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BRIEFING PAPER

Number CBP 7168, 22 October 2019

NHS Complaints Procedures in England

By Thomas Powell, Elizabeth Parkin Philip Loft

Inside: 1. Overview 2. The standard NHS complaints

process 3. Inquiries into complaints

procedures 4. The Health Service

Ombudsman 5. Medical negligence 6. Judicial review 7. Complaints about individual

healthcare professionals: professional regulation

8. Complaints in specific circumstances

9. Organisations that can help

Number CBP 7168, 11 October 2019 2

Contents Summary 3

1. Overview 4 Statistics on complaints to the NHS 4

2. The standard NHS complaints process 6 2.1 What does the NHS Constitution say about complaints and redress? 7

3. Inquiries into complaints procedures 9 3.1 The Francis inquiries 9 3.2 Health Select Committee reports 10 3.3 Public Administration Committee report 12

4. The Health Service Ombudsman 15 4.1 The Ombudsman’s remit 15 4.2 Health Service Commissioner for England (Complaint Handling) Act 2015 16 4.3 Public Service Ombudsman Bill 2016 17

5. Medical negligence 19 5.1 NHS Resolution 19 5.2 Government Reforms 21

6. Judicial review 23

7. Complaints about individual healthcare professionals: professional regulation 24

7.1 Who regulates healthcare professionals? 24 7.2 Proposals for reform 25

8. Complaints in specific circumstances 27

9. Organisations that can help 30

3 NHS Complaints Procedures

Summary This Commons Library briefing paper provides information on NHS complaints procedures in England. The standard two-stage NHS complaints procedure, where complaints are first raised locally and with the option of referral to the Health Service Ombudsman, can be used for most complaints about NHS services. However, other options may also be appropriate in some cases depending on the objective of the complaint, such as obtaining an apology, compensation, disciplinary action, a change in policy, or a clarification of the law. Section 9, at the end of the briefing paper, lists some of the organisations that can provide help and advice to patients who wish to make a complaint about NHS services.

It is important to note that some care services are provided by local authority social services departments. Complaints about these services are outside the scope of this briefing but further information is available from the Local Government Ombudsman website.

Procedures for NHS staff to raise concerns are covered in a separate Library Briefing Paper, NHS whistleblowing procedures in England (SN06490).

Information for complaint procedures is published by the Health Services in Scotland, Wales and Northern Ireland.

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1. Overview The standard NHS complaints procedure can be used for most complaints about NHS services. However, other options may also be appropriate depending on the objective of the complaint, such as obtaining an apology, compensation, disciplinary action, a change in policy or clarification of the law.1

Where legal action is being considered professional legal advice should be sought and this is not something the House of Commons Library can provide.

A complainant seeking compensation might consider legal action; someone wanting to reform NHS practice and procedures, or simply seeking an apology, might choose the standard NHS complaints route; an individual who believed that a specific medical practitioner was at fault might complain to the relevant professional body such as the General Medical Council, which could ultimately prevent a doctor from practising; and for clarification of the law the person might seek judicial review.

Special procedures apply in certain circumstances, for example to patients raising concerns about treatment under the Mental Health Act, or in individual cases where the NHS has decided not to fund a specific treatment or package of care.

Where a MP is writing to the NHS on behalf of a patient and states, in writing, that they have a patient's consent to access confidential patient information, this should be accepted by the NHS bodies concerned without further resort to the patient.2

Statistics on complaints to the NHS Written complaints on NHS services have more than doubled between 2005/6 and 2017/18. In 2005/6, there were 95,047 complaints, or 1,827 a week, compared to 208,626 in 2017/18, or 4,017 a week.3 Per hundred thousand population, the number of NHS written complaints has increased from 265.8 in 2008/9 to 375.1 in 2017/18.4 GP practices received a written complaint for around 1 in every 4,200 appointments in 2018/19, based on data from NHS digital.5 Factors influencing the number of complaints include the ability of local organisations to resolve issues when they first arises and patient awareness of the Patients Advice Service (PALs).6

1 If a complaint is made using the standard NHS complaints procedure this does not

prevent the complainant also using of any of the other types of procedure referred to in this note, including taking legal action.

2 NHS Confidentiality Code of Practice, November 2003, p. 43. 3 NHS Digital, Data on Written Complaints in the NHS 2005-06, 15 November 2006;

NHS Digital, Data on Written Complaints in the NHS 2018-19, 5 September 2019. 4 NHS Digital, Data on Written Complaints in the NHS 2018-19, ‘Data Tables, T1’. 5 ‘GPs receive just one written complaint for every 4,200 appointments’, GP, 16

September 2019. 6 NHS Digital, Data on Written Complaints in the NHS, 2018-19 (September 2019), p.

7.

5 NHS Complaints Procedures

Experimental statistics (being those recently developed and subject to future revision in their methodology), suggest that in 2018/19 an estimated 58.4% of written complaints were upheld or partiality upheld in Hospitals and Community Health Services, and 51.9% in GP and Dental Primary Care.7 In Hospitals and Community Health Services in 2018/19, an estimated 51.1% of complaints were made by patients, 10.5% by parents and guardians, and 2.6% by carers.8 In Primary Care (GP and Dental), an estimated 79.5% of complaints were raised by patients, 9.8% by parents and guardians, and 3.0% by carers.9

7 NHS Digital, Data on Written Complaints in the NHS 2018-19, ‘Data Tables, T1b, 9.’ 8 NHS Digital, Data on Written Complaints in the NHS 2018-19, ‘Data Tables, T4’ 9 NHS Digital, Data on Written Complaints in the NHS 2018-19, ‘Data Tables, T11’

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2. The standard NHS complaints process

The NHS complaints system is designed to provide explanations of what happened and, where appropriate, apologies and information about action taken to ensure similar incidents do not happen again. A full range of remedies are available through standard complaints procedures including apologies, explanations, remedial action and financial compensation for direct or indirect loss.

The legislation governing NHS complaints procedure is the Local Authority Social Services and National Health Service Complaints (England) Regulations 2009.10 The 2009 Regulations set out various obligations on NHS bodies, GPs and other primary care providers, and independent providers of NHS care in relation to the handling of complaints. For example, Regulation 14 of the 2009 Regulations imposes a duty on NHS bodies to provide a written response to complaints.11

Before a complaint is made, the NHS choices website suggests:

You'll find a Patient Advice and Liaison Service (PALS) in most hospitals.

