Version: 1.0 (Initial Release) | Date: 1 July 2025
1. Purpose
1.1 The purpose of this document is to define the process for the management and resolution of customer complaints.
2. Scope
2.1 This procedure applies to customers who have accessed the service either directly or indirectly i.e. through a third-party service agreement; or whilst using a contracted consultant who delivers services within a Harley Street Medics (HSM) Clinic. The complaint can relate to any product or part of the service delivered to the customer.
3. Reference Documents
3.1 QAP – Corrective and Preventative Actions (CAPA)
3.2 QAP – Customer Focus & Satisfaction
3.3 FM – Customer Complaint Form
3.4 FM – Patient Proxy Form
3.5 REF- Making a Complaint – Patient Guidance
4. Description of activities
4.1 General Policy
4.1.1 In any organisation the customer complaints process is key to allowing patients the ability to raise concerns about any element of the service.
4.1.2 The Clinic’s policy is to ensure that the complaints process is flexible and responsive to the needs of the individual complainant. In addition, it emphasises the need to communicate effectively with complainants and involve them in the decisions concerning the handling of their complaint. The policy seeks to ensure that:
- Patients / Customers who complain are listened to and treated with courtesy, respect, and empathy at all times.
- Patients / Customers who complain are not disadvantaged as a result of making a complaint.
- Complaints are investigated promptly, thoroughly, honestly and openly.
- Complainants are kept informed of the progress and outcome of the investigation.
- Apologies are given as appropriate.
- Action to rectify the cause of the complaint is identified, implemented, and evaluated through the Clinic’s Quality Improvement process.
- Learning from complaints informs service development and improvement.
- Complaints handling complies with all confidentiality and data protection policies and is transparent.
- Staff involved in complaints are given the appropriate level of support.
4.1.3 There are several ways that complaints can be made, and it is important to have a simple yet robust method of dealing with any complaint in any format. It is important that for any complaint the Clinic has a documented record of the complaint, and this may be in the form of a letter or an email or the clinic will complete the FM – 006 – Customer Complaint Form which we will use as a reference document for the initial complaint should the complaint be received verbally.
4.1.4 To comply with patient confidentiality requirements normally the clinic would only deal directly with the patient concerned. In the event that someone else complains on behalf of a patient or the patient nominates someone else such as a family member or legal representative, then the patient will be required to complete FM – Patient Proxy Form. Under NO CIRCUMSTANCES will the clinic disclose medical nor commercial information relating to the patient without this authority in place.
(Note – Members of Parliament (MP) are considered to have the consent of the patient when pursuing complaints on their behalf (GDPR special category data – Article 9).
4.1.5 If the patient wishes, this form can be e-mailed to them with the instructions on how to fill this out contained in REF – 002 – Making a Complaint – Patient Guidance.
4.1.6 All Complaints will be recorded on the complaint management system. Note that during the investigation process the complaint file MUST be routinely up dated with details of the investigation, how it is proceeding and all communication with the customer or their representative; both written & verbal.
(Note – information on Customer complaints will not be stored under the patients record)
4.1.7 It is important that all documents received, sent or created during the management of the complaint are identified appropriately and dated with the date they were either sent or received.
It is important that any e-mails that relates to a customer complaint should be replicated as a pdf and also saved in in the complaints folder.
4.1.8 Complaints will be accepted:
4.1.9 Within 6 months of the event the patient wants to complain about
4.1.10 Finding out you have a reason to complain, but no longer than 12 months after the event.
4.1.11 Complaints can be accepted after this time limit if it is deemed appropriate.
4.2 Initial Review
4.2.1 The complaint will be assigned to the Clinic Director (CD) for initial review. At this stage, the complaint may be “Accepted” or “Rejected”.
- Accepted: The complaint is considered as valid and requires further action.
- Rejected: The complaint is either not valid or may only be a concern.
Note: Although a complaint may be rejected it has been logged and it may only be a concern, but it is important that these are also tracked within the system.
4.3 Dealing with a complaint through the process
4.3.1 All staff are responsible for working to resolve concerns raised by customers / patients. Prompt action to resolve concerns can prevent them escalating into more serious complaints.
4.3.2 Where a complainant is reporting a poor experience within the Clinic, it is appropriate for the person receiving the complaint to apologise on behalf of the Clinic. Apologies and explanations of adverse events do not alone constitute an admission of liability.
4.3.3 Concerns and issues may be raised during a customer’s / patient’s visit or treatment at the clinic and the customer / patient may not wish to make these formal complaints. If staff are able to resolve them by the end of the next working day or earlier, they should attempt to do this.
4.3.4 When dealing with a complainant staff must:
- Ensure that they take time to listen and ensure they fully understand the concerns; this may mean asking for clarification where elements are unclear.
- Reassure the customer / patient that complaints are welcome as a means of enabling the service to improve.
- Respond to the issues raised or refer the complainant to someone who can assist them further.
- Contact the CD if any issue is serious and cannot be resolved by the end of the next working day.
- The manner used to respond to concerns must never be dismissive, curt, or negative. Care must be taken over the messages sent out in the first interaction as this will set the tone and often influence the likelihood of dealing with the issue and looking to repair the relationship.
- The member of staff to whom the complaint is made is responsible for ensuring it is recorded on the Complaint Form and is updating the complaints system.
- Note: A “Complaints Folder” containing paper copies of correspondence may be maintained during the complaints process for practical reasons, however on a routine and timely basis all documents will be added to the digital complaint folder.
4.3.5 Behaviour must be reasonable by all involved in this process. The actions of complainants who are angry, demanding, or persistent may result in unreasonable demands of, or unacceptable behaviour towards staff. Clinic staff are not expected to tolerate abusive or threatening behaviour, but all complaints must be given equal consideration and be investigated.
A complainant’s behaviour may be considered unreasonable if:
- The complainant has threatened, has harassed or been abusive towards staff.
- The complainant continually makes unreasonable demands on staff.
- The complainant insists on speaking to a particular member of staff.
- The complainant frequently changes the substance of a complaint and prolongs contact with clinic staff by raising new issues during a complaint investigation.
- The complainant refuses to believe documented evidence given as factual and continues to contact staff following closure of a complaint investigation.
- The complainant makes frequent phone calls or sends repeated communication re-iterating existing concerns.
NOTE: This list is not exhaustive or fully inclusive.
It is essential that staff document all aspects of the complaint handling and the incidence of any of the above behaviours whilst dealing with a complainant and record this on the complaint system.
4.3.6 All complaints will be referred to the CD in the first instance, who is responsible for investigating complaints.
4.3.7 The level of the investigation into a complaint will reflect the complexity of the complaint and may involve small investigatory team.
4.3.8 Significant or high-risk complaints, which raise serious concerns about clinical governance or performance of the Clinic must be escalated to the CD who will carry out the investigation.
4.3.9 If a complaint is likely to become the subject of litigation, advice will be sought from the Clinic’s legal representative and or the consultant’s medical indemnity provider. This will be required prior to compiling and providing a complaint response.
4.3.10 If a complainant alleges discrimination of any kind, a copy should be sent to the Clinic’s legal representative for review and comment.
4.3.11 As per previous sections, complete and accurate records must be kept and updated the complaint system and be available. These must include as appropriate:
- The original complaint and other relevant information.
- The issues considered.
- Decisions or actions taken.
- Discussions/correspondence with the complainant, their representatives, or advisors.
- Copies of all staff responses and all other information collected during the investigation.
- Clinical/legal advice taken and details of the advisors.
NOTE: All complaint investigations should address the underlying cause of the complaint and provide clear action plans to prevent them happening again which should be input to the Clinic’s corrective action system.
4.4 Responding to a Complaint
4.4.1 The response to a complaint must include a summary of the investigation findings and any actions taken to resolve the problems.
