The role of the Ombudsman in the new procedures and lessons from the past

AVMA

11 March 2009

What I said this time last year (26 March 2008)

Hard to believe that it’s almost 12 months since I was at AVMA’s annual conference this time last year.

In preparing for today's event, I looked back at what I said on 26 March 2008.

I talked about my role in the development of the new arrangements:

I spoke about my report to Parliament in March 2005, Making things better? A report on reform of the NHS complaints procedure in England.

That report set out our concerns about:

• fragmented systems;
• lack of patient focus;
• lack of leadership;
• lack of capacity;
• failure to provide appropriate remedies for justified complaints.
  

It also set out what we saw as the key elements of a reformed system:

• coherent and comprehensive coverage – across all health and social care providers;
• effective leadership and governance  - culture change;
• customer focused, accessible and flexible complaints systems;
• a quality service at local level – with the focus on outcomes not processes;
• the provision of just and appropriate remedies;
• and - improvements in service driven by learning from complaints.

So that was why we welcomed the commitment in 'Our health, our care, our say' to unify and reform the existing complaints arrangements across health and social care; and we welcomed the specific proposals in 'Making experiences count' in June last year.

I explained why I felt very much part of the design team – and why I am such a strong supporter of the new regime.

I spoke about the importance of effective local resolution – getting things right first time – and the opportunities for learning the lessons from complaints at a local level.

I also spoke about how the role of PHSO doesn’t change – but how the relationship with the NHS will change when we have the opportunity for a direct dialogue.

I said we expected to get more work in the short term – more enquiries, more substantive investigations – but that we were planning for that and we would be ready for it when it came.

I spoke about our Principles of Good Administration and Principles for Remedy. I trailed our next publication in the series: Principles of Good Complaint Handling – and asked for delegates’ input to that. Principles of Good Complaint Handling were  published in November 2008 following an extensive consultation.

I also trailed our forthcoming publications of case digests:

• NHS & Remedy – June 2008
• Principles into Practice – December 2008

I talked a bit about the sort of work we do at the Ombudsman's office and how we make a difference.

And finally I talked about the need to get to know each other better in the year ahead.

PHSO - Who we are, What we do and how we do it

I’m conscious that not everyone here will be familiar with my Office – who we are, what we do and how we do it.  So I thought I should start this morning with a brief outline of that – not least because that’s part of my billing this morning – and I’m a strong believer in keeping to commitments (or if you like doing what it says on the tin).

The ten minute guide to the PHSO.

The Ombudsman’s role in NHS complaints

The role of the Health Service Ombudsman

To undertake independent investigations into complaints that the NHS

 - Has not acted properly or fairly

 - Has provided a poor service

Our objective is

A new role for the Ombudsman?

• New two-tier process from April 2009
• The role of the Ombudsman, as an independent, impartial body to consider complaints, will not change
• Responsibility for the initial investigation of complaints remains with the local NHS

We've spent a lot of time in recent years setting out our framework of Principles. We've done that because we want to be open and clear with both complainants and public bodies in the Ombudsman's jurisdiction about what we expect when public bodies deliver services and the questions we ask in deciding whether maladministration and service failure have occurred. We want public bodies to understand how we will approach complaints and complainants to understand how we will consider their cases. We've also published digests of cases which illustrate how we apply our Principles in practice.

Preparing for April 2009 -

 making the Ombudsman's expectations clear

Helpful Publications

- Principles of Good Administration
- Principles for Remedy
- Principles of Good Complaint Handling
- Remedy in the NHS
- Improving public service: a matter of principle

Let me move on then to give you a flavour of how we apply our Principles of Good Complaint Handling.

'Principles of Good Complaint Handling' Published November 2008

• Getting it right
• Being customer focused
• Being open and accountable
• Acting fairly and proportionately
• Putting things right
• Seeking continuous improvement

Read also 'Principles of Good Administration' published March 2007 and 'Principles for Remedy' published October 2007
 
Getting it right

• Complaint response signed off by Chief Executive (the 'responsible person') or nominated representative
• Response addresses each aspect of complaint and is factually accurate
• Appropriate clinical advice taken
• 'Cross-agency' cases identified at the outset and a co-ordinated response made
• Accurate signposting to the Ombudsman – at the right time.