You can speak with a PALS member, who'll try to help you resolve issues informally with the hospital before you need to make a complaint.

If you're making, or thinking about making, a complaint, someone from the independent NHS Complaints Advocacy Service can help you.

You can seek advice from an NHS complaints advocate at any stage of the process.12

If an individual decides to make a complaint, the NHS has two stages in the standard complaints process:

Everyone who provides an NHS service in England must have their own complaints procedure.

You can often find information in waiting rooms, at reception, on the service provider's website, or by asking a member of staff.

You can either complain to the NHS service provider directly (such as a GP, dentist surgery or hospital) or to the commissioner of the services, which is the body that pays for the NHS services you use.

You should expect an acknowledgement and the offer of a discussion about the handling of your complaint within 3 working days of receiving your complaint.

Once your complaint has been investigated, you'll receive a written response.

10 Local Authority Social Services and National Health Service Complaints (England)

Regulations 2009 (SI 2009/309), made in exercise of the powers conferred by sections 113(1), (3) and (4), 114(1), (2) and (5), 115(1), (2), (4) and (5) and 195(1) and (2) of the Social Care (Community Health and Standards) Act 2003

11 Further information on patient’s rights to complain are provided in The Handbook to the NHS Constitution (January 2019).

12 NHS Choices website

7 NHS Complaints Procedures

If you have reached the end of the complaints process and are not happy with the organisation's final decision, you have the right to bring your complaint to the Parliamentary and Health Service Ombudsman to look at. His organisation is independent of the NHS. For more information, call 0345 015 4033 or visit the Parliamentary and Health Service Ombudsman website.13

The two stage complaints system described above was introduced in April 2009. Formerly there was an intermediate stage where the Healthcare Commission would conduct an independent review into the case concerned. The Healthcare Commission was abolished in April 2009 and although some of its functions were taken on by the Care Quality Commission, the new body did not take over the role of reviewing individual cases.14

When people have a complaint about an NHS service, they can complain to the provider of that service or to the commissioner of that service. For example, patients who have a comment or complaint about a GP, dentist, pharmacy or optician, which cannot be resolved locally, can contact NHS England, the commissioner of these services. CCGs oversee the commissioning of secondary care such as hospital care and some community services.

2.1 What does the NHS Constitution say about complaints and redress?

The NHS Constitution15 sets out the following patient’s rights concerning complaints and redress:

You have the right to have any complaint you make about NHS services acknowledged within three working days and to have it properly investigated.

You have the right to discuss the manner in which the complaint is to be handled, and to know the period within which the investigation is likely to be completed and the response sent.

You have the right to be kept informed of progress and to know the outcome of any investigation into your complaint, including an explanation of the conclusions and confirmation that any action needed in consequence of the complaint has been taken or is proposed to be taken.

You have the right to take your complaint to the independent Parliamentary and Health Service Ombudsman or Local Government Ombudsman, if you are not satisfied with the way your complaint has been dealt with by the NHS.

13 Information on the standard NHS complaints procedure is available from the NHS

Choices website 14 The NHS Complaints Procedure was altered following a consultation, Making

Experiences Count, undertaken in 2007. One of the main aims was to align NHS and social services complaints procedures.

15 NHS Constitution, 14 October 2015. The Constitution was first published in January 2009 following recommendations in Lord Darzi’s report High Quality Care for All (2008), chapter 7. Under the Health Act 2009, Section 2 all providers and commissioners of NHS care have a statutory duty to have regard to the NHS Constitution in all their decisions and actions.

Number CBP 7168, 11 October 2019 8

You have the right to make a claim for judicial review if you think you have been directly affected by an unlawful act or decision of an NHS body or local authority.

You have the right to compensation where you have been harmed by negligent treatment.16

The NHS Constitution also makes the following pledges which the NHS commits to achieve:

to ensure that you are treated with courtesy and you receive appropriate support throughout the handling of a complaint; and that the fact that you have complained will not adversely affect your future treatment (pledge);

to ensure that when mistakes happen or if you are harmed while receiving health care you receive an appropriate explanation and apology, delivered with sensitivity and recognition of the trauma you have experienced, and know that lessons will be learned to help avoid a similar incident occurring again (pledge); and

to ensure that the organisation learns lessons from complaints and claims and uses these to improve NHS services (pledge).17

16 Ibid., p. 10. 17 Ibid., p. 10.

9 NHS Complaints Procedures

3. Inquiries into complaints procedures

3.1 The Francis inquiries The first inquiry led by Sir Robert Francis QC into serious failures in care at Mid-Staffordshire NHS Foundation Trust between 2005 and 2008 highlighted widespread and systemic deficiencies in care at the Trust. The report found that contributing factors included ineffective action in response to patient complaints.18 A second inquiry led by Sir Robert into the events at the Trust, examining the role of the commissioning, supervisory and regulatory bodies, published its report on 6 February 2013. This report made a number of recommendations with regard to the handling of patient complaints.19

The Government’s initial response to the Francis report, published in March 2013, Patients First and Foremost, noted some changes to the way the Parliamentary and Health Service Ombudsman works:

The Ombudsman is changing the way it works to start investigations sooner and complete them more quickly. The Ombudsman will publish summaries of all investigations to publicise both good and bad practice, so that the public can make better informed choices about their care. It will focus on identifying systemic issues arising from individual and clusters of complaints and publish more thematic case reports to highlight big or repeated complaints and to build confidence in the value of complaints. It will make it easier for people to complain to them and will work with regulators to drive better information sharing about complaints to gain earlier insight into concerns about quality.20

The Government’s further response, Hard truths: the journey to putting patients first, was published in January 2014. It provided a commitment that NHS Trusts will report quarterly on complaints data and lessons learned, and the Ombudsman will significantly increase the number of cases she considers.21

In response to the Francis report, the then-Prime Minister David Cameron asked Ann Clwyd MP and the Chief Executive of South Tees Hospitals NHS Foundation Trust, Tricia Hart, to advise on how NHS hospitals can handle complaints better in the future.22 Their report, Putting patients back in the picture, was published in October 2013. It called for Trusts to provide patients with clear and simple ways of feeding back comments and concerns about their care on the ward.

18 The Independent Inquiry into care provided by Mid Staffordshire NHS Foundation

Trust, chaired by Robert Francis QC, 24 February 2010. 19 Report of the Mid Staffordshire NHS Foundation Trust public inquiry, 6 February

2013. 20 DH, Patients First and foremost: the initial government response to the report of the

Mid Staffordshire NHS Foundation Trust public inquiry (Cm 8576), 26 March 2013, p. 53.

