Patient complaints and feedback (Scotland): standard operating procedure (SOP)

Date of SOP preparation / SOP Prepared by (full name + position in pharmacy business) / Date of next review
SOP version number / Signature / Date review takes place and initials
SCOPE / This SOP sets out the procedures to be followed when dealing with patient or patient representative feedback, concerns or complaints regarding the pharmacy, staff or services, in order to be compliant with the Patient Rights (Scotland) Act 2011(‘the Act’), the Patient Rights (Feedback, Comments, Concerns and Complaints) (Scotland) Directions 2012 (‘the Directions’) and the NHS Scotland complaints procedures as set out in the Patient Rights (Complaints Procedure and Consequential Provisions) (Scotland) Regulations 2012 (‘the Regulations’)
Using the SOP /
  • This SOP has been designed to be used within community pharmacy premises
  • The SOP should be tailored, where appropriate, to reflect processes in individual pharmacies
  • Changes to the SOP should be considered carefully as some processes are based on legislative requirements or good practice recommendations
  • This SOP can be used in conjunction with the NPA resources “Patient Feedback, concern and complaints reporting template”, and “FAQs - Patient feedback, concerns and complaints- Scotland”
  • This SOP is not designed to be used as a legal document; rather it is designed to enable community pharmacists to comply with current legislation concerning patient feedback, concerns or complaints including the Patients Rights (Scotland) Act 2011 for working in a community pharmacy, referring to relevant guidance and legislation if necessary
  • The SOP should be agreed with the superintendent pharmacist and/or pharmacy owner

Legislation /
  • The Act gives patients a legal right to provide feedback on NHS services
  • The Directions require that all NHS staff should be able to listen and respond to feedback, comments and concerns appropriately, effectively and efficiently
  • The Regulations set out the NHS complaints procedure that must be followed
  • This legislation applies to all NHS staff including those working in NHS independent contractor pharmacies. Feedback and complaints can be provided directly to the NHS body
  • Additionally, the Regulations require every pharmacy to designate a member of staff to manage feedback and complaints
  • The Directions require that pharmacies ensure that all patient facing staff are trained on receiving feedback and complaints procedures and the associated guidance stipulates that complaints are fedback quarterly and feedback annually to their NHS Board

Background /
  • When a patient provides feedback, raises a concern or complains in a pharmacy there are procedures that the pharmacy needs to follow, as legislated by the Act, the Directions and the Regulations
  • Additionally, the General Pharmaceutical Council (GPhC) “Standards for registered pharmacies ,2012” require that:
  • “1.4 Feedback and concerns about the pharmacy, services and staff can be raised by individuals and organisations, and these are taken into account and action taken where appropriate”
  • “2.4 There is a culture of openness, honesty and learning”
  • It is important that all staff understand their responsibilities regarding patient feedback and the procedures to be followed in the event of a complaint
  • Staff should be able to signpost patients to information on how to provide feedback on the healthcare services provided by the pharmacy

SOP with guidance

Action/
activity / Procedure/steps / Guidance / Authorised member of pharmacy team
1) Employer’s responsibility / a) Ensure information is available to patients to support them to give feedback, comments or complaints
b) Ensure all patient facing staff can support patients or carers to feedback and complain
c) Designate a member of staff as the feedback and complaints officer
d) Ensure complaints and feedback are reviewed
e) Report complaints quarterly to the local NHS Board
f) Report feedback annually to the local NHS Board /
  • Information for patients should be clear and current and should include information about the Patient Advice and Support Service (PASS) - see:
  • The feedback and complaints officer is the main point of contact for patients who have a complaint
  • Reviewing feedback and complaints can help identify learning points to improve pharmacy practice

2) Training / a) Ensure that all patient facing staff receive training on the feedback and complaints procedures
b) Ensure training on receiving patient feedback and complaints is included in the induction process of new patient facing staff /
  • The Directions require every pharmacy to train all patient facing staff on feedback and complaints procedures
  • The Scottish Government has produced a reference leaflet for health professionals and patients: “Can I Help You? Guidance for handling and learning from feedback, comments, concerns or complaints about NHS health care services”
  • Training for pharmacists and pharmacy staff on dealing with feedback, concerns and complaints is available in a variety of forms from:
  • National Education Scotland:
  • NHS NES Scotland Knowledge Network:
  • Scottish Government: www.gov.scot/Publications/2012/03/6414/downloads
  • Training is available on the Act, the NHS Complaints procedure, as well as diversity and equality training and soft skills including active listening skills

