Introduction

The successful practice of dentistry depends on a good dentist–patient relationship, and a successful dental practice is dependent on the delivery of high‐quality dental care to patients, with whom there is a longstanding and trusting relationship. No dental team will be able offer perfect service to all patients all of the time. Mistakes and unforeseen situations will arise, but dissatisfaction and complaints are not an inevitable consequence of this, if such problems are identified early and promptly responded to in full.

A complaint may be considered to be an expression of dissatisfaction, which requires a response. Occasions when service has obviously failed to meet expected standards – late‐running or double‐booked appointments, missing laboratory work or adverse outcome – should be managed proactively and the affected patient provided with an early apology, explanation and solution. Dissatisfaction may, however, be much less apparent to the dental team, and may not be identified without actively encouraging patients to report it. When a patient is sufficiently dissatisfied with the service or the treatment that they have received and is driven to do something about it, they may complain to the dentist responsible for their care or to an external agency such as a commissioning organisation or the regulatory body – the General Dental Council. The route usually chosen is that which a patient perceives is the one most likely to produce a swift, meaningful and satisfactory outcome. The number of complaints made by dental patients is increasing around the world. This upward trend is particularly marked in the UK. An understanding of the factors likely to cause dissatisfaction, an appreciation of how to respond to a patient complaint, and an awareness of how complaints can be used to improve patient service are therefore essential for dental practitioners and their teams.

Complaints in Risk Management

Clinical governance is the term used to describe the framework which ensures that the clinical services delivered to patients continually improve and are as safe and effective as possible. Amongst the principles underpinning this approach to optimising the quality of patient care are risk assessment and risk management. These processes are utilised to minimise the occurrence of preventable, adverse outcomes. Complaints made by service users are amongst the measures used to identify clinical risk and thus reduce dissatisfaction and complaints amongst patients who subsequently present for treatment. Guidance on managing patient dissatisfaction and complaints emphasises the need for all members of a clinical team to reflect on and learn from such negative feedback. It is therefore only fair and motivating for staff to also record and disseminate information about positive feedback and praise of specific staff or aspects of service. Any correspondence of this nature should be forwarded, or at least copied, to the staff involved for use in professional portfolios. A telephone call or brief note to a patient to thank them for expressing their gratitude is usually well received.

Throughout the world, there is increasing scrutiny and assessment of the standards of clinical training in dentistry, improving access to high‐quality postgraduate study, and greater emphasis placed on lifelong learning and continuing professional development which, in a growing number of countries, is now mandatory. In addition, there is free and unrestricted access to the publications of organisations such as the National Institute for Health and Care Excellence in the UK and the National Institutes of Health in the USA, which review areas of clinical practice and provide guidance on best practice for clinicians including dentists. Evidence based practice has been universally accepted as a tool to direct developments in clinical practice, with systematic reviews such as those published by the Cochrane Collaboration being central to this. It is interesting, therefore, that despite enhanced access to information and improvements in the knowledge and understanding of members of the dental team, the number of professional challenges, including complaints that are received, is greater than ever before. This cannot be related to changes in clinical standards and should not be interpreted as an indicator that dental services are worse than before. A more sophisticated sociological explanation has been suggested.

Why Do Patients Complain?

Patients who complain about clinical services frequently feel that this is the only way to get their concerns heard, or to receive the apology to which they believe they are entitled. Other means of expressing dissatisfaction or giving feedback about their experience are often unavailable to patients. It is worth noting that complaints in dentistry are often not associated with the quality of clinical care but about the environment in which patients were treated, interpersonal difficulties, the attitude of staff, communication problems and unmet expectations of customer service. It should not be assumed that poor patient experience will automatically result in dissatisfaction, or that the worse an experience, the more dissatisfied a patient will be. The role of blame is very important and even after a very poor experience, if a patient does not regard the dentist as responsible or ‘to blame’ for this, they may still be satisfied with their management. Unfortunately, once a patient has become dissatisfied with the service provided by a dental care professional, they tend to become increasingly sensitive to inadequacies in the quality of subsequent service, with diminished tolerance of further unfavourable episodes. Ultimately such patients may become overly sensitive about aspects of their care to justify their dissatisfaction. Patients who have made complaints about their clinical treatment have been found to have done so:

• To gain an understanding of what happened to them, and what may have gone wrong during their treatment if complications arose.
• To report that they want their concerns addressed, and action taken to remedy the problems identified. They may seek an explanation, apology, further treatment or financial redress.
• To be reassured that the same thing will not happen again.
• Out of a sense of duty to protect others.