21 Department of Health, Hard truths: the journey to putting patients first, (November 2013).

22 HC Deb, 6 February 2013, cc281–283

Number CBP 7168, 11 October 2019 10

In February 2015, the Government published Culture change in the NHS: Applying the lessons of the Francis inquiries. The report sets out the progress that has been made in applying the lessons learned from the failings at Mid Staffordshire Trust, including the actions that have been taken to ensure that complaints about care are properly listened to and learned from:

Achievements in the past two years

• The Care Quality Commission is now routinely examining how well organisations handle complaints and those that fall short will have this reflected in their inspection findings.

• The Department of Health and NHS England have issued a new guide for patients on complaining, and a poster setting out how to make a complaint has been made available to the NHS.

Next steps

• The Care Quality Commission’s recent Complaints Matter report concluded that the quality of complaints handling was variable, and it raised concerns about the timeliness of responses to complaints.

• The Ombudsman has increased the number of cases she deals with, but more needs to be done to restore and maintain public confidence.

• A regular and standardised way of surveying people who have made a complaint in both primary and secondary care is required.

• A review of NHS complaints advocacy services will complete by Spring 2015.23

The review of the NHS Advocacy Services was concluded but not published because the “department took the view that local authority commissioning arrangements should drive the accessibility and quality of advocacy services.”24

3.2 Health Select Committee reports The Health Select Committee published a report, Complaints and Litigation, on the NHS complaints and litigation system in June 2011. It recommended that the Government should undertake a full review of the complaints system and consider the operational and legislative framework within which the Health Service Ombudsman operates. The Committee also called for greater access to advocacy, and procedures for speedy resolution of smaller claims.25

23 Department of Health, Culture change in the NHS: Applying the lessons of the

Francis Inquiries, February 2015, Chapter 2. 24 PQ, NHS: Complaints: Written Question, 164488, 16 July 2018. 25 Health Select Committee, Complaints and Litigation, HC 786-I 2010-12, 28 June

2011.

11 NHS Complaints Procedures

In January 2015, the Health Select Committee published a report on Complaints and Raising Concerns. The Committee found that the current system for complaints is variable:

Too many complaints are mishandled with people encountering poor communication or, at worst, a defensive and complicated system which results in a complete breakdown in trust and a failure to improve patient safety.26

The Committee recommended a single gateway for raising complaints and concerns:

We agree that the onus should be on the system to help a complainant. People should not be forced to search out the most appropriate way to raise concerns. We recommend that the complaints system be simplified and streamlined by establishing a single ‘branded’ complaints gateway across all NHS providers. This should be available online, but not exclusively so. There should be adequate resourcing to enable complaints to be examined, identified, and directed speedily to the appropriate channel.27

The Committee also stated that there is a strong case for integrating the complaints systems for health and social care, and that this should start with a single ombudsman.28

The Government published its response to the Committee’s report in March 2015. The response sets out the work the Government has undertaken to deliver improvements to the way health and social care complaints are handled:

In February 2015 the Government published Culture Change in the NHS: Applying the Lessons of the Francis Inquiries and Chapter 2 provided the detail and progress on many of these complaints handling projects. A summary of all the projects is detailed below:

• Issuing clarification that a threat of litigation should not automatically stop a complaint being investigated: A clarification note was published in March 2014;

• Building complaints handling into CQC inspections: The quality of providers’ complaints handling has been included in CQC inspections since October 2014;

• A measurable vision for complaint handling across health and social care: This work was published in November 2014;

• Setting of Standards for Complaints Advocacy: Healthwatch England published these standards in February 2015;

• NHS Constitution Complaints guide: the guide was published in February 2015;

26 Health Select Committee, Complaints and Raising concerns, HC 350 2014-15, 21

January 2015, p. 3. 27 Ibid., paragraph 31. 28 Ibid., paragraph 55.

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• Move to quarterly publication of hospital complaints data: This project is progressing well, and is on track for the new collection to start from April 2015, with publication of data expected late summer 2015;

• Regular and standard method to survey complainants: A workshop has been held to generate options, and these options have now been narrowed down and are being considered in more detail;

• Review of PALS and evaluation of NHS Complaints Advocacy arrangements: Both projects are underway and we envisage they will be complete by spring 2015.29

The Government stated that the matter of whether there should be a single health and social care Ombudsman is for Parliament to decide, and would be subject to a consultation led by Robert Gordon.30 As stated above in section 3.1, the review of the NHS Advocacy Services was concluded, but not published.31

The Government also set out that from April 2015, all NHS secondary care organisations will be required to submit revised quarterly complaints data to the Health and Social Care Information Centre for quarterly publication. It was proposed that Hospitals would start quarterly complaints reporting from April 2015,32 and experimental data has been published by the NHS since then.33

The Government also stated that Healthwatch England commissioned Citizens Advice to expand their health and social care section on “Adviceguide” to provide individuals with advice on navigating the health and social care complaints system, to make sure the public have access to accurate, current and accessible information in one place.34 Citizens Advice has a page on NHS advice.

3.3 Public Administration Committee report

In March 2015, the Public Administration Select Committee published its report into Investigating clinical incidents in the NHS. The report called on the Secretary of State for Health after the General Election to establish a national independent patient safety investigation body, funded by the Department of Health.

29 Department of Health, Government response to the House of Commons Health

Select Committee fourth report of session 2014–15: Complaints and raising concerns, pp. 3-4.

30 Ibid., p. 8. 31 PQ, NHS: Complaints: Written Question, 164488, 16 July 2018. 32 Department of Health, Government response to the House of Commons Health

Select Committee fourth report of session 2014–15: Complaints and raising concerns, p. 5.

33 NHS Digital, Data on written complaints in the NHS (2004/5-present). 34 Department of Health, Government response to the House of Commons Health

Select Committee fourth report of session 2014–15: Complaints and raising concerns, p. 6.