4.4.2 The response will include the contact details for complainants to use if they remain dissatisfied and wish to escalate.
4.4.3 A response to a complaint must be sent as soon as practicable. The Clinic’s goal is that all complaints will be acknowledged in writing within one working day and a formal response to the complaint will be sent within twenty working days where that is practical.
4.4.4 If a response is not provided or resolution of the complaint is not achieved, in the time agreed with the complainant, contact must be made with the complainant to negotiate a revised deadline. This must be documented. If the complainant does not agree to an extension and the original due date is not met the complaint is considered overdue.
4.4.5 If it is likely that a complaint will be overdue and the complainant has not agreed to an extension, a telephone call must be made to discuss this with the complainant, or a holding letter sent five working days before the response is due. Holding letters must explain the reasons for the delay and give an indication of when a response will be available. Regular contact must be maintained with the complainant.
4.4.6 Local Resolution Meetings will be offered to all complainants as many complaints arise from misunderstandings or poor communication in the first instance and a face-to-face discussion is regarded as the most productive method of progressing complaints to a successful resolution.
4.4.7 The CD will organise and attend all such meetings and will be responsible for ensuring that an accurate record of these meetings with a complainant is documented and minutes are placed in the complaints folder.
4.5 It is important to note that the process is a three-stage process as follows:
- Stage 1: As detailed above the CD along with the Complaint Handler if applicable will review the complaint, conduct an investigation and respond to the complainant.
- Stage 2: If the complainant is not satisfied with any part of the Stage 1 process, then the complaint will be escalated (normally) to the CEO who will review the initial investigation outcomes and conduct any further investigations as required. As above there will be a review meeting face to face with the complainant to discuss the findings and agree a way forward for both parties.
Both of these stages form the “Local Resolution” elements of the complaints process. - Stage 3: In the event that the first two process stages fail then the next step is to ask an external body – Hamilton & Fraser to become involved. This external organisation will have experience in dispute resolution and management, more information on this process are detailed in Section 4.6.
4.6 Independent Review
4.6.1 This may be required if all avenues of resolution and escalation are exhausted, and a complainant is still dissatisfied with the response they have received locally; they can request that their complaint is referred to an external organisation with experience in dispute resolution and management
4.6.2 Once the complaint has reached the Clinic Director level the response should provide the complainant with information that the final escalation point available to them would be an external service provider (ESP).
4.6.3 This ESP will be provided with a full dossier evidencing that the Clinic has done its utmost to resolve the complaint prior to offering the patient the opportunity to use this service.
4.6.4 The ESP will verify with the Clinic that the processes for local resolution and Medical Director Review have already been exhausted and obtain a response within 2 working days.
4.6.5 The ESP will facilitate discussions between the complainant and the Clinic where the complaint has not been through the local resolution process.
4.6.6 The ESP will ask complainants to clarify in writing which aspects of their complaint they wish to refer for adjudication and consent to this process and authorise the release of relevant case records from the Clinic.
4.6.7 The ESP will assign a named individual to consider the complaint who will have the necessary skills and experience to perform this role.
4.6.8 The ESP will remind complainants of their right to seek independent legal advice where any aspects of their complaint might give rise to a clinical negligence claim.
4.6.9 Once all of the above processes have been undertaken the complainant still has the right to pursue legal action if the nature of the complaint warrants this. It should also be noted that the regulator, HIS, is in general agreement with the use of an ESP as an impartial third-party service.
4.7 Final Review
4.7.1 On completion of the investigation, the CD will complete a final internal review of the results of the complaint investigation with the CEO, if required, and any other relevant members of staff.
4.7.2 The CD will complete the final complaint response letter, which will be approved by the CEO prior to sending.
4.7.3 The complaint response letter will be sent to the complainant clearly responding to the points raised in the original complaint and requesting formal acceptance of the outcome within ten working days.
