The Practice
18. In the UK, a person’s human rights are protected by the Human Rights Act 1998. This is underpinned by the principles of fairness, respect, equality, dignity and autonomy (FREDA). In practice this means having regard for the rights of people, treating them no differently to others and treating them with compassion.
19. The Equality Act 2010 makes it unlawful for disabled people to be treated less favourably than people who are not disabled. Under the Equality Act, the Practice is obliged to make all reasonable adjustments to make sure disabled people have equal access to its services.
20. Our Principles say, ‘all public bodies must comply with the law and have regard for the rights of those concerned. They should plan carefully when introducing new policies and procedures. Where public bodies are subject to statutory duties, published service standards or both, they should plan and prioritise their resources to meet them.’
21. It is not for us to make comments on the law but it is our role to uphold our Principles. These say public organisations should ‘get it right’ by acting in line with the law and considering the rights of those concerned. We expect NHS organisations to act in line with the FREDA principles when they provide services.
22. An assistance dog has been trained to assist a person with a specific disability and the dog has been qualified by one of the organisations registered as a member of Assistance Dogs (UK).
23. Mr U’s assistance dog is qualified by Canine Partners. Canine Partners is registered as a member of Assistance Dogs (UK). We have seen the assistance dog’s identification book.
24. All assistance dogs have formal identification and have been granted certification by the Department of Health because the dog’s high standards of training, behaviour, health and welfare mean it should be permitted to accompany its owner at all times and in all places within the UK.
25. The EHRC guidance states that assistance dogs are highly trained and most are instantly recognisable by the harness or dog jacket they wear. But it is not a legal requirement for assistance dogs to wear a harness, jacket or lead slip.
26. An identification book gives information about the assistance dog and the training organisation. It is not a legal requirement for the owner to carry the book and assistance dog users should not be refused a service because they do not have the book with them.
27. Mr U says the Practice welcome team greeted him outside and asked him what he was going to do with the dog. Mr U says he said, ‘I am going to take him in with me: he is a qualified assistance dog’ and he pointed out the dog’s uniform which he was holding ready to unhook from the handlebar of his chair to put on the dog.
28. The welcome team then asked for the manager to come outside. Mr U says they questioned him ‘inappropriately and in full sight and hearing of other people’ about what he needed his dog to do for him. Mr U says they ‘could see the canine partners tag on the dog’s lead’.
29. Mr U says the manager did not ‘allow or encourage’ him to explain the dog ‘had a legal right’ to accompany him in the building. Mr U says he ‘immediately became stressed and unable to think clearly enough to finish putting his dog’s uniform on, or to think to get out his assistance dog passport (this is the same as an ID book referred to above).
30. He says he had limited time to go in and have his second vaccination. He says he felt he had no choice but ‘to give in’. Mr U says without his permission, or even attempting to ask him if they should, they ‘helped’ him to remove his dog’s lead from the wheelchair and walked him to the door with his dog’s lead in the manager’s hand. Mr U says, ‘I felt my dog was being confiscated’.
31. Mr U says the Practice was set up for COVID-19 vaccinations in the same way as it was when he had attended with his dog for his first vaccination. He says there was a one-way system through the building and although the corridors are narrow, he was used to navigating this with his dog.
32. Mr U says in narrow spaces the assistance dog ‘will be commanded to either go ahead, or to follow the wheelchair’, and him entering the clinic with both his wheelchair and assistance dog would not have caused difficulty.
33. Mr U says staff did not recognise the effect the incident had on him and his dog and did not give him a meaningful apology.
34. The Practice manager says Mr U’s dog was tethered to his powered wheelchair using a ‘companion dog’ lead, not one of the more clearly identifiable harnesses he would associate with assistance dogs. They said Mr U did not show any documentation to confirm his dog as an assistance dog.
35. They explained that with the large footfall they were dealing with, they had to keep as hygienic an environment as possible and asked if it would be possible for the dog not to enter if it was not needed for assistance. They said Mr U agreed to that, although they accepted Mr U’s preference was for the dog to stay with him.
36. The Practice said this was ‘a snap decision taken in the midst of an extremely busy covid vaccination clinic’ and made in the ‘perceived best interests’ of maintaining safety and access for Mr U, other patients and its staff.
37. It explained it saw approximately 800 people on that day, so there was a lot of traffic in the one-way system from the entrance, past the vaccination rooms to the exit. It said, ‘The clinic was vaccinating a mixture of patients, mostly elderly and clinically vulnerable at that stage in the campaign.’
38. The Practice also explained Mr U was wider than an average person due to his wheelchair and dog, and he had no markings to show his dog was an assistance dog.
39. As this incident was during a vaccination appointment, there are no records of what happened. The discussion between the manager and Mr U was not witnessed (by anyone we could now take a statement from) and we understand they both have a different account of how that conversation went. Without witnesses it is difficult to know exactly what happened, what was said, or the tone and way it was said.