13 NHS Complaints Procedures

The Committee found that there were failings in the current NHS complaints procedures:

the current NHS processes for investigating and learning from untoward clinical incidents are complicated, take far too long and are preoccupied with blame or avoiding financial liability.35

The Committee said that there are such serious concerns about the capacity and capability of the Ombudsman service that complete reform is needed:

Complainants deserve an Ombudsman they can have confidence in. There are serious questions about the capacity and capability of the Ombudsman’s office, in particular in relation to complaints involving clinical matters. We are aware of considerable anguish and disquiet where Parliamentary and Health Service Ombudsman [PSHO] investigations fail to uncover the truth, and of pain inflicted by the Ombudsman’s defensiveness and reluctance to admit mistakes. This underlines the need for improved competence and culture change throughout the system, including in the PHSO. PHSO leadership is aware of the need for this change, but it is proving more challenging than expected. We welcome the PHSO’s aim to improve the quality and accessibility of its services. However, the Ombudsman’s office is under considerable strain. Fundamental reform of the Ombudsman system is needed.36

The Committee have also stated that reform of the complaints process would mean more complaints are resolved at an earlier stage, leading to less subsequent referrals to the ombudsman:

We pursue this topic in the hope of achieving quicker and more effective resolution of incidents of clinical failure locally, leading to faster learning and more positive change, without the need for a complaint, and therefore a substantial reduction in the number of people whose cases reach as far as the Ombudsman.37

The Chair of the Committee, Bernard Jenkin, reported that the Secretary of State for Health appeared to support their proposals:

We are very pleased that the Secretary of State for Health has already appeared to have accepted the principle of our main recommendation. His engagement with this inquiry has been exceptional. The Shadow Health Secretary has also made a commitment to review all hospital deaths.38

The Government responded to this report in July 2015 in part of their published document, Learning not blaming. On the Committee’s recommendations on the Health Service Ombudsman, it stated:

We would like to see improvements in the pace and responsiveness of the Parliamentary and Health Service Ombudsman, and – crucially – much greater patient and public confidence in its work. We agree with the Committee that fundamental reform of the Ombudsman system is needed. The

35 Public Administration Select Committee, New independent investigator of clinical

accidents needed, say Committee, 27 March 2015. 36 Public Administration Committee, Investigating clinical incidents in the NHS, 27

March 2015, HC886 2014-15, para 75. 37 Ibid., para 9. 38 Public Administration Select Committee, New independent investigator of clinical

accidents needed, say Committee, 27 March 2015.

Number CBP 7168, 11 October 2019 14

Government have signalled their intention to simplify and modernise the existing Ombudsman structures, as outlined in the draft Public Service Ombudsman Bill announced in the Queen’s Speech on 27 May.39

More generally, about complaint handling in the NHS, the Government response said:

We are working to put in place a more open and transparent culture in which all forms of feedback – comments, concerns, compliments and complaints – are welcomed and acted upon.

[…]

Over the last two years action has been taken in a number of areas. We have increased transparency by improving the quality and frequency of national complaints data in secondary care. The first quarterly data returns will be published in the summer and for the first time there will be more granular detail on the issues being complained about. We have sought to build an enduring national partnership of organisations committed to working together to improve complaints handling, and looking at complaints within a wider context.

[…]

We continue to believe it is important that improvement in the handling of complaints is linked to wider issues around hearing the patient voice, learning lessons and focussing on providing safe, high quality services. Delivering this requires the whole care system to play its part. As steward of the system the Department will convene a new national partnership of organisations which looks at complaints improvement within a wider context, building on the work done to deliver commitments set out in “Hard Truths”, and considering how to improve the culture around patient feedback, including complaints.40

39 Department of Health, Learning not blaming: The government response to the

Freedom to Speak Up consultation, the Public Administration Select Committee report ‘Investigating Clinical Incidents in the NHS’, and the Morecambe Bay Investigation, Jul 2015, pp. 41-2, 46-7.

40 Ibid., pp. 43-5.

15 NHS Complaints Procedures

4. The Health Service Ombudsman

4.1 The Ombudsman’s remit The office of the Health Service Ombudsman was created by the NHS Reorganisation Act 1973 following pressure for an effective resolution of grievances, given the exclusion of the NHS from the 1967 Parliamentary Commissioner Act, as outside the direct responsibility of what was then the Minister of Health. The office was subsequently modified by the Parliamentary and Health Service Commissioners Act 1987, the Health Service Commissioners Act 1993 and the Health Service Commissioner (Amendment) Act 1996.

This last Act considerably broadened the scope of the investigations by enabling the Health Service Commissioner to investigate all aspects of NHS care and treatment, including clinical judgement. It was designed to place the Ombudsman at the top of a unified NHS complaints procedure. Complainants can refer their case directly to the Health Service Ombudsman and do not have to go through their MP (and cases can continue to be referred to the Ombudsman during a pre-election dissolution period).41

The current remit of the PHSO is set out in the Health Service Commissioners Act 1993 (as amended), which gives the Ombudsman power to investigate in certain circumstances, including:

3 (1) On a complaint duly made to [the Commissioner] by or on behalf of a person that he has sustained injustice or hardship in consequence of

(a) a failure in a service provided by a health service body,

(b) a failure of such a body to provide a service which it was a function of the body to provide, or

(c) maladministration connected with any other action taken by or on behalf of such a body,

(1ZA) Any failure or maladministration mentioned in subsection (1) may arise from action of

(a) the health service body,

(b) a person employed by that body,

(c) a person acting on behalf of that body, or

(d) a person to whom that body has delegated any functions.

A complaint under the 1993 Act may be made by an individual or a body of persons, whether incorporated or not, other than a public authority.42

In November 2014, the Parliamentary and Health Service Ombudsman, the Local Government Ombudsman and Healthwatch published a ‘vision’ for what good complaints handling should be like. My expectations for raising concerns and complaints sets out five key user-led principles for raising complaints and concerns:

41 PHSO, ‘How we can help MPs’ (July 2015), p. 2. 42 Health Service Commissioners Act 1993, Section 8.

Number CBP 7168, 11 October 2019 16

• I felt confident to speak up

• I felt that making my complaint was simple

• I felt listened to and understood

• I felt that my complaint made a difference

• I would feel confident making a complaint in the future43

The CQC will use the framework in its new inspection regime, and NHS England will also use it as a performance management tool as part of the NHS Outcomes Framework.44

Number of Complaints The Parliamentary and Health Service Ombudsman’s (PHSO) 2018/19 Annual Report states that they received 112,262 enquiries, of which 29,841 were handled complaints.45 Of these, 1,722 complaints relating to the NHS were accepted for investigated in 2018/19.46 This compared to 23,422 received enquiries in 2010/11, of which 12,219 complaints related to the NHS. In 2010/11, 339 of the complaints accepted for investigation related to the NHS.47

4.2 Health Service Commissioner for England (Complaint Handling) Act 2015

On 2 July 2014, David Davis presented the Health Service Commissioner for England (Complaint Handling) Bill, having come 19th in the Private Members’ Bill ballot. The Bill received Royal Assent and became an Act of Parliament on 26 March, coming into force on 26 May 2015.