Being customer focused

• Easily accessible and flexible complaint handling arrangements
• Listen to the complainant to understand the complaint and the outcome sought
• Keep the complainant informed about progress
• Share the likely conclusions of the investigation in high risk or complex cases
• Identify one point of contact in 'cross-agency' complaints

Being open and accountable

• Document, and have readily available, all key issues considered and decisions/actions taken including:
  – discussions with the complainant
  – clinical advice taken, with details of the adviser(s)
  – national/local policy or guidance consulted
• Draft a final response letter that:
  – offers honest and evidence-based explanations of what happened and explains medical terms in plain language
  – sets out the conclusions reached, based on the evidence

Acting fairly and proportionately

• Respond in a way that is proportionate to the issues raised in the complaint
• Undertake an initial risk assessment in deciding how to take the complaint forward
• Give all relevant parties an opportunity to have their say or comment, including staff
• Act fairly towards staff as well as customers, manage unacceptable behaviour or unreasonably persistent complainants

Putting Things Right

• Offer an appropriate remedy - to address any injustice suffered and to avoid recurrence in future
• Clearly communicate any remedy to all involved
• Refer to the 'Principles for Remedy'
• The Ombudsman and the Department of Health are clear that a financial remedy can be considered where that is appropriate 

Seeking continuous improvement

• Set out actions to secure improved practice in future
• Ensure the complainant is updated on actions taken as a result of the complaint
• Ensure systems are in place to report outcomes to Trust Board and Scrutiny Committee

Let me read you one last quote from our Principles.
'These Principles are not a checklist to be applied mechanically. Public bodies should use their judgment in applying the Principles to produce reasonable, fair and proportionate results in the circumstances.  The Ombudsman will adopt a similar approach in deciding whether maladministration or service failure has occurred.'

The Ombudsman’s approach

• Initial Assessment
  – within remit
  – properly made
  – completed local resolution
• Further assessment
  – evidence of maladministration, failure in a service or failure to provide a service
  – unremedied injustice
  – probability of a worthwhile outcome
  – Possible short intervention
• Investigation

The other thing we care deeply about – when we uphold a complaint - is securing good outcomes – for the complainant – and for the future.

Securing good outcomes

• In 99% of cases, NHS bodies and practitioners comply with the Ombudsman's recommendations
• Where we have concerns that a practitioner’s actions or omissions pose a risk to the health and safety of patients, we will contact the relevant professional regulator and/or their employer
• We are developing a strategic relationship with the Care Quality Commission to drive improvements in services
• We wish to have more regular dialogue with the NHS – what do you want to know about our work?

So that’s a bit about who we are, what we do and how we do it.

A lot has happened since we last met

Going back to where I came in – a lot has happened in the 12 months since I last spoke at an AVMA conference:

• Health and Social Care Act 2008
• Creation of Care Quality Commission – regulator not complaint handler (and the abolition of the Healthcare Commission)
• We published our Principles of Good Complaint Handling (Autumn 2008)
• We’re about to get some new complaints Regulations.
• NHS Constitution & Handbook (January 2009)

I’d like to pause over the Constitution for a bit because I'm rather excited by it. It seems to me that what the Department has very helpfully done is set out in one place a large chunk of what 'Getting it right' means in the NHS context. So we have:

NHS Constitution – 7 Principles (1)

• The NHS provides a comprehensive service, available to all.
• Access to NHS services is based on clinical need, not an individual’s ability to pay
• The NHS aspires to the highest standards of excellence and professionalism
• NHS services must reflect the needs and preferences of patients, their families and their carers.

NHS Constitution – 7 principles (2)

• The NHS works across organisational boundaries and in partnership with other organisations in the interest of patients, local communities and the wider population.
• The NHS is committed to providing best value for taxpayers’ money and the most effective, fair and sustainable use of finite resources.
• The NHS is accountable to the public, communities and patients that it serves.