3) Feedback and complaints officer / a) The feedback and complaints officer should:
  • Be the main point of contact for patients and staff when feedback or complaints are received
  • Record the feedback, concerns and complaints
  • Investigate patients’ concerns in line with NHS Complaints procedures
  • Respond to patients in accordance with the NHS Complaints procedure.
  • Take the complaint further to mediation with the local NHS Board if resolution has not been obtained by 20 days
  • Review complaints and feedback to identify changes to practice that will improve patient care
  • Record any changes made as a result of patient complaints or feedback
  • Supply the local NHS Board with information on NHS feedback and complaints
/
  • The Patient Rights (Complaints Procedure and Consequential Provisions) (Scotland) Regulations 2012 require every pharmacy to designate a member of staff to manage feedback, concerns and complaints who will be known as the feedback and complaints officer
  • There is no requirement for the feedback and complaints officer to be a pharmacist

4) Other patient facing stafff / a) All patient facing staff should:
  • Know who is the feedback and complaints officer for the pharmacy
  • Signpost the patient or carer to the feedback and complaints officer
  • Actively listen to patients and carers providing feedback or a complaint
  • Respond appropriately to patients and carers providing feedback or a complaint
/
  • The Directions require all patient facing staff to support patients or carers to feedback and complain

5) Confidentiality / a) Maintain patient confidentiality in line with NHS policy
b) Store any documents recording patient complaints and feedback in accordance with the NHS Scotland Code of Practice for Patient Confidentiality /
  • Information should only be shared with other staff involved in the patient care
  • Never discuss a patient in a public place or within hearing of public and do not pass information to an external organisation without first getting the patient’s consent
  • Patient consent maybe required in the case of a carer providing feedback or complaint
  • Documents recording patient complaints and feedback may contain patient confidential information

6) Receiving feedback and complaints / a) Pharmacy staff receiving feedback or a complaint about an NHS service should:
  • Listen actively using communication aids if required
  • Signpost to the feedback and complaints officer if possible
  • Check the concern is understood
  • Ensure the patient has any necessary care
  • Record the concern.
  • Apologise if something has gone wrong
  • Obtain patient consent if required
  • Confirm the desired outcome for the patient or carer
  • Decide if it is feedback or a complaint
  • Explain and provide information on the NHS Complaints procedure.
  • Provide the PASS leaflet
  • Confirm the patient wants the complaint dealt with by the NHS complaints procedure
  • Confirm patient’s full name, address and preferred contact details
  • Confirm the name and address of the person making the complaint
  • Explain when and how the patient will be responded to
  • Provide contact details for the feedback and complaints officer for the pharmacy
/
  • Feedback and complaints can be received verbally in person, by telephone, or in writing including email, text, fax or letter
  • Consider any difficulties the patient may have in providing feedback or complaints
  • This could be literacy, language or cultural difficulties
  • Support the patient according to their needs
  • Be aware of local NHS interpretation services, large print leaflets and other NHS communication aids
  • When making a complaint, patients should provide their full name and address
  • A complaint should be made within six months and no more than one year from the incident or from finding out about the incident
  • A template form for recording complaints and feedback is at Appendix 2
  • The patient should be provided with the information leaflet to explain the Patient Advice and Support Service (PASS) which can be downloaded at
  • A patient leaflet explaining the Act is available to download at
  • This is available in a variety of forms and languages by contacting National Education Scotland 0141 223 1435 or email

7) Timeline / a) Respond to complaints and feedback within specified time limits /
  • Complaints need to be responded to within three days or, if this is not possible, acknowledged within three days and investigated within 20 days
  • If no resolution can be met within 20 days then alternate mediation must be used
  • Complaints should be reported to NHS Boards quarterly
  • Feedback, comments or concerns should usually be responded to within 7 days and reported to NHS Boards annually

8) Review / a) Regularly review patient feedback and complaints
b) Record any action taken as the result of receiving feedback or complaints /
  • Regular review of patient feedback and complaints can identify staff training needs or changes required to the pharmacy premises or workflow processes which would improve patient care
  • Any action taken as a result of receiving feedback or complaints to improve patient care should be recorded and noted for submission to the NHS Board

9) Reporting / a) Report complaints quarterly and feedback annually to the NHS Board /
  • Scottish Government guidance to NHS Boards in The Patients Rights (feedback, Comments, Concerns and Complaints )( Scotland) Directions 2012 require every pharmacy to report complaints quarterly and feedback annually to their NHS Board – NHS Board will provide reporting details
  • The Directions legislate that you must report to the NHS Board the following details:
  • Number of complaints
  • Number of complaints where dispute resolution was used
  • Whether the response was within 20 days
  • Summary of key themes of complaints
  • Summary of action taken to improve patient care services