The Act has two distinct objectives that together seek to improve the handling of complaints by the Health Service Commissioner for England [known as the Health Service Ombudsman]. The Act amends Section 14 of the Health Service Commissioners Act 1993 as follows:

(2) Where the Commissioner has not concluded an investigation before the end of the 12-month period beginning with the date the complaint was received, the Commissioners must send a statement explaining the reason for the delay to the person who made the complaint.

The general report [laid annually by the Ombudsman to Parliament] must include information about-

(a) how long investigations that were concluded in the year to which the report relates took to be concluded,

43 Local Government Ombudsman, Healthwatch, Parliamentary and Health Service

Ombudsman, My expectations for raising concerns and complaints, November 2014, pp. 8-9.

44 Local Government Ombudsman, Healthwatch, Parliamentary and Health Service Ombudsman, My expectations for raising concerns and complaints, November 2014, p. 4.

45 PHSO, ‘Annual Report and Accounts 2018-19’ (July 2019), p. 27 46 PHSO, ‘Annual Report and Accounts 2018-19’ (July 2019), p. 35. 47 PHSO, ‘Annual Report 2010-11’ (July 2011), pp. 8, 15.

17 NHS Complaints Procedures

(b) How many of the investigations took more than 12 months to be concluded; and

(c) The action being taken with a view to all investigations being concluded within 12 months.48

The Government supported the Bill and the Department of Health drafted Explanatory Notes, with the consent of David Davis, the sponsoring Member. The Explanatory Notes provided the following summary of the Bill:

The Health Service Commissioner for England (Complaint Handling) Bill seeks to increase the effectiveness of the Commissioner (known as the Health Service Ombudsman), who is the final tier of the NHS complaints system. It does so primarily by requiring the Health Service Ombudsman to take action with a view to concluding investigations of complaints within 12 months, and by requiring her to inform the complainant, in any case where this timescale is not met, of the reason why not.49

Further information is provided in the Commons Library briefing, Health Service Commissioner for England (Complaint Handling) Act 2015 [Chapter 29] (CBP 07170).

4.3 Public Service Ombudsman Bill 2016 In December 2016, the Cabinet Office published a draft Public Service Ombudsman Bill, which intended to absorb the existing remits and responsibilities of the existing Parliamentary Ombudsman, Health Service Ombudsman and Local Government Ombudsman. This would create a Public Service Ombudsman (PSO) for UK reserved matters and for public services delivered solely in England. The House of Commons Library published a Briefing Paper on the Bill.

The proposed legislation was a response to the 2014 Public Administration Committee (PAC) report, Time for a People’s Ombudsman Service, which called for a consultation on the creation of a single public service ombudsman for England. The October 2014 Gordon Report, Better to serve the public: Proposals to restructure, reform, renew and reinvigorate public service ombudsmen, recommended that the Government should legislate to create a new single public service ombudsman. The Government response to the consultation was published in October 2015.

When the Bill was published in December 2016, the then- Parliamentary and Health Service Ombudsman, Julie Mellor, supported the Bill and stated:

The creation of a single Public Ombudsman Service will make it easier for people to have their complaints about public services resolved. The current complaint system is too complex and fragmented, leaving people confused as to which ombudsman to turn to if things go wrong or haven’t been resolved locally. We

48 Health Service Commissioner for England (Complaint Handing) Act 2015, Section 1. 49 Explanatory Notes, Health Service Commissioner for England (Complaint Handling)

Bill, para 3.

Number CBP 7168, 11 October 2019 18

have long been urging the government for these reforms, and are delighted we are one step closer to making this a reality.50

The current Parliamentary and Health Service Ombudsman, Rob Behrens, told the Public Administration Committee in 2019 that he was also in favour of the Bill’s adoption.51

In March 2019, the Government stated that “the draft bill will be progressed as and when a legislative opportunity arises.”52

50 Local Government Ombudsman, Ombudsmen welcome publication of draft

legislation on ombudsman reform, 5 December 2016. 51 Public Administration and Constitutional Affairs Committee, Parliamentary and

Health Service Ombudsman Scrutiny 2017-18, HC 1855 (22 January 2019), Q81. 52 PQ, Public Sector: Ombudsman: Written Question, 234661 (20 March 2019)

19 NHS Complaints Procedures

5. Medical negligence In cases where someone has been harmed as a result of negligence by an NHS organisation or healthcare professional, an individual might consider taking legal action against the NHS or member of staff concerned. The aim of taking legal action is usually to try and obtain compensation. Compensation payments can be made following a successful claim of medical negligence and settlements are sometimes made out of court following the initiation of legal action.

Taking legal action against an NHS body or any local authority can be long, costly and complex. It is therefore advisable to seek professional legal advice.

5.1 NHS Resolution NHS Resolution handles claims made against NHS organisations and independent sector providers of NHS care in England and, since April 2019, beneficiaries of state-backed indemnity for general practice. The body is a replacement for the NHS Litigation Authority (NHSLA) that existed between 1995 and April 2017.53

The Five Year Plan of NHS Resolution ‘Delivering fair resolution and learning from harm’, published in April 2017, saw its role as:

Tackling the rising costs of harm to the healthcare system and addressing the causes of harm with a joint objective to reduce serious brain injury at birth, shared with NHS Improvement;

improving the experience of patients and healthcare staff when something goes wrong; and

increased and earlier support for those providing NHS care who are involved in incidents.54

The then Secretary of State for Health, Jeremy Hunt, commented that the changes would ensure “an enhanced focus on learning and prevention, not just litigation.”55 The focus of resources into intervening in maternity related cases earlier is part of the Government’s drive to halve the rates of stillbirth, neonatal and maternity deaths, and brain injuries suffered at birth by 2025.56

All NHS trusts pay NHS Resolution an annual contribution to receive indemnity coverage, as do some private sector providers, clinical commissioning groups and arms-length bodies of the Department for Health and Social Care.57 When a claim is made, NHS Resolution is responsible for acting on behalf of the NHS body involved and as a result does not offer advice to individual patients.

