There are a lot of complaints these days about services but don’t forget that we used to have no services at all.
Trust between the public and the services has gone down.
Complaints provide valuable feedback for services.
A new way is needed so families and services can participate together.
At a social occasion some time ago a very upper-class lady, obviously of the better sort, rounded on my wife and exclaimed “are you a complainer?”. That incident has become part of family lore, but it’s a good question if you have a dependant or you yourself are at the receiving end of care services.
This article looks at the business of complaining inside and about a care service, and is a commentary on how the voluntary care organisations fit into current society, and the complaint culture that seems to be all around us.
Before looking at complaints themselves, let’s remember that those of us who have been involved in building up a care service for many hundreds of families are looking at a success story! Forget for a moment the current shortfalls, the frustrations because of the shortage of resources, the scandals, the anger of many families and the rest of the negatives. Think of the positives, and the good changes that have occurred in the delivery of services to intellectually impaired persons and their families over the last forty years!
Some years ago, most voluntary services were created against a social background in Ireland, where:
- There existed no provision for boys and girls that were intellectually disadvantaged, (to use the, now, thankfully, outmoded term, “mentally handicapped”);
- Many, desperate families led local movements, that resulted in the establishment of volunteer-led services – these grew from a few helpers in a borrowed room, depending on endless coffee mornings raising a few punts (it was punts in those days!), to complex organisations spending millions of taxpayers’ money;
- Parents were facing the burden of children who had grown into young adults with major difficulties. They were desperate for almost anything, and often they were living in difficult circumstances as well;
- Parents sought assistance and relief, from whatever source, not quite as supplicants. But a due deference to authority was the norm.
What has changed?
This social environment steadily changed, as one would expect over thirty or so years. That deference to those who have power is gone as a feature in Irish society, and now:
- Families are recognising that what were once voluntary “charity” funded services are, in fact, taxation funded professional services provided by suppliers under contract to the State, and since families are paying, then they have a right to expect to see their children’s needs met fully;
- Families are aware of the scandals in organisations that purport to be focused on care, but where it appears that in some cases staff are featherbedded and media exposure has shown appalling care practice, and in some cases alleged fraud;
- Where once there was a close community spirit between the local care workers (residential and day) and local people, there has been a separation.
The former synergy has been eroded by overarching central management which has driven highly-trained, professional staff to be acutely aware of regulations/inspections and the threat to them if they fail to comply.
Even the language demonstrates this separation, for instance:
- the “house parent” has become “the CRM, the Client Service Manager”,
- the individual client is now the subject of “a business plan”;
- Family views may sometimes be unreasonable, but parents will have spent their entire lives from the birth of their children, struggling to adapt to their changed family circumstances, very often fighting officialdom, and now in the current climate finding themselves distrustful of the care sector and its management. It need not be a surprising that many are angry.
At the risk of giving offence, it may be said that parents are sometimes binary in their complaints. The “binary approach” decrees that every organisation or person is either an angel or a demon! Typically, and quite rightly, parents focus on two areas, firstly on particular events relating to the treatment of their family member, and secondly, the treatment meted out to them by the service provider when they have, possibly, forcibly, expressed their complaint.
Even the prevailing personalities of individual staff members becomes a powerful component in the handling of complaints. At this point the “tone” of management becomes critical, along with the culture within the organisation. Unfortunately, each member of the management string is saddled with the risk of blame, liability, reputational issues, and serious accountability; this, consciously or otherwise, creates an organisational culture, which in turn drives the tone of how the service provider responds to a complainant.
All complaints occur within a community context, and part of the context is the reputation that a service has with a care service organisation, and what contributes to the reputation of a service is not easy measured. The public often look at what the media are saying and what they hear from local sources about internal disputes and problems, and arrive at skewed conclusions. Unfortunately, the service user is dealing with providers that usually have a local monopoly and the user has no redress except to complain.
Often management simply do not have the resources to meet quite reasonable requests, or have some other reason not to. In these situations, simply placating the complainant may be seen to provide an easy way out at the time, although it is somewhat dishonest! Obviously, integrity in handling complaints is critical, even if that means a clear NO. A common observation by complainants is “nothing was done” – nothing happened, and here good communication is found wanting.
Families complain about the lack of transparency in big organisations, although when queried on this issue, management will often insist that transparency is what they would wish to have. But, how much to tell, how much to disclose, and in the present climate, how much may be disclosed continuously bedevils a social service organisation. On the other hand, privacy law can be used as a handy defence mechanism. The customer in the shop wants to know what is in the packet, equally the consumer of care packages wants to know what is going on!