4.7.4 If the complainant accepts the findings, the process will continue from 4.8 below and the complaint will be formally closed.
4.7.5 If the complainant does not accept the findings, the following steps will be followed:
- Stage 1 Complaints: The complaint will be escalated to the Clinic Director and changed to a Stage 2 complaint. The complaint will continue from 4.2 above.
- Stage 2 Complaints: The complaint will be escalated for independent review to the an ESP and the complainant advised. The process will continue from 4.6 above.
- Stage 3 Complaints: The clinic views the decision of the ESP as final, as per 4.6 above, and the complaint process will be closed.
4.8 Closing a Complaint
4.8.1 During the investigation process the complaint system will have been updated with the relevant details in the fields below:
- Investigation: Including any communications by email within the complaint record.
- Non-Conformances: Details of the non-conformance identified.
- Corrective Action: Details of actions taken to correct the complaint and any email correspondence. This will be completed in line with QAP – 018 – Corrective and Preventative Actions.
- Preventative Action: If relevant, details of actions taken to prevent recurrence of the issue which caused the complaint and any email correspondence. This will be completed in line with QAP – 018 – Corrective and Preventative Actions.
- E-Mails Sent: This is a repository of all e-mails sent on this incident. This provides an excellent audit trail for communications on the incident.
- Final Review
4.8.2 The complaint file will be checked to ensure that all paper copies of documents, emails and any other electronic documents created during the complaint investigation have been scanned and saved to the complaint file.
4.8.3 The complaint will be formally closed on the complaint system.
4.8.4 At this point the complaint is deemed as being closed with all data regarding the incident stored in the complaint file and accessible for review at any point in time.
4.9 The Regulator
4.9.1 The complainant will be informed at the start of the process, that at any point during the complaints process, they have the right to complain directly to Healthcare Improvement Scotland HIS. Details are as follows:
Healthcare Improvement Scotland
Programme Manager
Independent Healthcare Services Team
Healthcare Improvement Scotland
Gyle Square
1 South Gyle Crescent
Edinburgh
EH12 9EB
Email: his.ihcregulation@nhs.scot
4.10 The Financial Ombudsman Service
4.10.1 If you have a complaint that relates to the performance of our finance service provider; if you believe that you have been mis sold any products or services; or if you believe that there have been any financial irregularities in your dealings with Harley Street Medics, your complaint will be dealt with through our standard complaints process. In these cases, if you feel, after the complaints process has been completed that you are still not satisfied with the outcome you can raise your issue with the Financial Ombudsman Service whose contact details are as follows:
Financial Ombudsman Service, Exchange Tower, London, E14 9SR
Website: www.financial-ombudsman.org.uk
Email: complaint.info@financial-ombudsman.org.uk
Phone: 0800 023 4567 or 0300 123 9123
5. Roles & Responsibilities
5.1 All staff must be familiar with complaints handling processes. This includes details of how customers / patients can make complaints, and to whom.
5.2 The CD is responsible for the effective operation of this policy and procedure within the Clinic.
5.3 The CD is responsible for the effective management of all complaints within the Clinic.
5.4 The CEO is the escalation point for any local complaints that cannot be resolved by the CD.
5.5 The CEO is responsible as the handler for all complaints that indicate patient safety may have been compromised within the Clinic and all complaints that come via a patient contact with the GMC or any other regulatory body.
5.6 The CEO will be responsible for handling any complaint that results in litigation or the involvement of a Medical Defence provider.
6. Monitoring compliance with and effectiveness of procedure
6.1 Any issues that arise from a failure within this process for whatever reason will be logged on the Clinic Corrective and Preventative Action System and will have route cause corrective action performed on them.
6.2 There will also be a monthly review of customer complaints which will review inputs from all sources with this process and any actions arising will be fed into the Corrective Action process.
7. Review frequency
7.1 This policy will be reviewed periodically and no later than 3 years from date of publication. All versions of this SOP will be archived.