53 ‘Jeremy Hunt announces major overhaul of NHS quango’, Health Service Journal, 21

March 2017. 54 NHS Resolution, Delivering fair resolution and learning from harm: Our strategy to

2022 (2017), p. 3. 55 ‘Jeremy Hunt announces major overhaul of NHS quango’, Health Service Journal, 21

March 2017. 56 NHS Resolution, ‘Learning from avoidable injuries at birth’, 25 September 2019. 57 National Audit Office, Managing the costs of clinical negligence in trusts (September

2017), p. 5.

Number CBP 7168, 11 October 2019 20

The NHS Resolution website explains how claims are handled:58

To receive compensation, you will need to show both ‘breach of duty of care’ and ‘causation’ has taken place.

What is breach of duty of care?

The health practitioner must have acted in a way which fell short of acceptable professional standards. Known as the ‘Bolam’ principle, this tests whether the actions of the health professional in question could be supported by a ‘responsible body of clinical opinion’. This test is not about what ‘could have been done’ – that other health professionals might have done something differently, but whether it ‘should have been done’ – would a ‘responsible body’ of health professionals support the action taken?

There is also a further test known as ‘Bolitho’. This means that the court should not accept a defence argument as being ‘reasonable’, ‘respectable’ or ‘responsible’ without first assessing whether such opinion is susceptible to logical analysis.

What is causation?

The harm suffered must be shown, on the balance of probabilities, to be directly linked with the failure of the health professional to meet appropriate standards. If, for example, there was a good chance that the harm would have taken place even if the health professional had acted differently, then a claim is unlikely to succeed.

You will need to establish both a breach of duty of care and causation to be entitled to receive compensation. Compensation is aimed at putting you back, as close as possible, to the position you were in prior to the negligent care.

Useful links for claimants

The following organisations are able to help you locate a legal firm in your area with appropriate experience in dealing with these types of claim:

Your local Citizen’s Advice Bureau

Action Against Medical Accidents (AvMa)

The Law Society

A NAO Report on Managing the costs of clinical negligence in trusts from 2017 provides a diagram of the process for resolving clinical negligence claims in the NHS:

58 NHS Resolution, Advice for claimants (last updated 3 April 2019).

21 NHS Complaints Procedures

5.2 Government Reforms The NAO report Managing the costs of clinical negligence in NHS Trusts (September 2017) stated that number of successful clinical negligence claims where damages had been awarded rose from 2,800 (2006/7) to 7,300 (2016/17). The overall cost of claims has risen from £0.4 billion 2006/7 to £1.6 billion in 2016/17. It estimated that 45% of the increase in resulting costs to the NHS was due to the rising number of claims, 33% from rising payments for damages, and 21% from claimant legal costs.

In January 2017, the Government announced its intention to impose a new fixed cap of £25,000 on the amount of costs that legal firms can recover on all clinical negligence cases. There is currently no limit on legal costs that can be recouped and the Government expected the new cap will help in saving the NHS up to £45 million a year in litigation costs.

On this announcement, Jeremy Hunt said:

It’s important that when significant mistakes happen in the NHS, patients are able to have an open dialogue with a trust about

Number CBP 7168, 11 October 2019 22

what went wrong, receive reassurance of what is being learnt, and can discuss what form of recompense or redress may be appropriate. Legal action should only be one part of this process. Unfortunately, what we often see in lower cost claims is a deeply unfair system where unscrupulous law firms cream off excessive legal costs that dwarf the actual damages recovered. We believe this creates an adversarial culture of litigation, which is inflating insurance premiums and drawing away resource from the NHS at a crucial time.

In July 2017, Lord Justice Jackson published his review of options to extend fixed recoverable legal costs for all personal injury claims with damages up to £250,000. It recommended that the then-Department of Health and the Civil Justice Council set up a working party with both claimant and defendant representatives to develop a bespoke process for handling clinical negligence claims up to £25,000, with fixed recoverable costs. It also noted that fixed recoverable costs would not be suitable for most clinical negligence claims above £25,000.59 The Department established a working group in February 2018,60 and in July 2019 the Government stated it would consider the reports of the now-completed consultation. 61

59 Review of civil litigation costs: Supplemental report- fixed recoverable costs (2017),

pp. 113-18. 60 Introducing Fixed Recoverable costs in lower value clinical negligence claims- The

Consultation response: Written statement - HCWS472, 20 February 2018. 61 NHS: Negligence: Written Question, HL 16485, 19 June 2019.

23 NHS Complaints Procedures

6. Judicial review The right to make a claim for judicial review is derived from administrative law. As noted above, an individual should seek professional legal advice if they are considering taking legal action.

A judicial review is a procedure that enables someone to challenge a decision of a public body, such as an NHS organisation or the Secretary of State for Health, on the basis that the decision is unlawful.

A decision might be unlawful if:

• the decision-maker does not have power to make the decision, or is using their power improperly,

• the decision is irrational, • the procedure followed by the decision-maker was unfair or

biased, • the decision was in breach of the Human Rights Act, or • the decision breaches European Community (EC) law.

Judicial review is not a form of appeal. The judge will look at how decisions are made, rather than judging the decision itself. To be entitled to make a claim for judicial review, someone must have a direct, personal interest in the action or decision being challenged. Further guidance on applying for judicial review can be found on Her Majesty’s Courts Service website, with detailed guidance on bringing a judicial review case to the Administrative Court.62

62 Further information is available from ‘Introduction to Judicial Review’, by the Public

Law Project.

Number CBP 7168, 11 October 2019 24

7. Complaints about individual healthcare professionals: professional regulation

7.1 Who regulates healthcare professionals?

If someone believes that the behaviour of a medical practitioner, or other healthcare professional, might call into question his or her fitness to practise, then a complaint can be made to the relevant professional body. For example, in the case of a doctor, this would be the General Medical Council (GMC) or in the case of a nurse, the Nursing and Midwifery Council (NMC).

A list of the bodies that currently regulate healthcare professionals in England is provided below, together with details of the professions they regulate:

─ General Chiropractic Council (GCC): the GCC regulates chiropractors.

─ General Dental Council (GDC): the GDC regulates dentists, dental therapists, dental hygienists, dental nurses, dental technicians, clinical dental technicians and orthodontic therapists.

─ General Medical Council (GMC): the GMC regulates doctors.

─ General Optical Council (GOC): the GOC regulates opticians.