Complaints should be seen as valuable to a service provider. On the one hand, they provide some valuable feedback from the consumer on service standards and relationships; on the other, they represent an opportunity to test and sometimes correct the system’s quality controls and internal staff relationships; they can also expose the culture (of blame or supportive) within the service provider – prompting the analogy that without crashes, flying would not be as safe as it is.
In human services, dealing with people – both those receiving the services and those delivering them, all complaints are sensitive, sometimes toxic, and very often this becomes a battlefield. The worst possible way for services to deal with complaints is in a combative manner, although sometimes the exchanges that surround complaints can easily become threatening.
So what can be done?
Perhaps organisations should focus their attention on, and devise a new way to manage, the interface between user/family and the front line of service provision, between the customer and the provider.
Unless this “interface” is given attention, then complaints and misunderstanding will multiply (think Irish Water). The user is a “customer”, a vulnerable, anxious customer, who has suffered in ways that people who have not been there find it difficult to understand. They look to the supplier, not only for their rights, but for an empathetic and respectful response, certainly not any combative form of response.
A clear, structured policy by management to make users and their families “participants”, not simply “receivers”, would be good.
It is of interest to understand why it is that attempts to involve families in the governance process often seem to have failed. Why does the appointment of people who are seen to be representative of the user generally lead to dissension at the Boardroom table? Or, why does the creation of “focus” groups and other similar devices fail? The reasons are complex: they may turn on the professional vs the amateur viewpoint, and much else besides. However, two gaps in understanding by non-executive directors stand out – how to be effective, and how and when to use their powers. There is, furthermore, the problem of the balance of governance powers between non-executive boards (very much part- time), and professional executives, who generally want to be left to run the show as they deem proper! – and who can blame them for that?
Most organisations who provide care services are set up as “guarantee companies”. This is a corporate model that lays down certain ways in which the entity must be managed.
There are three key components in the governance structure of a typical Guarantee Company:
- the members,
- the board of directors, and
- the executive.
In general, the current position is that the Members and the Directors are self-appointed. There are exceptions, but structures to ensure a positive and clear input by the service users and their families are not common.
Hitherto, the “Members” component of the governance structure has been largely ignored. In fact, some care organisations have dismissed their members, and others are considering doing just that. But, maybe a carefully worked-out system of seeking and appointing members could create a “third force” in governance that might achieve a balance, ensuring the Company’s accountability upward to the statuary authorities, and downward to its customers. It might also provide a body embedded in the community that would have obvious benefits if the Members themselves understood their purpose and powers.
Done in a thought-out, deliberate and structured way, this is a change that would embrace the users and their family into the governance structure of the Company.
To take this a little further…
Perhaps members could become shareholders, able to purchase a nominal set of shares at a set price (say ten €1 shares?). The shares would be non-transferable, and would be bought back by the Company in certain circumstances. Of course, there would be no dividend distribution. Technically, ownership of a share would give the service user/family a clear stake in the service provider’s governance. It would make them a participant, if not in the direct management of the organisation then at least with a powerful influence. Moreover, the Directors and the Management would recognise a body to which om they would clearly be accountable.
This is high-risk stuff, difficult to design and operate, probably distasteful to executive management, nevertheless worth consideration. Again, the object should be to achieve participation.
Maybe service providers should turn their attention away from their accountability upwards to the HSE and other authorities and consider in depth their accountability downwards to the customer?
To sum up
Clearly, at the interface between the consumer of services and the deliverer, there are problems in the relationships between “them and us”. The service provider defence, if challenged, says that only a small voracious minority of consumers are generating bad feelings and the majority are happy with all aspects of service delivery. If this “statistical” defence is offered, it’s a poor argument and unsafe. Whatever the ratio between the “good view” and “bad view”, the provider must take clear steps to maintain its reputation in the community, not just for its own benefit, but so that users and their families have comfort in the quality of the service provided to their children.
Society is moving in a way that service providers should move, i.e. to embrace the consumer as a participant and to find ways actively to empower families in the organisation’s governance.
Public services in modern times must have a consumer orientation and for their part families should put aside the old deference and become knowledgeable and understanding participants in the governance of services.
Participate not Placate!
Some attempts have been made to do this, but seem to have failed – why? The failed processes need to be carefully examined by executive management and the non-executive board and a new model designed. The community must be brought into the governance process in a positive way.
Does this mean change for executive management, the non-executive board and governance?
Yes, it most certainly does.