The year 2004 marked my first full year in office and coincided with, perhaps, the most fundamental reform of the Irish health services since the foundation of the State, the development of a single unified national public health service. I have decided to mark this new development by way of a review of my Office's experience of dealing with complaints in the public health and personal social service sector. Of its nature my Office is primarily concerned with things that go wrong in those services. It is not surprising, therefore, that I am critical of aspects of the service highlighting shortcomings on a regular basis, and will continue to do so in the future. However, I am very keen to present the outcome of this review to the new Health Service Executive (HSE) in a spirit of learning and encouragement. I hope that this will assist the Executive as it begins its journey towards providing a first class, quality, public healthcare system.
I have also approached this report in the context of Quality and Fairness, the National Health Strategy. I share the vision and desire of that Strategy to achieve a health system that supports and empowers the individual to achieve full health potential, that is available, that is fair and is one in which the individual can have trust, and where the views of the individual will be taken into account.
Extending the Office's Remit
The enactment of the Health Act 2004, is an important landmark in the development of the Office of the Ombudsman. Since 1985 my Office's jurisdiction was limited to the administrative actions of the health boards and those hospitals which came under their direct control. Actions which, in the opinion of the Ombudsman, involve the exercise of clinical judgement are, and will continue to be, excluded from my remit. The new legislation makes provision for the establishment of a statutory complaints procedure in the health service, not only for those services delivered by the Executive but also for those agencies providing services on behalf of the Executive. The net outcome of this development will be that the major hospitals in the Dublin area, the so called Public Voluntary Hospitals, will come within my jurisdiction, as will other similar hospitals in the rest of the country, together with institutions, nation-wide, providing services on behalf of the HSE to the intellectually disabled.
My remit is also being extended by provisions contained in Part 3 of the Disability Act 2005. I will have jurisdiction to deal with complaints about actions relating to access to public buildings and services, and also in relation to sectoral plans drawn up by a number of key Government Departments, including the Department of the Tánaiste Health and Children. This legislation also has specific implications for health service providers in the area of the assessment of need, service statements and redress.
Many of the above mentioned bodies will be unfamiliar with the operation of my Office, and this report is also directed to them as they prepare for the introduction of the new statutory procedure and, in turn, scrutiny by my Office. There will be occasions when my Office will be at odds with these bodies, it will be critical of their actions and it will highlight shortcomings. This will be at the heart of my relationship with them and is something which derives from the very nature of my Office. I accept that many of these bodies will be unfamiliar with how my Office operates and that there may be a certain element of tension as they consider this new form of accountability.
Impact of Shortcomings in the Health Services
My Annual Reports detail the myriad ways in which my Office has impacted on the lives of ordinary individuals who have had cause to complain about our health and personal social services; families seeking answers from hospitals about the care of their loved ones (particularly where death has occurred), older people seeking affordable care to which they have an entitlement, parents seeking allowances for their seriously disabled children, querying the lack of health services for their children, or applying for medical cards or health related personal social services. The devastating impact of such shortcomings in the health services has been brought home to everyone through the ongoing nursing home debacle, which emanated from a long running failure to acknowledge the illegality of actions which raised charges on patients in public nursing homes and other institutions.
Learning
Of no less importance is the role of my Office in helping those same service providers to improve their services, by pointing out mistakes and unfair practices and by guiding them towards a better way of delivering public health care.
A point often made to me by complainants is that the service providers should learn from their mistakes, so as to ensure that other people do not experience similar problems.
Over the years my Office has engaged with the agencies in the public health services in developing better quality decision making in the delivery of their services to the public. My staff engaged with the former health boards, and specific professional groups, in seminars and training exercises on the issues which are of importance to me in the examination of complaints, principles of good administration, best practice for public servants, the rights of users of the health service and the management of complaints. The emphasis in all of these interactions was always positive i.e. how to improve the quality of the health service delivered. This educative aspect casts the Ombudsman in the role of a "critical friend" and I look forward to the further development of this role with the new Executive and the other agencies providing public health services.
This Report
I now see the opportunity to develop this function further by way of highlighting, in this special report, issues for the attention of the new HSE based on the experience of my Office, developed in the course of the examination of complaints about the health service. My objective in this report is not simply to focus on the failings identified. In order to assert its positive nature I have decided, on this occasion, not to identify the individual agencies in the examples which I use. This is at odds with my usual procedure, which I will maintain in my Annual Reports, as an element of the accountability which is a vital aspect of my work.
The learning that I want to highlight in this Report falls under the following general issues;
- an understanding of the concept of maladministration (Chapter 1)
- the need to focus on the rights of patients (Chapter 2), particularly the right to safe treatment (Chapter 3)
- the importance of good record-keeping, particularly medical and nursing records (Chapter 4)
- the importance of good communications, between medical, nursing and administrative staff and between healthcare staff, patients and their families (Chapter 5)
- the need to acknowledge that things do go wrong and, when they do, that staff are empowered to resolve the problem as close as possible to the point of grievance (Chapter 6 )
- the need for delegation and clear lines of authority within the HSE as a whole (Chapter 7 )
- the Ombudsman's Statement of Good Practice For The Public Health Service In Dealing With Patients (Chapter 8)
In particular, I want to highlight the Statement of Good Practice For The Public Health Service In Dealing With Patients, which I have developed from my Office's experience of dealing with complaints against those hospitals that were administered by the former health boards. The Statement also takes account of the ethical guidelines published by the Medical Council and the Code of Professional Conduct published by An Bord Altranais.
I see this Statement as a code of good practice for the health service in dealing with patients and, together with the Ombudsman Act, I intend to use it as a framework in my examination of complaints relating to public healthcare. I hope that the Statement will be embraced positively by all health agencies, so that it becomes a living reality for all patients.
In the coming months I also intend to take other initiatives to assist health agencies in their examination of complaints. The series of seminars on good complaint-handling, which my Office conducted with great success with the health boards, will be relaunched for the new bodies coming within jurisdiction. I also intend to re-publish some of my Office's existing guidance notes in a format which is customised to the needs of the health services.
These updated guidance notes, together with the Statement of Good Practice For The Public Health Service In Dealing With Patients, published in this report, will form a Code of Good Administrative Practice For The Public Health Service. The Code will constitute a comprehensive framework, in conjunction with customer service protocols developed by individual health service agencies, which the Ombudsman will utilise in the examination of complaints relating to the health services.
Of course, the success of these initiatives is critically dependent on the development of good working relations between my Office, the HSE and the other new bodies coming within remit. In Chapter 7, I describe the challenges which the HSE is facing on this issue, and the need for early action on the development of new liaison arrangements with my Office.
Finally, returning to this Report, I hope it will be of benefit to the HSE and to those agencies providing services on its behalf. I look forward to developing a good working relationship with these agencies and thereby facilitating better outcomes for all the users of the health services in Ireland.
Emily O'Reilly
Ombudsman
March 2006