40. The Practice’s policy on assistance dogs in place at the time says:
‘Ideally, we will have the dog’s details (e.g. name and gender) on the handler’s clinical record as well as to how they help their handler. Both the handler and dog can then be greeted properly and any additional needs met even if the dog is not wearing a specific disability organisation’s branded jacket or labelled harness (e.g. Hearing Dogs for Deaf People)’.
41. The policy does not clarify that it is not a legal requirement for assistance dogs to wear a harness, jacket, lead slip or provide an ID book.
42. On 7 May, the Practice manager explained to Mr U’s mother:
‘I asked in which manner does the dog provide assistance and had an amicable, sympathetic discussion with your son who was articulate but did not offer up any information with regards to how the dog would provide assistance beyond he is always with him. He did not present an assistance dog “passport” of any description.’
43. The Practice told us it does not know the exact nature of the conversation between Mr U and the Practice manager, but it noted that Mr U had no markings to identify his dog as an assistance dog. It said the manager thought the dog was a companion dog.
44. The Practice updated its policy after Mr U’s complaint. The new policy clarifies that it is not a legal requirement for assistance dogs to wear a harness, jacket, lead slip or ID book. It says:
‘Most assistance dogs are recognisable by a harness or jacket; however the law does not require the dog to wear a harness or jacket to identify it as an assistance dog. Some, but not all assistance dog users, will carry an ID book giving information about the assistance dog and the training organisation together with useful information, but again this is not a legal requirement.’
45. The Practice says this was a case of miscommunication and it was not intentional discrimination towards Mr U.
46. We accept from his account that Mr U explained his dog was a qualified assistance dog. He had the dog’s uniform hooked on his wheelchair and the dog was wearing a Canine Partners tag on its lead. Mr U wrote a complaint shortly after the incident and we can see his account has been consistent. The fact that the Practice manager asked Mr U, ‘in which manner does the dog provide assistance’ strongly supports Mr U’s account that he had explained the dog was an assistance dog.
47. We understand Mr U felt wrongly questioned in public about his health and disability. We understand this made Mr U feel stressed and unable to think clearly enough to finish putting his dog’s uniform on or get out his assistance dog passport.
48. We can see the Practice says the dog was tethered to a powered wheelchair using a companion dog lead and Mr U did not show any form of documentation to show his dog was an assistance dog.
49. We tried to understand what the Practice means by a companion dog lead. The CCG’s response refers to a ‘Companion Dog UK leash’ and the Practice refers to ‘a companion dog lead’ several times. We were unable to find an organisation called ‘Companion Dog UK’ as referred to in the complaint response. Our understanding is it means a general dog lead.
50. We have no reason to doubt Mr U’s account. We accept that he explained his dog was an assistance dog. We also think it is likely the welcome team would have reported to the Practice manager that Mr U had arrived with his assistance dog. This should have been enough for them to allow him access to the building for his vaccination in line with the EHRC’s guidance and our Principles that say organisations should act in line with the law and consider the rights of those concerned.
51. We consider it was acceptable for the Practice manager to ask about the dog when it was not immediately obvious that it was an assistance dog.
52. We accept that the Practice says this incident was caused by miscommunication and it did not intentionally discriminate against Mr U. But the Practice manager was the person in charge that day. They knew Mr U was a vulnerable, disabled person and once he explained his dog was an assistance dog, he should have been free to access the building like the rest of the patients that day. We accept that Mr U’s communication may not have been clear and he may have seemed to hand the dog over without much objection. But, given he is a vulnerable patient, we think it was the Practice manager’s responsibility to understand what was going on in this situation. They recognised that Mr U would rather keep the dog with him and we think they missed an opportunity to explore this further and give Mr U a chance to explain himself.
53. We accept that being questioned about this in public was very distressing for Mr U. We know he felt he was being forced to hand over his dog and that this was the only way to get his vaccination. Even if the Practice manager did not intend to come across this way, this is how it was very strongly felt by Mr U. We think the Practice manager should have thought more carefully about how they approached this situation and how their questioning would have felt for Mr U.
54. We find failings with how the Practice managed this.
55. We can see this has had a significant impact on Mr U and his mental health. When something goes wrong, the NHS Complaint Standards expect an organisation to make a meaningful apology, accept responsibility for the mistake, and provide an explanation and appropriate remedy.
56. We have seen that Mr U and the Practice have worked together to improve the information on the Practice website for people with a disability. Mr U has made suggestions for improvements and the Practice told him it would consider these.
57. The CCG’s final response explained the Practice would continue to make sure staff commitment to completing equality and diversity training is maintained and it would tailor its services and access for patients with ‘particular needs’, including people who use assistance dogs.
58. The Practice has also reviewed and updated its policy on assistance dogs.
59. We can see the Practice has taken some steps to improve its service. But we are not satisfied this is enough to put right Mr U’s injustice, as the policy needs more detail.
60. We looked at the new policy and can see it does not specify what the purpose of the policy is and does not explain who the policy applies to. The policy does not give any information on the requirements (if any) for dogs entering Practice premises.
