Memorandum from the Parliamentary and
Health Service Ombudsman
INTRODUCTION
I welcome the opportunity to give evidence to
this inquiry by the Committee. As the Committee says in its Issues
and Questions paper, "Any attempt to provide customer
centred public services must involve listening and responding
to the experiences of those who use them". My experience
of investigating complaints about services provided by Government
departments and agencies across the UK, and by the NHS in England,
indicates that public service providers need to listen more and
respond better to the experiences of the users of their services.
I have focused my response on the areas of the
Issues and Questions paper which deal with Minimum Standards for
Public Services and Learning from Complaints.
Question 1: Can public services learn from the
way that either non public sector organisations or overseas governments
make use of user experience in service delivery and design?
1.1 Undoubtedly. My experience of working
with colleagues in the British and Irish Ombudsman Association,
whose membership includes both private and public sector Ombudsmen,
tells me that public services can learn a great deal from the
"voice" that is provided for all service users by effective
mechanisms for complaint and redress. My contacts with colleagues
in the International Ombudsman Institute echo that experience.
1.2 Ombudsmen can also share their experience
in ways that can be very helpful; for instance we have learned
a great deal from studying the integrated way complaints about
health and social care services in Northern Ireland are dealt
with.
Question 2: Is it possible to set minimum standards
for public services? If so, how is this best done?
2.1 My Office is currently consulting bodies
in jurisdiction and a range of other stakeholders (including,
of course, the Committee itself) on draft Principles of
Good Administration which are, as our consultation document
says: "Broad statements of what the Ombudsman believes
bodies within jurisdiction should be doing to deliver good administration
and good customer service". We see these as a "framework
to which bodies in our jurisdiction will have regard in the discharge
of their duties".
2.2 We aim to publish a final version of
the Principles at the end of March 2007. In the course of the
2007-08 financial year we will be publishing a variety of case
studies which demonstrate how we have applied these Principles
in practice in investigating complaints.
2.3 Various types of minimum standard might
be appropriate to different public bodies. For some bodies, it
will be sufficient that the relevant law should set the standard;
for others, organisational or departmental service standards will
be appropriate. There are a number of examples of standard-setting
from our health work. Where we can rely on standards of fitness
to practise from the General Medical Council, or guidelines from
the National Institute for Health and Clinical Excellence, we
have a clear basis for our assessment of the delivery of clinical
care.
2.4 Once standards have been set and accepted,
bodies should not seek to avoid the consequences of failure to
meet them. Clear standards must be matched by clear accountability.
Question 3: What role do measures of customer
satisfaction have in assessing the standards of public services?
How should user views be monitored? How can the cost effectiveness
of user surveys and feedback mechanisms be assessed?
3.1 Measures of customer satisfaction are
among a range of methods that can be used to assess the quality
of public service. My Office conducts regular complainant feedback
and wider stakeholder surveys. In 2004 one such survey told us
that we needed to improve our communication with complainants
and adopt a more tailored approach to each complaint. Bodies in
jurisdiction also gave us useful feedback on how we could work
more effectively with them. As a result of the feedback from users,
we overhauled our business approach in 2005 and subsequent feedback
has shown this to have been effective.
3.2 We have also found such surveys helpful
in identifying the low level of awareness of our service among,
for example, younger people and ethnic minority groups. We are
accordingly taking steps to increase our accessibility and raise
awareness of our service among all those who may need it. We are
therefore convinced that there is value in such measures of user
awareness and customer satisfaction.
3.3 At the same time it is essential that
public bodies, and those that hold them to account, should have
access to a rounded picture of performance, and so a range of
measures is needed. For example, we also monitor closely how we
are performing against the customer service standards we aspire
to as well as tracking the number of complaints made about the
service we provide, and their outcomes, and the number of occasions
on which we are the subject of applications for judicial review,
and the outcome of any such applications. This helps to give us
a balanced picture of our performance. We would expect bodies
in jurisdiction to adopt a similarly balanced approach to assessing
their performance.
3.4 On cost effectiveness, I would suggest
that user and stakeholder surveys should form part of an agreed
research strategy and budget, with clearly defined costs and clarity
as to anticipated benefits and how they will be monitored.
Question 4: What constitutes best practice in
responding to complaints about public services?
4.1 Our draft Principles of Good Administration
contain much that is relevant to best practice in responding
to complaints about public services.
