Select Committee on Health Written Evidence

Memorandum by the Heath Service Ombudsman for England (PS 11)


  I welcome the opportunity to contribute to the debate about how best to ensure patient safety in the NHS. The inquiry is particularly timely given the recent discussions about the draft NHS Constitution and the receipt of Royal Assent for the Health and Social Care Act 2008 which establishes the Care Quality Commission as the new single regulator for health, adult social care and mental health.

  My role as Health Service Ombudsman for England is to consider complaints made by or on behalf of people who have suffered because of unsatisfactory treatment or service by the NHS. My office has been investigating complaints about the NHS for over 30 years and I base my submission to your inquiry on our experience of these complaints.

  As Ombudsman I am independent of Government and the NHS and provide an impartial service to both citizens and the NHS bodies within my jurisdiction. I can investigate not only complaint handling and the administrative aspects of health care, but also the clinical aspects of a complaint, such as a failure to provide reasonable diagnosis, care and treatment, or to follow prevailing clinical standards. The majority of the complaints which complainants bring to me involve aspects of clinical care. Where I uphold complaints because I have identified maladministration or poor service leading to an unremedied injustice or hardship, I make recommendations to the body or individual concerned. These recommendations are tailored to remedy the individual injustice or hardship and, where appropriate, to prevent a recurrence of the circumstances of the complaint, thus promoting learning from complaints.

  In my submission I do not address every issue raised in the terms of reference of your inquiry. Instead I would like to briefly focus on those areas where knowledge gained from my investigations provides me with an evidence base with which to inform my response: how to ensure that teaming is implemented and how patients and the public can be involved in ensuring that services are safe.

  An important way of ensuring that learning in the NHS is implemented and that patients and the public are involved in making services safe is through the effective management of complaints. This is why in my recent response to the Department of Health's consultation on the future regulation of health and adult social care, I welcomed the proposal to include a specific registration requirement on the topic of "Responding to people's comments and complaints". I suggested in my response that the regulations should make specific reference to complaints as a source of learning and valuable feedback to inform risk management, quality assurance and clinical governance arrangements.

  The majority of the complaints investigated by my office are about care and treatment provided in a primary care setting. This is why I support Government proposals to include primary care in the registration arrangements, to eventually require all GP practices to register with the Care Quality Commission and to bring all "high street" dentists into the registration system. In this context, information about complaints made locally or to the Ombudsman about primary care providers could be used by the Care Quality Commission in its assessment of whether primary care providers are complying with the registration requirements.

  Together with the Department of Health and the Healthcare Commission I have worked over the last couple of years on an outcome-focused complaints standard for NHS complaints, based on inputs from complainants, complaint handlers and other key stakeholders. The introduction of the reformed complaints system in health and social care from April 2009 will enhance the opportunities to learn from complaints handling. It will require a greater emphasis on effective complaint handling at local level; effective local leadership; a significant cultural shift by the NHS from a defensive application of process to a welcome for the learning from complaints and a will to resolve them; the need for an outcome-based approach to complaints; and effective governance arrangements across all organisations to underpin and support this approach, and to ensure that learning from complaints is shared across the NHS and social care.

  The new system will be simpler and less drawn out for both the complainant and the service provider, allowing the new regulator, the Care Quality Commission, to focus on its core business of regulation and inspection, without the additional demand of complaint handling which sits uneasily with its primary role. A strategic alliance between the Ombudsman and the Care Quality Commission will ensure that any recommendations the Ombudsman may make for systemic change are complied with, and followed up in the inspection regime

  I would also like to highlight the importance of good record keeping in ensuring the safety and quality of care: my experience of handling complaints has shown that there is a strong correlation between keeping good records of the provision of care and treatment and good governance more generally. I have seen that poor record keeping is more likely to reflect an organisational culture lacking in transparency, openness and accountability in which safety and good quality care cannot flourish.

  I believe that the focus on more effective local resolution is a key to making the new system work in practice and I intend to play my part in assisting NHS bodies to prepare for the changes. My "Principles of Good Administration" set out the sorts of behaviour I expect when public bodies deliver public services; my "Principles for Remedy" flow from the "Principles of Good Administration" and set out my views on how public bodies should approach providing remedies.[91] I have also recently carried out a consultation on draft "Principles of Good Complaint Handling" which I expect to publish later this year, so that they can inform the NHS as it seeks to improve the way it handles complaints.

  This latest set of Principles sets out for complainants and bodies in jurisdiction what the Ombudsman expects by way of good complaint handling. The sixth of these Principles is about "Seeking continuous improvement"—this will be about learning. But it will also be about attitude and culture, for example looking at whether an organisation understands and practises learning from complaints. This is important, as a health body's approach to complaints handling is often a telling barometer of its approach to clinical governance and service performance more generally and is therefore a key measure of quality and efficiency that should not be overlooked.

  Finally, I would like to draw your attention to a report on Remedy in the NHS which I laid before Parliament in June. The report summarises 12 NHS cases previously investigated by my office, highlighting examples of both good and bad practice in dealing with complaints. In two of the cases we decided to involve the relevant regulatory bodies, Monitor and the GMC, because of concerns about the quality of nursing care provided by an NHS Foundation Trust and about inappropriate actions by a locum GP.[92] These cases are a good example of how my office can help to make health services safe for patients.

  I hope you find these comments useful and should you wish to discuss these matters further I would be happy to do so.

Ann Abraham

Health Service Ombudsman for England

September 2008

91   Both sets of Principles can be found on our website at Back

92   See "Remedy in the NHS-Summaries of recent cases" (HC632) which is available on our website at Back

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