─ General Osteopathic Council (GOsC): the GOsC regulates osteopaths.

─ Health and Care Professions Council (HCPC) (formerly the Health Professions Council): the HCPC currently regulates arts therapists, biomedical scientists, chiropodists/podiatrists, clinical scientists, dietitians, hearing aid dispensers, occupational therapists, operating department practitioners, orthoptists, paramedics, physiotherapists, practitioner psychologists, prosthetists/orthotists, radiographers, social workers in England and speech and language therapists.

─ Nursing and Midwifery Council (NMC): the NMC regulates nurses, midwives and specialist community public health nurses.

─ The General Pharmaceutical Council (GPhC): the GPhC regulates pharmacists, pharmacy technicians and pharmacy premises.

─ The Professional Standards Authority for Health and Social Care (PSA) (formerly the Commission for Healthcare Regulatory Excellence): the PSA aims to protect the public,

25 NHS Complaints Procedures

promote best practice and encourage excellence among the regulators of healthcare professionals listed above.63

The Commons Library has published a briefing Professional regulation in health and social care (CBP8094, September 2017). Some further background on proposals to reform the system of professional regulation is provided in the section below.

7.2 Proposals for reform The Law Commission The Government white paper, Enabling Excellence: Autonomy and Accountability for Healthcare Workers, Social Workers and Social Care Workers (February 2011), stated that it would ask the Law Commission to undertake a simplification review of the existing legislative framework and to develop a draft Bill for consultation, to conclude by the end of the 2010-2015 Parliament.

In April 2014, the Law Commission published its proposals for major reform of the professional regulators in a draft Bill and an accompanying report, Regulation of Health and Social Care Professionals. The Law Commission proposed a series of changes to ensure regulation becomes more effective. Key recommendations included:

- new powers for the regulators to make their own rules

- a new barring scheme to prevent certain professionals who have committed serious crimes from practising;

- greater use of mediation in fitness to practice proceedings;

- consistency across the regulators in the way that fitness to practise hearings are conducted;

- enhanced duties on the regulators to consult the public and work collaboratively;

- less Government interference in the rule making process and the appointment of the regulators/PSA boards.

Government response The Government published its response to the Law Commission in the form of a written statement in January 2015. The Government stated that it had accepted the large majority of the Law Commissions’ recommendations in full, and others in part. It committed to legislate on the Commission’s proposals in the future.64

In January 2017, the Department for Health launched a consultation on the proposals for a draft bill. On the question of reducing the number of regulatory bodies, 58% of the 819 responses supported the principle.65 The government replied to the consultation in July 2019. It stated:

63 The Department of Health Liberating the NHS: Report of the arms-length bodies

review published in July 2010 considered the role of the CHRE. The review noted that it continued to fulfil an ongoing need but proposed to make it self-funding and extend its remit to social care.

64 HC Deb, 29 January 2015, HCWS235 65 DHSC, Promoting professionalism, reforming regulation: Government response to

the consultation (July 2019), p. 20.

Number CBP 7168, 11 October 2019 26

The UK and Devolved Governments will now develop secondary legislation to put in place:

• Modern and efficient fitness to practise processes;

• Better supported professionals; and

• More responsive and accountable regulation.

We will also make two legislative changes recommended by the Williams review66 and accepted by Government:

• To remove the General Medical Council’s (GMC) right to appeal decisions of the Medical Practitioners Tribunal Service (MPTS) to the High Court; and

• To modify the GMC and General Optical Council (GOC) powers to require information from registrants for fitness to practise purposes to exclude reflective practice material.

We will consult on draft legislation to deliver these changes in due course.67

The Williams Review, conducted in response to the Bawa-Garba case, stated that the right of appeals against fitness to practice decisions should be removed from the GMC to “ensure a consistent approach to appeals across healthcare professions that are statutorily regulated.”68

In response to the 2017 consultation and the question of reducing the number of regulatory bodies, the UK and Devolved Governments said in July 2019 that they “acknowledge that more work is needed before bringing such a proposal forward… [and] any proposals to reconfigure the regulatory bodies will be subject to public consultation.”69 The GMC and Nursing and Midwifery Council both welcomed the Government response to the 2017 consultation.70

66 The Williams Review into gross negligence manslaughter in healthcare (11 June

2018). 67 DHSC, Promoting professionalism, reforming regulation: Government response to

the consultation (July 2019), pp. 3-4. 68 The Williams Review into gross negligence manslaughter in healthcare (11 June

2018), p. 50. 69 DHSC, Promoting professionalism, reforming regulation: Government response to

the consultation (July 2019), p. 24. 70 ‘Ministers push back radical shake-up of professional regulators’, Health Service

Journal, 9 July 2019.

27 NHS Complaints Procedures

8. Complaints in specific circumstances

Special procedures apply in certain circumstances, for example to patients raising concerns about treatment under the Mental Health Act 1983, in cases where a specific drug or treatment is being refused by the NHS, and regarding eligibility for NHS continuing healthcare.

People detained under the Mental Health Act 1983 The Care Quality Commission (CQC) has powers under the Mental Health Act 1983,71 to make sure that health services are correctly applying and interpreting the Act. In particular, the CQC can keep the use of the Mental Health Act (MHA) under review and check that the Act is being used properly where the Act is used to restrict a person's rights. The CQC has published a guide to complaining about the use of the MHA. An individual’s rights can be restricted under the powers of the 1983 Act in the following ways:

• Detention under the MHA: People who are suffering from severe mental disorder may be detained in hospital for assessment and/or treatment, where this is necessary for their own health or safety, or for the safety of others.

• Treatment being received under a Community Treatment Order: Patients who are detained in hospital may be given a Community Treatment Order upon discharge from detention. They are then subject to supervised community treatment, where they must meet certain conditions to remain in the community. The conditions usually include compliance with treatment and living at a named address.

• Treatment or care being received under Guardianship: Guardianship is designed to be a framework of minimum constraint to enable mentally disordered people to receive care outside of hospital. People subject to Guardianship may or may not be receiving specialist mental health treatment, but can be required to live at a certain place and attend other places for treatment, work, training or education.72

The CQC cannot formally investigate all aspects of an individual’s care and treatment but it can provide advice and assistance to those making a complaint against a health service. The full procedures are not covered in this briefing paper but the CQC website provides further information.