4.2 In relation to the Principle of "Putting
things right", we say this involves:
— Putting mistakes right quickly and
taking action to correct policies and procedures which are found
to be ineffective, unworkable or unfair.
— Providing clear and timely information
on how and when to appeal or complain.
— Operating an effective complaints
procedure, which includes providing appropriate redress.
And the more detailed guidance says:
— When mistakes happen, public bodies
should acknowledge this, explain what went wrong and put things
right quickly and effectively. Action should be taken to review
and amend any policies and procedures that are found to be ineffective,
unworkable or unfair, giving adequate notice before changing the
rules.
— The actions of a well-run organisation
can sometimes have an adverse impact on an individual because
of their particular circumstances, even though statutory obligations
and/or service standards have been met. Public bodies should be
alert to this possibility, and respond flexibly to avoid, or remedy,
any such adverse impact occurring.
— Public bodies should provide clear
and timely information on how and when to appeal or complain;
they should operate an effective complaints procedure which investigates
complaints thoroughly, quickly and impartially and provides appropriate
redress to the complainant and any others similarly affected.
4.3 In relation to the Principle of "Seeking
continuous improvement", we say this involves:
— Keeping policies and procedures under
regular review to ensure their effectiveness.
— Welcoming feedback and using it to
improve services and performance.
— Ensuring that lessons learned from
complaints contribute to providing better services.
And the more detailed guidance says:
— Public bodies should keep policies
and procedures under regular review to ensure they are effective.
— Public bodies should actively seek
and welcome feedback and use it to improve their public service
delivery and performance.
— The lessons learned from complaints
should be captured and reviewed in order to contribute to future
service development.
4.4 Organisations which deal effectively
with complaints are also upholding another of our Principles by
"Being open and accountable". The ability
to accept mistakes openly, both individually and corporately,
is an important part of good complaint handling and service improvement.
If there is a culture of open resolution of problems and learning
from complaints, organisations will do well; if they are defensive
or legalistic in response to complaints, services will not improve.
COMPLAINTS ABOUT
US
4.5 No organisation is perfect, and PHSO
makes itself accountable in a variety of ways for its own performance.
PHSO's own complaints procedure, for dealing with complaints about
our own service has been developed on the following principles:
— our complaints procedure is accessible
and simple to follow;
— our response to complaints is quick;
— we keep a corporate record of all
complaints about us;
— we provide a review by someone who
has not previously been involved;
— where we make a mistake, we offer
appropriate redress; and
— we use the learning from complaints
to improve our service.
4.6 Information about complaint numbers
and outcomes, and the lessons to be learned from them, is included
in regular performance monitoring reports to the Office's Executive
and Advisory Boards. Our performance in handling such complaints
is reviewed in internal audit reports. We include information
on complaints about our service in our Annual Report. We would
like to see a similar approach to complaint handling in the work
of all public bodies.
EXAMPLES OF
GOOD PRACTICE
BY BODIES
IN PHSO'S
JURISDICTION
4.7 We have also had experience of good
practice by public bodies in responding to our findings and recommendations.
Continuing Care and the Department of Health
We received a large number of complaints about
assessments of eligibility for NHS funding of long term care and
we identified systemic problems across England in the implementation
of the law and the eligibility criteria. We published two special
reports in 2003 and 2004, containing a number of detailed recommendations
for improvements to the system.
The Department of Health engaged constructively
with us to bring about the necessary improvements. We also met
representatives from all the (then) 28 strategic health authorities
to provide direct feedback on the problems and to encourage the
introduction of better practices and procedures. As a result there
has been a significant decrease in the number of continuing care
complaints upheld by us and, we believe, a significant improvement
in the quality of service provided by the NHS in this area.
We received a large number of complaints about
the administration of tax credits and I published a special report
on tax credits in June 2005. We developed a constructive dialogue
with Her Majesty's Revenue and Customs (HMRC) following the publication
of that report and I believe there have been many significant
improvements to the tax credit system since then. I was particularly
pleased to see that the complaints handling teams within the Tax
Credit Office were re-structured at the beginning of 2006 to provide
a greater emphasis on individual case-ownership and increased
customer contact. I especially welcomed the recognition that different
customers require different levels of contact and support. Resolving
disputes quickly and at the lowest possible level of the complaints
process is an integral part of an effective complaints handling
system and I am pleased that the Tax Credit Office has focused
resources on resolving complaints at the first point of contact
and in the light of the full facts of the case.