10) Encouraging patient feedback / a) Encourage patient feedback /
  • Patient feedback can be encouraged in various ways:
  • Posters prominently displayed inviting feedback to any member of staff and highlighting the feedback and complaints officer contact details
  • Patient leaflets on feedback and complaints procedures either directly or indirectly via the NHS or Patient Opinion
  • Feedback and suggestion box accessible by patients and compliant with patient confidentiality guidelines –the NPA Sales department has a suitable survey box which can be wall mounted: item PSB0001A, available by contacting 03301230190 or at
  • Feedback forms issued at the time of receiving a pharmacy service –an example is provided at Appendix 1
  • Social media ––the pharmacy website, Facebook or Twitter can all be used for patients to provide feedback or for the pharmacy to invite feedback using surveys

References and further reading

  • General Pharmaceutical Council “Standards for registered pharmacies”, September 2012:
  • National Education for Scotland “-Can I help you? deal with patient feedback, concerns and complaints”:
  • NHS Education for Scotland Knowledge Network, “Valuing feedback and complaints”:
  • Patient Opinion :
  • Scottish Government, “Can I Help You? Guidance for handling and learning from feedback, comments, concerns or complaints about NHS health care services”:www.gov.scot/Publications/2012/03/6414/downloads
  • The Patient Rights (Complaints Procedure and Consequential Provisions) (Scotland) Regulations 2012: http://www.legislation.gov.uk/ssi/2012/36/contents/made
  • The Patient Rights (Feedback, Comments, Concerns and Complaints) (Scotland) Directions 2012:
  • The Patient Rights (Scotland) Act 2011: http://www.legislation.gov.uk/asp/2011/5/contents

Appendix 1

The feedback and complaints officer for this pharmacy is:

The feedback and complaints officer should be contacted at:

When you receive feedback or a complaint from a patient or carer about an NHS service, you should:

  • Listen actively using communication aids if required – interpretation services, leaflets etc
  • Signpost to the feedback and complaints officer if possible
  • Check the concern is understood – explain back to the person complaining what you think their issue is
  • Ensure the patient has any necessary care; f they require further medicine or care, alert your pharmacist
  • Record the concern using the template form
  • Apologise if something has gone wrong
  • Obtain patient consent if required – t may not be the patient who is complaining
  • Decide if it is feedback or a complaint
  • Confirm the desired outcome for the patient or carer - this may not always be reasonable to achieve
  • Explain and provide information on the NHS Complaints procedure.
  • Provide the PASS leaflet –downloadable or in print
  • Confirm whether the patient wants the complaint dealt with by the NHS complaints procedure
  • Confirm the patient’s full name, address and preferred contact details
  • Confirm the name and address of the person making the complaint
  • Explain when and how the patient will be responded to
  • A complaint needs to be acknowledged within 3 days and resolved within 20 days if at all possible
  • Feedback should be acknowledged within 7 days
  • Provide contact details for the feedback and complaints officer for the pharmacy
  • Contact the feedback and complaints Officer for the complaint to be investigated as soon as possible

Appendix 2 Template feedback and complaint form

Patient NHS feedback and complaint form
Date / Date incident took place
Complaint Y N / Feedback Y N
Name of person receiving feedback or complaint
Name and address of patient
Feedback and complaints officer available? / Y / N
Name of person making feedback or complaint
Address
Relationship to patient
Patient consent required? Y N / Patient consent
Confirmed? Y N / By? / How? / When?
Description of events leading to feedback or complaint
This description confirmed as correct by the person? Y N
Apology given? / Y / N / PASS
leaflet given? / Y / N / NHS Complaints explained / Y / N
Complainant confirmed NHS Complaints Procedure to be used? / Y N
Feedback and complaints officer contact details provided? / Y N
Details of when and how person complaining will be contacted provided? / Y N
Feedback and complaints officer alerted? / Date? / How?
Investigation description
Tick below which theme best describes the complaint or feedback
Staff / Dispensing / Stock / Premises / Communications / Other
Outcome of investigation
Communicated to person by / Agreed by complainant?
Name / Date / Face to face / Phone / email / ≤3 days? / ≤20 days?
Y / N / Y / N
Actions taken to improve future patient care
Date resolved / Within 20 days? / Y / N
Further resolution required by involving Local NHS Board / Y / N
This document may contain patient confidential information and as such should be stored in line with NHSScotland Code of Practice on Protecting Patient Confidentiality.
Highlighted sections should be reported to the local NHS Board quarterly for complaints and annually for feedback and should also include the number of complaints/feedback

Pharmacy staff declaration

IMPORTANT: The following declaration must be made by all members of the pharmacy team involved in delivering these services. To meet with the current legislation ensure that all pharmacists (including locums) and members of the pharmacy team have read, signed, understood and are implementing this SOP.

Declaration: I have read and understood this SOP and agree to implement the procedures set out in it when required.

Date / Full name and GPhC registration number (if applicable) / Signature

Disclaimer: The information published is, to the best of our knowledge, correct at the time of publication. However, no responsibility will be accepted for any consequences of decisions made using this information.