Since April 2009, patients subject to certain aspects of the Mental Health Act 1983 have had statutory access to an Independent Mental Health Advocate (IMHA).73 IMHAs are intended to help and support patients to understand and exercise their legal rights. IMHAs will be

71 Prior to the creation of the CQC in April 2009 these powers were exercised by the

Mental Health Act Commission (archived). 72 The mental health charity MIND also provides an outline guide to the Mental Health

Act 1983. 73 The Mental Health Act 2007 amended the 1983 Act to include provisions for an

advocacy service for patients. Section 30 of the 2007 Act introduces new sections 130A-D in the Mental Health Act 1983.

Number CBP 7168, 11 October 2019 28

available to most detained patients as well as patients under supervised community treatment or guardianship.74

The Independent review of the Mental Health Act 1983 was published in December 2018 and included recommendations on complaints under the Act:

• Section 132 of the MHA should be amended to require managers of hospitals to provide information on making complaints to patients and their nominated person.

• Staff dealing with complaints should have an understanding of the MHA so they are aware of the particular impact of detention.

• Information going to hospital Boards should be separated between complaints made by patients detained under the MHA and complaints made by informal patients.

• The Government and CQC should take steps to improve the systems that handle complaints from patients and their carers across providers, commissioners, police and local authorities to improve transparency and effectiveness across the system.75

The Government confirmed in September 2019 that a White Paper will be published in response to the review by the end of 2019.76

Decisions on exceptional cases: Individual Funding Requests (IFRs) Although the NHS can have a policy not to fund a particular treatment (unless recommended by a NICE technology appraisal), it cannot impose a blanket ban. If a doctor feels that a treatment is clinically appropriate, given a patient’s individual circumstances, they can submit what is known as an Individual Funding Request (IFR), requesting that the treatment be commissioned and funded for that particular patient.

The NHS England Standard Operating Procedure for IFRs (updated May 2018) provides guidance for the process for an IFR panel to consider individual patient requests for specific procedures/treatments. In the event that the IFR panel does not agree funding of the procedure or treatment, either the patient or patient’s carer or their referring clinician may request a review of an IFR panel decision. Reviews are considered by an IFR review panel, which considers whether the process followed by the IFR panel was consistent with the standard operating procedure for IFRs.77 Individual clinical commissioning groups (CCGs) should have their own IFR policies and further information on IFRs for specialised services can also be found in an NHS England guide for patients.

74 Department of Health, Mental Health Act 1983: Code of Practice (January 2015),

pp. 54-61 provides more information on IMHAs. 75 Modernising the Mental Health Act: Increasing choice, reducing compulsion

(December 2018), pp. 97-8. 76 PQ, Mental Heath Act 1983 Independent Review: Written Question, 284806 (2

September 2019). 77 For further details of the review process see pages 14 to 16 of the NHS England

Standard Operating Procedure.

29 NHS Complaints Procedures

The National Institute for Health and Care Excellence (NICE) provides evidence-based information for the NHS in England and Wales on the effectiveness and cost-effectiveness of healthcare interventions. It publishes mandatory technology appraisal guidance (stipulating clinical interventions – mainly medicines –, as well as advisory clinical guidelines and public health guidance.

For drugs and treatments not covered by NICE technology appraisals the NHS Constitution states:

You have the right to expect local decisions on funding of other drugs and treatments to be made rationally following a proper consideration of the evidence. If the local NHS decides not to fund a drug or treatment you and your doctor feel would be right for you, they will explain that decision to you.78

The 2019 Handbook to the NHS Constitution explains that while NHS commissioners can have a policy not to fund a particular treatment, they must consider requests for funding in exceptional individual cases:

Administrative law requires that the decisions of NHS bodies and local authorities are rational, procedurally fair and within their powers.

In addition, decisions by the courts have made it clear that, although an NHS commissioner (which will include a local authority commissioning public health services from 1 April 2013) can have a policy not to fund a particular treatment (unless recommended in a NICE technology appraisal recommendation), it cannot have a blanket policy; i.e. it must consider exceptional individual cases where funding should be provided.79

People refused NHS continuing healthcare The Library Briefing Paper NHS continuing healthcare in England (CBP6128) sets out the eligibility criteria, assessment process and dispute resolution procedures for NHS continuing healthcare.

78 NHS, NHS Constitution (27 July 2015), p. 7. 79 NHS, The Handbook to the NHS Constitution (January 2019), p. 50.

Number CBP 7168, 11 October 2019 30

9. Organisations that can help There are a number of organisations that can provide help and advice to individuals who want to complain about NHS services, including:

• Healthwatch: The Health and Social Care Act 2012 included measures intended to strengthen the voice of patients from April 2013, including the creation of local HealthWatch organisations and “HealthWatch England,” a new independent consumer body within the Care Quality Commission. The Government has said that where a local HealthWatch becomes aware of poor complaints handling within an organisation, such as a provider or commissioner of local care services, it would be able to submit views to that organisation, in the form of reports and recommendations.80

• Action against Medical Accidents (AvMA): AVMA is an independent UK wide charity. It can help patients to consider the options that may be open to them after suffering a medical accident, including providing contacts for specialist solicitors. AVMA have a helpline: 0845 123 2352 (open Monday to Friday, 10am to 3.30pm).

• The Care Quality Commission (CQC) is the independent regulator of health and social care in England. The CQC does not have a role in handling individual complaints but it does have powers to ensure registered service providers are handling complaints properly. It will also use feedback from users of NHS services to spot patterns of incidents indicating that there could be a problem.

• Citizens Advice Bureau: CABs can advise on NHS complaints. • The Independent Complaints Advocacy Service (ICAS): ICAS is a

free, confidential and independent service which can help patients make a formal complaint about NHS services.

• Independent Mental Health Advocates (IMHAs): From April 2009, patients subject to certain aspects of the Mental Health Act 1983 have statutory access to an Independent Mental Health Advocate (IMHA).81 IMHAs can help and support patients to understand and exercise their legal rights.

• The Patient Advice and Liaison Services (PALS): There is a PALS in every NHS trust and they can provide further information and discuss options about how complaints can be resolved. Some complaints can be taken up by PALS on patients behalf, while other complaints may require an investigation to be carried out, subject to the nature of the complaint. You can find your local PALS through PALS Online or by visiting the NHS website.

80 Healthwatch, ‘Our history and functions’. 81 Under the Mental Health Act 1983 (Independent Mental Health Advocates)

(England) Regulations 2008 (SI 2008/3166).

BRIEFING PAPER Number CBP 7168, 11 October 2019

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