NHS Constitution – 6 Values

• Respect and dignity
• Commitment to quality of care
• Compassion
• Improving lives
• Working together for patients
• Everyone counts

NHS Constitution – 5 Rights
Complaints and redress

• To have any complaint you make about NHS services dealt with efficiently and to have it properly investigated.
• To know the outcome of any investigation of your complaint.
• To take your complaint to the independent Health Service Ombudsman, if you are not satisfied with the way your complaint has been dealt with by the NHS.
• To make your claim for judicial review if you think you have been directly affected by an unlawful act or decision of an NHS body.
• To compensation where you have been harmed by negligent treatment.

NHS Constitution – 3 Pledges
Complaints and redress
The NHS also commits:

• To ensure you are treated with courtesy and you receive appropriate support throughout the handling of a complaint; and the fact you have complained will not adversely affect your future treatment.
• When mistakes happen, to acknowledge them, apologise, explain what went wrong and put things right quickly and effectively.
• To ensure that the organisation learns lessons from complaints and claims and uses these to improve NHS services.

Constitution Handbook (p63)
'The pledges are consistent with the Ombudsman's Principles of Good Administration, Principles of Good Complaint Handling and Principles for Remedy which the Department of Health fully endorses.'

NHS Finance Manual (para 2.13)
'HMT's Managing Public Money contains guidance about the steps public bodies should take where they have caused injustice or hardship by maladministration or service failure. The PHSO published Principles for Remedy in October 2007 setting out six principles that represent best practice and are directly applicable to NHS procedures.'

And finally – coming right up to date:

Consolidated trilogy of Ombudsman's Principles (March 2009 – copies here for you today)

Ombudsman’s Principles
Published March 2009

• Principles of Good Administration
• Principles of Good Complaint Handling
• Principles for Remedy

So lots of reference material available on what 'Getting it right' means:

The Complaints Regulations
The NHS Constitution
The Ombudsman's Principles

The Ombudsman’s role in NHS complaints

This new framework has been a long time in development but I believe that the stage is now set for the dawn of a new era in NHS complaints handling.

If there is one lesson to learn from the past it’s how not to do it.

What have we been doing to prepare? 

As I've said a lot has been happening in the past 12 months – and we’ve been pretty busy at PHSO as well.

• We've secured additional resources to prepare for and operate in the new world.
  (2008/09 £3.4 million, 2009/10 and 2010/11 circa £10 million in principle sanction)
• Opened a new office in Manchester
• Recruited over 100 additional staff
• Worked with DoH to support the Early Adopter pilot
• Worked with Healthcare Commission and DoH in a tripartite NHS Complaints Transition Board to ensure the smoothest possible transition for complainants and bodies in jurisdiction – meeting monthly since October – final meeting next week.
• Developing our relationship with ICAS
• Begun a dialogue with CQC (and Monitor) on building a strategic alliance between Ombudsman and regulator
• Begun a dialogue with Commission for Equality and Human Rights along similar lines.

What are we working on now?

• Ensuring all our staff are up to speed with the new arrangements
• Finalising the transition of casework from Healthcare Commission to Ombudsman.
• Refreshing our leaflets and website
• Planning regular monthly electronic updates and newsletters for complaint handlers and advice organisations
• Developing an interactive section of our website for NHS complaint handlers and advocacy organisations
• Planning and designing 4 x regional conferences in June and July for complaint handlers, advice organisations etc. (in Manchester, Birmingham, Leeds and London)

In summary

We’ve been strong supporters and promoters of these changes – we believe they will make things simpler, quicker and better for complainants and the NHS.

We’ve been planning and preparing for these changes for many months.

We're resourced, we're enthusiastic and ready to go.

I believe that we are better placed – all of us - than we have ever been to Make Experiences Count.

In 2005 I set out what I saw as the key elements of a reformed system:

• coherent and comprehensive coverage – across all health and social care providers;
• customer focused, accessible and flexible complaints systems
• a quality service at local level – with the focus on outcomes not processes;
• the provision of just and appropriate remedies;
• and - improvements in service driven by learning from complaints.

And of course our biggest challenge:

• effective leadership and governance  - culture change.

We recognise that both the NHS and advice organisations are likely to need some help and support from us as we move into the new world – and we've been working on that as I hope I've made clear this morning. You’ll be hearing and seeing a lot more from us in the coming weeks and months.

We want an ongoing dialogue from now on – and into the future.

On that basis – I hope I've left plenty of time for questions.

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