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The NHS Patient Advice and Liaison Service (PALS) needs support to deal more effectively with patients’ concerns. Research found a lack of awareness of the service among clinicians and patients. It identified missed opportunities for PALS services to learn from each other and, in turn, improve patients’ satisfaction with the NHS.

PALS has been part of every NHS trust since 2002. Staff are a point of contact for patients with concerns, their families and carers. PALS can give advice about the formal complaint process, but its goal is to resolve patient concerns quickly and informally where possible.

There has been little research into how well PALS is working. In this study, the research team interviewed PALS staff and clinicians. They found that the role of PALS has broadened since it was set up. Staff said it had become a catch-all service to pick up duties other staff cannot do. The service also has different responsibilities in different trusts because of local funding, community needs and managers’ priorities.

Most patients’ concerns relate to communication, staff attitudes and waiting times. NHS managers tend to pay more attention to formal complaints than to concerns. The study found that strategies used to resolve common concerns are therefore not shared between PALS teams, and opportunities to learn are lost.

The service can increase patient satisfaction by quickly resolving a problem, the researchers say. Providing PALS staff with a more structured way of recording and grouping concerns and their resolution could make the service more efficient across trusts.

Further information about PALS can be found on the NHS website.

What’s the issue?

The vast majority of patients are satisfied with the care they receive from the NHS. However, sometimes people have concerns about an aspect of their care. An explanation and apology can sometimes be enough to resolve their concerns before they escalate into complaints or even claims.

PALS was set up to deal with informal concerns. But PALS staff can also advise and provide information about making a formal complaint. People who have been seriously harmed (through an error in surgery, for example) are more likely to make a formal complaint. This is sometimes the correct action to take.

Since 2002, every NHS trust has had a PALS to support patients, their friends and families when raising concerns. PALS staff are a point of contact, giving information and resolving a range of problems. They provide support in person, by email, by post and by telephone.

PALS staff offer confidential advice, and help patients navigate services. They may act as mediators between families and staff, and sometimes as patient advocates (supporting patients raising concerns). However, the service differs across NHS trusts. The responsibilities of each PALS are shaped by the population they serve, their funding and the priorities defined by their trust’s senior leadership.

The service has not been reviewed since 2008. Researchers wanted to see how it has evolved. They wanted to explore the role of staff, look at the nature of complaints the service deals with, see what barriers staff face when resolving concerns, and explore how PALS data might be used for wider learnings.

What’s new?

The study was carried out in 4 acute trusts (which generally provide tests and treatment for physical illnesses) and 4 mental health trusts. Researchers interviewed 3 people within each trust (24 in all): a PALS manager, PALS officer and clinician (such as a nurse) suggested by the PALS manager.

Four themes emerged:

  1. The role of PALS
    PALS staff described a lack of guidance about the scope of its duties. They said PALS had become a catch-all service which picked up tasks that no-one else in their trust would do. However, PALS’ core responsibility to help patients, has remained unchanged. It is a point of contact for patients and service users. An interviewee said: “I’m here for the patients. I’m happy to help anybody as much as I can.
  2. Concerns and resolution
    PALS staff said most concerns were about communication (what staff said, or how they spoke to patients), staff attitudes and waiting times. The service mediates between clinicians and patients (or families), for instance, if patients are reluctant to approach a clinician directly. PALS teams can resolve conflicts informally, and with a human touch that is missing from the formal complaint process. An interviewee said: “Hopefully we can resolve things quicker so we can just walk up to a ward and see someone… or do a quick phone call. Whereas the complaint process is… 3 days to acknowledge, 25 working days to respond.”
  3. Barriers to resolution
    Neither clinical staff nor members of the public were sufficiently aware of PALS and what it does. In some mental health trusts, PALS offices were hidden, and teams could only be reached by phone, post or email. Clinical staff could lack the time and inclination to liaise with PALS, they did not always update their contact details, and managers move frequently. An interviewee said: “We have no way of knowing at all what services are open, what services are not, who’s managing which service.
  4. Learning from concerns
    PALS staff said managers focus on formal complaints and are unlikely to reflect on trends in patient concerns. Opportunities to learn how best to resolve concerns are missed. PALS teams vary in the detail and the extent of records they keep; there is no consistent approach. An interviewee said: “All we’re doing at the moment is counting the numbers. And the most detailed analysis that we do… is the number of days to completion.”

Why is this important?

The researchers believe this is the only study in the last decade to have looked at PALS. They say the service can give people a quick, human resolution to concerns, which should improve satisfaction with the NHS.

People with unaddressed concerns might lose trust in the NHS, and this can be difficult to earn back. It may make them reluctant to seek help in future, or to follow medical advice. By acting as an impartial go-between, PALS staff help maintain people’s trust in healthcare professionals.

On top of its core duties, PALS has become a catch-all service in some trusts. Staff have taken on patient liaison work not covered by anyone else. The study highlighted differences between trusts. For instance, some PALS staff regularly visit wards to talk to patients, engage with staff and pre-empt problems. Other teams train clinical staff on how to communicate with patients and resolve concerns as they happen.

Descriptions of the roles that different teams play, and how they work, could form the basis of a guide for PALS teams.

What’s next?

The researchers say that PALS teams could reduce formal complaints, increase patient satisfaction and advise other PALS teams about effective ways of resolving concerns. For this to happen, standardised policies are needed on the role of PALS across the country. The service needs to be supported, and both patients and clinicians need to be more aware of it.

