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SPEECH TO NHS CONFEDERATION SEMINAR

21 June 2007

The value of the individual voice

My fellow speakers have described the various ways in which the collective voice of the community can get itself heard in the Health Service.

I want to talk about what we can learn – and how we can improve services – including healthcare – by listening to individual voices; and specifically, to focus on a specific element of individual voice: the voices of those people who take the time and trouble to give us their feedback by making a complaint.

Listening to that voice offers two main opportunities:

• First, to resolve the issue and delight the complainant, leaving their faith in the NHS intact, or even improved, and contributing to the vision that the individual really does have both voice and voice – and can make a difference.

• Secondly, to learn from the complaint and improve services for other people.

With opportunities, as we all know, come threats. The threat here is that people whose complaints are not heard become disillusioned, lose trust and become frustrated (we know this from experience and our research) which amongst other things results in a negative recruiting environment for local patient leaders – or simply silence. No voice.

So, the voice of the individual patient, as expressed in complaints, is hugely valuable – not only for the complainant but also for all of us. That’s where the Ombudsman has a distinctive role - in levelling the playing field in those most unequal of disputes between the citizen and the mighty NHS – and thereby enabling those individual voices to be heard.

The complaints investigated by the Ombudsman are only a small proportion of the many thousands of complaints with which the NHS in England deals each year, but they are among the most serious and potentially the most instructive.

Let me give you an example of where the NHS has learned from complaints made to the Ombudsman.

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CASE STUDY ONE

Some time ago we issued a report of our investigation into a complaint about the death of a young woman. She was taken to A&E following a cycling accident; her parents were contacted and arrived at the hospital an hour later, by which time her condition had deteriorated and she was undergoing full resuscitation, including a thoracotomy and external heart massage. The extent of her injuries was not made known to her parents and, despite their requests, they were not allowed to see her because of the nature of her injuries and the distressing nature of the resuscitation process.

Forty minutes after arriving at the hospital, her parents were told that she had died. They were suspicious that their daughter’s injuries had been underestimated and that there had been undue delay in treating her. They believed that she need not have died, and were devastated that they had been denied the opportunity of seeing her before she died. They were unable to come to terms with her death.

As a result of the complaint which followed, and the Ombudsman’s report, the Trust introduced a number of measures, one of which was to offer relatives the opportunity to be present during resuscitation should they so wish. The Trust recognised that this would have resource implications as relatives would need to be supported, but felt that it was an appropriate step to take.

Some time later a young man with appalling self-inflicted injuries was treated in A&E at the same Trust. He was accompanied by his parents, who were invited into the resuscitation room and therefore witnessed the attempts to save their son’s life. They were supported by a nurse who explained to them what was happening. Their son died. They said afterwards that, had they not seen it for themselves, they would not have believed the number of people involved and the extraordinary effort that had gone into trying to save their son. They knew that everything possible had been done to save him, and that would make it easier for them to break the news of his death to the rest of their family, and to come to terms with their loss.

Of course, the vast majority of complaints are dealt with at local level, by NHS bodies, which is as it should be. That is where learning needs to happen. The Healthcare Commission reviews cases where the complainant is dissatisfied with the local stage. If a complainant is still dissatisfied after the Healthcare Commission’s review, the complainant can come to the Ombudsman.

But what is very clear to me – and I’m sure to you as well - is that it is much better for complaints to be resolved locally – so that those individual voices can be heard – and acted on - at local level. Patients, professionals, the Service - everybody benefits if problems are dealt with quickly and sensitively, on the ward or in the surgery.

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Making things better?

Of course, the NHS track record in this area is not so good. As my Office knows well from experience over the past 30 years.

It was on the basis of that experience that in March 2005 we published our report Making things better? A report on the reform of the NHS complaints procedure in England . That report set out our blueprint for a modern, responsive, patient-focused complaints handling system for the NHS.

We advocated a shared commitment to improving complaints handling at every level of the NHS. We said that there had to be leadership from the Department of Health in determining policy and setting standards; and from the Healthcare Commission as regulator, using the levers of regulation to drive up improved performance in complaint handling.

But, as importantly, we said that there needed to be leadership at a local level if things were ever going to change. Under the heading of ‘Leadership, culture and governance’ we said that:

‘This will involve the Boards and Chief Executives of NHS bodies creating a culture of openness and learning. There should be clear standards of behaviour set and followed by the leadership of each local organisation, and the monitoring of performance on complaints by managers and the Board. Managers need to ensure that arrangements for complaint handling are well connected with clinical governance and quality improvement activity.’

In short, improvements in complaints handling need to be underpinned by a corporate commitment to taking complaints seriously.  

With that in mind – and to aid our discussion - let me suggest three questions that those of you with responsibility for leadership, governance and management in the NHS might ask yourselves:

In your organisation:

• Who deals with complaints and how senior are they?

• When was the last time your Board received and discussed a detailed report of complaints received, and their outcomes; and the lessons learned as a result?

• Can you describe two service improvements your organisation has made as a result of learning from complaints?

I hope that some of you will share the answers with us before we finish this session today.

