As NHS structures and systems are overhauled, the final report of the Mid Staffordshire NHS Foundation Trust Public Inquiry is expected in January 2013. The Inquiry, into devastating failings in care at Staffordshire Hospital, examines the broader NHS monitoring system: the commissioning, supervisory and regulatory organisations. Its goal is to find out why problems at the Staffordshire Hospital were not identified and acted upon sooner.
Last year, the then Ombudsman, Ann Abraham, gave evidence to the public inquiry. Explaining that we are not a regulator or an early warning system, she emphasised the importance of acting on intelligence gained from complaints. She said:
‘Patients and their families need to be empowered and encouraged and enabled to have their say. When they do speak up, they need to be listened to and what they say needs to be acted on. And that won’t happen if NHS boards don’t demand regular information about complaints, and their outcomes, and ask to be told what trusts are doing differently as a result of learning from complaints.’1
As the Health Service Ombudsman, we listen to the experiences of individual patients and make judgments on their complaints. Often the people who contact us feel that what happened to them has not been listened to and their voice has not been heard. The information and data we hold can help to ensure that the experiences of individual patients are heard and acted upon more readily in future.
We want to share the information we hold more widely, with providers and commissioners, regulators, MPs and Parliament and patients. By doing so, we can help others evaluate services and inform commissioning decisions; provide data about service quality and choice to the health sector regulators; and provide insight to regulators and to Parliament on system-wide failures within the NHS. We will continue to alert the professional regulators to patient safety concerns resulting from the practice of individual clinicians and will seek to collaborate with voluntary or other organisations to influence service improvements.
To do this, we want to collect and publish more data about the complaints that we receive. We aim to publish summaries of all investigations and provide periodic complaints data to NHS organisations. Alongside this work, we will continue to publish reports such as this one, putting information about NHS complaint handling in the public domain while highlighting good and bad practice.
As the new NHS arrangements are implemented, we will provide information about patients’ experiences to the new NHS commissioners – both to the local clinical commissioning groups that directly buy services from the NHS and independent providers, and to the national NHS Commissioning Board that will commission primary and specialist care. We will do this to help inform their commissioning role. We will also work with the NHS Commissioning Board to assist in embedding good complaint handling across the NHS.
We are looking at ways we can improve both our response to complaints and the service we provide. This includes looking at the language we use when communicating our work to complainants and to the wider public. In the coming months, we will review our processes to see how we can investigate more complaints, and conclude those investigations more quickly.
Among the most serious complaints we receive are those where someone believes that NHS failings contributed to a patient’s death. To ensure that our work in this area is of most benefit to our complainants and to the wider public, we have commissioned an external review of the way in which we handle cases involving potentially avoidable death. The review will make recommendations about how we can respond to such complaints in future, including how we can best identify and share patient safety concerns and lessons learnt with service providers and the regulators. More information about the review is available on our website.
This report outlines the learning from our casework in 2011-12, and suggests how the NHS can improve its complaint handling in some of the most troublesome areas. It also sets out ways in which our own work is changing to enable us to share more information more widely.
The NHS provides high-quality health care for thousands of us every day. When things go wrong, good complaint handling will help restore high-quality, patient-centred care. To achieve this, high standards of complaint handling need to be part of the new landscape — championed and understood by practitioners, commissioners and senior executives across the NHS. We hope this report will help to make this happen.