There is still more to do but it would appear
from the improvements in HMRC's turnaround times for dealing with
complaints, and the reduction in the number of complaints upheld
at the higher levels of the complaints process, that these changes
are helping to improve the service provided to customers.
4.8 Individual complaints can also lead
to systemic improvements as the following examples show.
Disability and Carers Service
Sign It!, an organisation which supports deaf
users of British Sign Language (BSL), complained on behalf of
Mr A, who is profoundly deaf and communicates using BSL, that
the Disability and Carers Service (DCS) refused Mr A's renewal
claim for disability living allowance in 1999, when he reached
the age of 16, and a new claim in 2001. In common with many profoundly
deaf people who use BSL, Mr A has difficulty reading. The decisions
and information about his appeal rights were sent to him in letters
he was unable to read and understand and he did not appeal at
the time of the decisions.
When we investigated the case, DCS agreed that
the 1999 and 2001 decisions were incorrect due to official error,
since the adjudication officer did not fully take into account
the fact that Mr A was still in full time education and used BSL
as a first language. The DCS paid Mr A around £9,500 in respect
of the disability living allowance he should have received between
1999 and 2003.
The investigation revealed problems with how
the DCS handles claims from people who are profoundly deaf. There
were procedures in place to help people like Mr A but the system
was not working well. We hosted a meeting between Sign It! and
the DCS to discuss the steps the DCS could take to improve the
service. The DCS agreed to look into several additional cases
to try to resolve the problems and identify where things went
wrong. They are also taking steps to improve the consistency and
quality of decision making; to target people with hearing impairments
to increase accessibility and raise awareness of disability living
allowance; and to make improvements to their IT system to increase
understanding among staff of communication issues and various
conditions, including hearing impairment.
Sign It! told us, "The hard work you
have put in collecting and collating essential evidence has been
instrumental in bringing about what I feel will be a landmark
change in the way our duty of care towards the disabled in our
society is discharged".
Sometimes improvements can be local and quite
specific. We investigated a complaint at a NHS hospital which
concerned the treatment of a man by percutaneous endoscopic gastroscopy
(PEG—used to help in feeding patients). During the course
of that investigation senior medical staff told us that the complaint
had prompted the hospital to carry out an audit of the use of
such procedures. This revealed that the number of PEG procedures
performed at the hospital was two to three times what would normally
be found at a hospital of that size. It also suggested that the
death rate of some groups of patients who underwent PEG at the
hospital was unacceptably high. The audit resulted in the hospital
changing its practice, and subsequently there was a reduction
of 50% in the number of PEG procedures, with a higher success
rate.
Question 5: Is information about complaining easy
to find and accessible?
5.1 The short answer is "no".
To meet the needs of customers, a good public service complaints
system should:
— Be easy for people to access by a
variety of means. People who have difficulty making a complaint
should be helped, if necessary by referring them to advisory services.
— Have procedures that are clear, simple
and signposted.
— Be well publicised, with understandable
information in several formats and put in places where customers
will see it.
— Be supported by staff who understand
the system, are able to recognise a complaint when they see one,
and know what to do about it.
5.2 However, our experience of handling
cases concerning complaints procedures in Government departments
and the NHS has not generally been positive. There is often no
consistency and no coherence. In my Annual Report for 2005-06
I summarised the situation in this way:
"Navigating through the system is not
always easy for people who want to complain about a service. There
is a plethora of complaints systems across public services and
little in the way of consistent standards for handling complaints,
even within some departments".
5.3 In my report Making Things Better?,
published in March 2005, I set out my concerns about NHS complaint
handling and made a number of recommendations for improvement.
Although the Government has announced that it will be seeking
to combine the complaints systems for health and social care,
I have not seen any significant improvements for NHS complainants
since my report was published.
Question 6: Should users be more directly involved
in service delivery? If so, how can this be achieved?
6. Complaints are one important way in which
the user can become more involved in service delivery and its
improvement. Thus, when we make recommendations about service
delivery in response to complaints from users, we are providing
them with a means of making their voices heard and making providers
listen. But when it comes to learning from complaints (and other
forms of public involvement), public bodies need to avoid tokenism.
Proper assessment of lessons learned from complaints should be
part of the governance of every well-run organisation.
January 2007
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