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Principles of Good Administration

Some of you will know that earlier this year my Office published our six Principles of Good Administration. We did that because we wanted to be open and clear with both complainants and the public bodies within jurisdiction about the sorts of behaviour we expect when public bodies deliver public services, and the tests we apply in deciding whether maladministration and service failure have occurred.

Two of those six Principles are:

• ‘Putting things right’ – putting mistakes right quickly and effectively; and
  
• ‘Seeking continuous improvement’ – learning lessons from complaints and using them to improve services and performance.

Let me give you another example of a complaint that came to us which illustrates how those Principles can be put into practice. So often complaints are met with defensiveness, delay and a failure to put things right and learn for others. In this case it was the Ombudsman who eventually ‘put things right’ - making sure that the individual voice of the service user was heard; but to give credit to the Trust - they picked up the ‘continuous improvement’ challenge, building on that bad experience and turning it into a positive one from which everyone could benefit.

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CASE STUDY TWO

In this case there were two related complaints about the provision of occupational therapy and physiotherapy by a Primary Care Trust to a child with special care needs. The child’s parents came to the Ombudsman after their repeated attempts to get things right locally had failed.

The first complaint was about the absence of occupational therapy for the child while attending school some distance from home. His Statement of Special Educational Needs recommended one hour per week of occupational therapy, but the occupational therapy service had not approached the local education authority about providing it. We found that there were serious failures of organisation and management in the occupational therapy service. This was compounded by poor communication and decision-making at many levels of the Trust. The result was that the child was not receiving the service he should have received.

We recommended that the Trust urgently address the provision of occupational therapy to out-of-borough children and carry out an urgent review of what should be delivered, and how. The Trust agreed to all the recommendations.

The second complaint concerned the provision of physiotherapy to the child while attending a nursery and later at an infant school. Our investigation found that the physiotherapy service provided also fell below an acceptable standard. The Trust had been aware that there were not enough staff to cope with the high demand for paediatric physiotherapy services, but had not been sufficiently proactive in doing anything about it.

We made – and the Trust agreed to – a number of recommendations to ensure that similar problems did not occur in future. The family received an apology from the Trust for their poor service and a payment of compensation in recognition of the inconvenience and distress they had experienced.

The child is now educated at home and the local authority have made a substantial payment to the family in compensation for the educational services that the child did not receive while he was at school. The family have used the money to help buy a larger car, with more boot space to accommodate a larger wheelchair, and a number of special needs toys and equipment. This means that the boy can go out more and gets to meet more people as a result of which, his father told us, he is ‘ an altogether different child’.

And finally – the child’s father has also accepted an invitation to take part in the Trust’s Service User Forum!

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So those are some of the positives about how the individual voices of complainants can drive service improvements. But if that’s not enough of an incentive, there are also plenty of other reasons to get this right.

In these times when balancing the books is a key issue for the NHS, it is worth remembering the possible financial consequences of poor complaint handling. Apart from the opportunity cost (just think of all the things that managers and clinicians could be doing if they weren’t answering questions from the Ombudsman), in an increasingly litigious world, there are clear potential savings to NHS bodies in avoiding compensation claims when complaints are handled properly and promptly; and even more so if complaints are used rigorously by Boards as a vehicle to ask questions of managers and staff.

Boards that fail to do this properly are missing out on a vital source of management information which could lead to service improvements and efficiency savings. Complaints raise recurring themes: poor record keeping; poor communication with patients and their relatives and carers; care planning that is inadequately tailored to patients’ needs; poor supervision and management.

There is also surely a message for both commissioners and providers. Good complaint handling can help improve reputation as well as avoid expensive problems. In the new landscape of choice, a good complaints record is one way in which trusts can gain competitive advantage. But a bad and highly-publicised complaints record will lose business for a hospital.

Complaints, however, are so much more than internal management information. They are also a rich and currently underused resource for all those charged with holding the Service to account.

Oversight and scrutiny committees and Local Involvement Networks should all make sure they are aware of relevant complaints and the lessons that can be learned from them.

The same is true of the regulators. The effectiveness of bodies’ complaints handling is also increasingly something that the Healthcare Commission and Monitor have in their sights.

So the overall message is clear: the Service must be aware, from the Board to the ward, of the need to deal with complaints effectively and promptly.

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Conclusion

It is clear from this session that what might be called the ‘landscape of voice’ in the NHS is complex, but I am sure that we can make sense of it.

The role of the Ombudsman is not to compete with the interests represented by any of my fellow speakers, but to fulfil our particular niche in this crowded landscape.

As I said at the outset we enable individual voices to be heard. We need to share our knowledge and expertise better and more widely by publishing regular case studies more than we have in the past, and drawing wider conclusions from them where appropriate.

It feels timely to be talking to you today in the week when the Department of Health has published its consultation document on proposals for a new streamlined health and social care system. I am pleased to see that the proposals draw heavily on our 2005 report, Making things better? and the dialogue we have had since then with the Department, the Healthcare Commission and others.

The Department of Health says that the consultation paper: ‘proposes a radical new approach to complaints handling which is more flexible and supports organisational learning.’ That is encouraging talk – all we need to do now is put it into action.

Ann Abraham , Parliamentary and Health Service Ombudsman June 2007

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Last updated: 25 June 2007