Dealing with persistent or unreasonable complaints

MDDUS advisers have seen an increasing trend over the past few years where both medical and dental practices are seeking advice and assistance in dealing with persistent complainants, many cases with an element of verbal abuse and aggression directed towards staff.

Pre-pandemic it was fairly normal for our advisers to offer specific advice to members on a complaint and that tended to be the end of the matter. More recent engagement with practices and case file experience suggests that complainants are becoming more unremitting and difficult to manage.

Stressful cycle

Handling such complaints can contribute to a more challenging work environment, with practices already dealing with higher patient demand, increased waiting times for appointments, tests and reports, as well as longer patient referral times. This may be further compounded with increased staff sickness levels through Covid and other illnesses, including stress-related conditions.

Such pressure can, understandably, result in instances where practices may be less empathetic towards complainants and in their responses to complaints, particularly when a practice feels that however they respond patients will complain further. A perceived resistance to dealing with negative feedback could be interpreted as the practice being less approachable and helpful, leading to an escalation in complaints.

This may also create situations in which some patients exacerbate already difficult issues with additional interpersonal conflict. Complainants may become more aggressive in their behaviour, or more persistent in pursuing a complaint that previously might have been more easily resolved.

Forceful versus abusive behaviour

Any complaint is by definition an expression of dissatisfaction with the service but it can take on a new dimension if it involves verbal abuse, foul language, implicit/explicit threats or violent behaviour.

It is important not to lose sight of the fact that patients can act out of character in times of distress. Indeed, the Scottish Public Services Ombudsman (SPSO) confirms that they do not view behaviour as unacceptable just because a complainant is forceful or determined, and they acknowledge that many complainants are angry or upset. They do, however, make clear that they will not accept aggressive or abusive behaviour and emphasise that violence is not restricted to acts of aggression that may result in physical harm, but also includes behaviour or language (whether verbal or written) that may cause staff to feel offended, afraid, threatened or abused.

No doubt, abusive behaviour or actions by a patient using your service can make it very difficult to deal with a complaint. This could involve abuse of staff or disregard of the complaints management process, and when this occurs practices must take action to protect their staff.

Practices must also consider the impact of such patient behaviour on their ability to do their work and provide an effective professional service.

Policies and guidance on unacceptable behaviour

All practices should have a complaints policy in place, with timelines compliant to local jurisdictions. Practices should also have an unacceptable behaviour or engagement policy, which clearly sets out what types of behaviour will not be tolerated and how any breaches will be dealt with. This should be clearly communicated to patients via the practice website, information leaflets or suitable posters in reception. Such a policy should be considered a separate function from complaints management.

Any practice policy for addressing unacceptable behaviour should reflect the requirements of the relevant regulatory guidance and any contractual obligations.

General Medical Council guidance on Ending your professional relationship with a patient gives examples of the types of rare circumstances of breakdown of trust between doctor and patient which may justify ending the professional relationship. These include where a patient:

• has been violent, threatening or abusive
• has stolen from you/the premises
• has persistently acted inconsiderately or unreasonably
• has made a sexual advance to you.

Paragraph 5 states that you should warn a patient that you are considering ending the professional relationship. This normally requires the patient to be sent a formal letter which clearly outlines the specific reasons for the warning and the potential consequences should there be any repeat behaviour. We would recommend that warning letters detail how you investigated the concerns raised in relation to the patient’s unacceptable behaviour, for example by reviewing any CCTV or telephone recordings and speaking to team members involved. A warning letter is valid for 12 months.

The General Dental Council’s Standards for the dental team (paragraph 1.7.8) also states: “In rare circumstances, the trust between you and a patient may break down, and you may find it necessary to end the professional relationship. You should not stop providing a service to a patient solely because of a complaint the patient has made about you or your team”.

It goes on to advise that “you must be satisfied that your decision is fair and that you are able to justify this. You should write to the patient to tell them your decision and the reasons for it”.

Both the GMC and the GDC are clear that you should not end a professional relationship solely because of a complaint the patient has made. There will however be cases in which the termination of the relationship is justified, even against the backdrop of an ongoing complaint. The key is to ensure that you can justify your decision with reference to the practice policy and regulatory guidance and that arrangements are made promptly for the patient’s continuing care. It is advisable to separate complaint correspondence from that related to a warning or decision to remove a patient.

Other types of unacceptable behaviour

As noted above, one of the examples given by the GMC that may lead to a breakdown of trust is where the patient has persistently acted inconsiderately or unreasonably. This may come into play when a patient’s behaviour impacts substantially on the work of the practice. Some practical examples might include:

• repeatedly demanding a complaint response within unreasonable timescales, for example in the number of calls or contacts over a short period
• insisting on speaking to a particular individual when that is not possible under the circumstances
• patients repeatedly complaining about the same issue after it has been investigated and responded to.

In effect, it is when a demand is taking up excessive amounts of time, particularly if disadvantaging other patients.

MDDUS advisers are always available to support members with advice and assistance in these matters, and we would encourage early contact with MDDUS to assist with the complaint process. Complaints and the emotions and behaviours they can generate in all involved parties can be diverse and complex and we can assist members with the individual circumstances and challenges they face.

Practical tips

In dealing with challenging complaints, some practical tips include:

• Take a breath before reacting instinctively.
• Try to understand the issue from the complainant’s perspective and demonstrate empathy.
• Make sure a proper investigation into the matters raised has been carried out, with all aspects of the complaint considered to minimise opportunities for a complainant to persist with any unanswered points.
• Double-check the wording of complaints response letters and other written communications including any warning letters.
• Take advice from MDDUS or colleagues.

KEY POINTS

• Seek early assistance from MDDUS with persistent complainants or those displaying unreasonable/disruptive behaviour.
• Be aware that patients can also act out of character when in pain or frustrated by issues such as delayed access to care.
• Consider developing an ‘engagement policy’ which clearly sets out what is acceptable and unacceptable behaviour.
• Be prepared to challenge and manage unacceptable behaviour.
• Remain aware of professional and regulatory standards when ending professional relationships with patients.

Alan Frame is a risk adviser at MDDUS