The researchers say a national review of the service could lead to a more structured process for resolving concerns. The team would like to explore the different models in use across the NHS to help PALS teams share good practice with each other. PALS could be advertised more widely in the NHS to make clinicians aware that it can support them as well as their patients.

PALS does not currently collect data on concerns. The researchers suggest that the current procedure for formal complaints could be adapted by PALS to manage concerns. A national framework for recording and grouping patient concerns would include actions taken and the outcomes. PALS teams could share this information with one another.

Studies such as this provide detailed information from staff interviews. Further work could look at PALS in different sites, and include the views of physicians. It could explore how often PALS resolves concerns and prevents formal complaints, and how well-received their staff training (on communication) and patient engagement (talking with patients on wards) is.

You may be interested to read

This Alert is based on: Shepard K, and others. How do National Health Service (NHS) organisations respond to patient concerns? A qualitative interview study of the Patient Advice and Liaison Service (PALS). BMJ Open 2021;11:e053239

The 2008 report explaining the potential of PALS: Evans D, and others. Patient Advice and Liaison Services: results of an audit survey in England. Health Expectations 2008;11:3

A factsheet from Age UK about PALS: Resolving problems and making a complaint about NHS care.

Problems with formal complaints processes: Martin, GP and others. Why do systems for responding to concerns and complaints so often fail patients, families and healthcare staff? A qualitative study. Social Science & Medicine 2021;287:114375

Patients’ insights into hospital care:  O’Hara JK, and others. What can patients tell us about the quality and safety of hospital care? Findings from a UK multicentre survey study. BMJ Quality & Safety 2018;27:673–682

Funding: This study was funded by the NIHR Policy Research Programme, conducted through the Quality, Safety and Outcomes Policy Research Unit.

Conflicts of Interest: The study authors declare no conflicts of interest.

Disclaimer: NIHR Alerts are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that views expressed in NIHR Alerts are those of the author(s) and reviewer(s) at the time of publication. They do not necessarily reflect the views of the NHS, the NIHR or the Department of Health and Social Care.


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Comments

Study author

Historically, many people whose care had gone wrong were treated badly. They said no-one apologised or gave any explanation. A lot of research shows that people who make formal complaints are unsatisfied with the response they receive and feel that their questions have not been answered. They want something more human than the NHS formal complaints process can give them.

The PALS service provides that much-needed human touch. But it hadn’t been looked at in detail since 2008. We wanted to see if elements of it could be improved. We found that there was little guidance on what PALS should be doing. PALS services have evolved in different ways and some have very innovative ways of responding early and resolving patient concerns. We believe that much could be gained by sharing these approaches, strengthening PALS teams and by organisations taking a much more proactive approach to responding to patient concerns and complaints.

Charles Vincent, Professor of Psychology, University of Oxford

Hospital Manager

I liaise regularly with the PALS team at the trust in which I work, raising concerns from patients. This research made me reflect on the opportunities we have to learn from the concerns and feedback that PALS receive, the themes within them and the data that PALS hold.

This paper underlined the value of PALS teams. They resolve patients’ concerns and support improvement and learning across NHS trusts. I have shared the research with those involved in the PALS service at my trust.

The study is based on a good quantity and range of interviews with a sensible mix of people from each Trust. The researchers make suggestions and recommendations for improvement in national policy and local implementation in NHS trusts. The main opportunities to act are most likely at a local level. NHS trusts can implement processes to collect, review and act upon data held within PALS.

This is the only research into PALS teams over the last decade. It will be a useful reference for those working in and with the service.

Rob Newton, Associate Director of Policy, Leeds Teaching Hospitals NHS Trust

Researcher

Most of my research is on integrated care. This study is extremely relevant, and makes a good contribution. In-depth reading of the interview findings could help us to understand barriers and lead to improvements in practice. Individual PALS would need to accept that the findings are applicable to their own service, before acting on them.

The researchers interviewed 24 people, of whom 8 were professionals. I would like to see a large survey and perhaps case studies, plus an audit of outcomes. This would include a broader range of experiences and could produce richer data.

Yannis Pappas, Director, Centre for Health Service Organisation and Delivery, University of Bedfordshire

Lived experience

This paper made me think about the importance of identifying themes and sharing them more broadly. It is a reminder that poor communication underpins many problems and complaints.

It sounds as if trusts are resistant to hearing about complaints and challenges, which makes PALS reluctant to share them. This makes action and change difficult. But there could be a recommendation, for example, to compile data at a national level across PALS and share it with trusts.

Angela Slater, Public Contributor, County Durham

Academic clinician and researcher

PALS is relevant to us all: clinicians, patients and the public. Having a person and service to help raise concerns and resolve complaints is vital. This is an important and robust interview-based study on PALS, where little previous research has been conducted.

I was concerned that the service lacks visibility, particularly in mental health trusts. I would like to see this change, and the key findings implemented and acted upon. There is ample evidence in here of what needs to be done. There also needs to be as much interest and learning from concerns as from complaints. A robust system of recording and using concerns data could improve practice. We need a national framework for recording concerns (as well as complaints).

It is hard to determine why this has not been developed after 20 years of PALS. Resources may have been lacking, or perhaps concerns data was not sufficiently valued as a means of driving quality improvement. I would suggest this is a serious oversight.

Jill Maben, Professor of Health Services Research and Nursing, University of Surrey

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