In any service industry, including dentistry, it is acknowledged that most dissatisfied clients (patients) do not complain. They choose instead to find an alternative service provider and tell others why! Dental patients who do complain have therefore given this serious thought and made time to do so; they will therefore expect a swift and professional response.

Complaints about dental services are made as a result of a patient having a reason and the motivation to complain. The patient may perceive that they have good reason to complain, as a result of a problematic event or experience (e.g. clinical inadequacy, problems in accessing services, communication failures, or interpersonal difficulties such as staff rudeness or indifference). The motivation to make a complaint results from the emotional response to the problematic event or experience, and an expectation of what the complaint will achieve – apology, explanation, prevention of recurrence, or to see justice done. The key to resolving a complaint is to understand the motive for it being made. Satisfactory resolution is unlikely if a complainant’s motivation and expectations are not fully explored and understood. If these are not explicit in the complaint received, then they should be clarified with the patient.

Complaints about Dental Care

Within most healthcare systems, a patient has a right to complain about their experience, whether this is justified or not. Professional standards for dentists and dental care professionals demand that patients’ interests are put first and protected. Respecting the right of a patient to complain, and responding to this in a helpful and timely manner, is therefore an ethical and professional responsibility. Good communication skills, especially non‐verbal skills, minimise the risk of complaints being made and are the cornerstone of successful complaints management. The development of good non‐verbal communication skills is advantageous in all professional exchanges, but is especially valuable when managing complaints.

Particular attention should be paid to:

• Making eye contact with the patient which conveys a sense of interest, trust and desire to connect with them.
• Appearing interested and engaged in the conversation which demonstrates that the dental care professional is actively listening to the patient and values what they have to say.
• Looking at ease and relaxed which makes the patient feel comfortable and welcome.
• Speaking to a patient as an equal, in a manner that they can understand, in order to put them at ease which is known to improve compliance and satisfaction.

In the primary care setting, dental practitioners working both within a health service system and in private practice will be expected to have a written complaints procedure, which should be available to patients. There is variation in the regulations pertaining to complaint handling in different countries, and indeed across the UK’s national health service. These differences relate mainly to the responsibility for local complaints management, the timescale within which complaints must be managed, and the organisation to which they may be escalated, if not resolved locally to a patient’s satisfaction.

Complaints about dental services may be made by any adult patient, or a family member, carer or advocate of an adult who is unable to complain independently. Caution should be taken in responding to a complaint made by a friend or relative of a patient who has the capacity to do this for themselves. It would be usual in these circumstances for the written permission of the patient concerned to be sought prior to a response being made. Parents or those with legal responsibility for children may complain on behalf of a child, but increasingly complaints are received from children and young people who are dissatisfied with their care.

A time limit for the receipt of complaints pertaining to clinical treatment is usually set by local and national policy. For example, in the UK, complaints should normally be made within 6 months of the event that is being complained about, or within 6 months of a patient finding out that they have a reason to complain. It would therefore usually be expected that complaints would be received within 12 months of the event, but in exceptional circumstances this time limit may not apply. The complaints process of a healthcare provider would not normally be expected to resolve issues of negligence or liability, or to award compensation.

Throughout the complaints process a patient has the right to:

• Be treated with courtesy.
• Be provided with support where necessary.
• Have mistakes acknowledged.
• Receive an explanation and apology.
• Expect that remedial action is taken quickly and effectively.
• Escalate their complaint to a professional body, regulator or ombudsman if they are dissatisfied with the way that it has been handled locally.

Complaints may be received from a patient or their representative by any member of the dental team, either verbally in person or on the telephone, in writing or electronically. It is therefore essential that all members of the team are aware of the complaints handling procedure in the environment in which they work. If a verbal complaint is made, this should be recorded in writing and copied to the complainant as soon as possible. Complaints may also be registered through health service provider websites, patient advice and liaison teams, the complaints office of primary or secondary care organisations, care quality commissions or the regulatory body with whom the dental care professional is registered. Once received, the aim of those managing complaints should be early, local resolution without the involvement of higher, external agencies.

The effective management of complaints arising in dental practice is essential, because modern healthcare services place patients at the centre of the design and delivery of clinical services. Addressing dissatisfaction and complaints effectively ensures that the standards of clinical services delivered to patients continually improve as areas of poor performance are acknowledged, learnt from and improved. Whatever the problematic experience and motivation for a patient to make a complaint, it is not uncommon for further complaints to be made as a result of poor or inadequate handling of the original one. Professional regulating bodies and public and private healthcare systems expect their registrants and members to practise in an increasingly reflective manner and encourage clinicians to use complaints to identify areas of their practice that may benefit from improvement. The other consequences of failing to effectively manage complaints locally include: