach, a  feel good experience. On reflection I think this paper is avoiding complexity and seeing it as a problem for the consumer. Is that fair?

Why do people take medications that are of marginal benefit or doing them harm? Why do so many patients attend and ask for their scripts without any concern for their health and the continuing relevance of these medicines?

My introduction to the study of repeat prescribing was Michael Balint’s excellent research work with a group of GPs entitled “Treatment or Diagnosis: research into repeat prescribing in general practice” published in the 1970s. Although this predates many pharmaceutical treatments for chronic disease, it raises critical issues with regard to human behaviour and receiving medications as a surrogate for care. These are perhaps more relevant today. What does taking the medication mean for that person? Did it start when their mother died, perhaps their child or spouse? Is it the one remaining legacy of a doctor that helped them a great deal and is missed terribly? Does it avoid conversation and inquiry and keep the doctor happy?

A friend told me how he turned up for a script for his epileptic medicine for years after he stopped taking it, just to keep the doctor happy – he was too scared to say he had stopped it. Many people are afraid to stop taking something that affects them negatively for fear of something worse – the wrath of relatives or doctor? The fear of withdrawal effects?

We are the source of repeat prescribing and if we expect people to be organised 99% of the time, then a few people will run short unexpectedly every day. Should we blame them? The amounts vary – 28 or 30 tablets for some things – 25 or 50 tablets for others – 5 or 2 repeats. How do they manage at all? Is the list of medications in their file an “all time list” or an up-to-date managed list. Do you actually know what they are taking?

Then we have the narcotic repeat prescriptions – perhaps 100,000 medical addicts who cannot be late or they feel sick. When will we doctors learn that narcotics do not work for chronic pain, in fact they clearly exacerbate the problem. And Endone should be banned (along with its long acting preparations). What are we doing to people? A pain clinic referral is unlikely to help as the return letters  only seems to justify the damage or at least ease the conscience of the GP.

Finally, we can insist on people waiting for an appointment if they urgently need a script but have been reviewed recently, as a punishment and monetary tactic. This enables the doctor to be seen and the fee to be subsidised or bulk billed.  Is this a reasonable use of public money and is there any measurable benefit?

Repeat prescribing is truly complicated, involving issues of compliance, funding, safety, quality and motivation. Difficulties cannot be seen solely as a problem patients bring on themselves.  The doctor’s statement “Your lack of organisation doesn’t constitute our emergency” could be reflected as “Your complexity, dependency inducement and chaos causes our emergency”. Whatever your point of view, repeat prescribing illustrates the complexity of modern general practice.