61. The current policy does not say what the responsibilities of the dog owner are or who is responsible for overseeing the function and impact of this policy. The policy does not say which (if any) areas assistance dogs are not allowed in (restricted areas). It does not give enough information on justifiable separation or reasonable objections for access for assistance dogs, or what should happen when a reasonable objection exists.
62. After reviewing the policy, we have not seen enough information on monitoring and compliance (to make sure the policy works) or on training and implementation.
63. We do not think the updated policy gives enough guidance to prevent a similar incident from happening in the future.
64. We have made recommendations at the end of the report.
The CCG
65. NHS Complaint Standards say staff investigating a complaint should give everyone involved the opportunity to give their views and respond to emerging information, where appropriate. They should take everyone’s comments into account and act openly and transparently. They say service users who make complaints, and colleagues directly involved in the issues, must have their say and be kept updated when complaints are investigated.
66. The standards say when an organisation finds it made a mistake, it should give a meaningful apology, accept responsibility for the mistake, explain why things ‘went wrong’ and provide an appropriate remedy.
67. Mr U complained to the CCG on 1 June 2021. Mr U said he decided to complain to the CCG because his complaint was about the Practice manager and he ‘could not see there was a higher level of management to refer’ his complaint to.
68. Mr U says the CCG made significant points in its first response which it later stated were incorrect.
69. Mr U says he felt betrayed and helpless. He says he was very stressed and his mental health got worse.
70. In its first response, the CCG said it investigated the complaint with the Practice. It decided Mr U was not ‘treated appropriately and things should have been done differently’. It also confirmed there was ‘no legal requirement’ for Mr U to identify his dog as an assistance dog, and his dog had the ‘legal right to assist’ while he was having his vaccination.
71. The CCG said the Practice apologised for the impact this had on Mr U and that it would be making changes following Mr U’s feedback. It also said the Practice invited Mr U to meet with it to make sure its approach was accurate.
72. This meeting took place on 26 August. Mr U said he met with a doctor, who he said looked surprised by the arranged meeting. Mr U explained the meeting continued in a ‘stilted manner’ and the doctor did not offer an apology or an acknowledgement of any mistakes.
73. The Practice contacted the CCG on 16 September as the CCG’s complaint response was not shared with it before or after it was sent to Mr U. The Practice challenged the response as being factually inaccurate.
74. The CCG sent its second and final response on 7 January 2022. This said the first response did not reflect the Practice’s view of the situation and it had not committed to making the changes detailed in the first response.
75. It said the CCG did not believe the Practice ‘acted illegally or discriminatorily’ towards Mr U but that the Practice manager had ‘acted in good faith based on the information he had at the time’.
76. It explained the Practice would continue to make sure staff commitment to completing equality and diversity training was maintained and it would tailor its services and access for patients with ‘particular needs’, including people who use assistance dogs.
77. The CCG apologised for the inaccuracies in its first response and explained it had changed its complaint handling process. Specifically, it would make sure that in the future, practices would review the final response before it is sent, and actions would be agreed by all parties concerned.
78. The CCG’s complaint handling policy that was in place at the time says:
‘where the complaint can be investigated and responded to directly by the CCG, it will be forwarded to an appropriate investigation lead who will conduct a thorough investigation and where appropriate, will identify any learning to be implemented as a result.’
79. It adds:
‘where other organisations are involved in the complaint, the details will be shared as necessary for investigation and response back to the Customer Services Team. This information will then be reviewed and collated into an overall response from the CCG and any learning identified will be included’.
80. The CCG told us its first letter ‘stands’ and its second response was an extra letter to clarify points after discussions with the Practice.
81. But this is not the impression Mr U has. And the Practice has said the CCG’s first response did not accurately represent the Practice’s response to the complaint and was ‘misconceived’.
82. The CCG did not coordinate its response with the Practice or share it with it before, or when it sent it to Mr U. This was also not in line with its own policy or the NHS Complaint Standards. This is a failing.
83. This had a significant impact on Mr U and his mental health. We consider that the actions of the CCG prolonged Mr U’s injustice and the impact he felt from the Practice’s actions. Having upheld his complaint and assured him improvements would be made, it then changed its mind.
84. Our investigation has found failings in the Practice’s actions. Our findings are in line with the CCG’s original findings. We are not satisfied that the CCG’s second response fully considers both accounts, or reflects the guidance applicable to allowing assistance dogs to accompany their owners. The change of response has seriously undermined Mr U’s confidence in the complaint process and has not given him a solution to what he experienced and how it made him feel.
85. In its final response, the CCG accepted responsibility for its mistake in complaint handling. It also explained how it would improve its services, so a similar mistake did not happen in the future. This is a positive change but we are not satisfied that it goes far enough because the CCG’s second investigation and response also seems to be flawed.
86. We thought carefully about whether to make any recommendations for service improvements to the CCG. In doing so, we reviewed the CCG’s recent Quarterly Report which outlines that, since the formation of the ICB, NHS England took over the responsibility and management of all formal complaints relating to GPs, including clinical care and access to services. Because of this, there is no benefit in making any specific recommendations about how the CCG should improve its investigations of GP complaints.
87. We have made recommendations to put right the injustices we have found at the end of the report.