I am delighted to have been invited to speak to you today as part of the Patient Survey Showcase. It is clear from listening to the other speakers that what brings us together today is a shared commitment to improve the services that patients receive in hospital and to put patient experience at the forefront of service delivery.
As Ombudsman, I deal with complaints from members of the public who are unhappy with the administrative actions of a wide range of public service providers. These include the Health Service Executive (HSE), public voluntary hospitals, public nursing homes and, since August 2015, private nursing homes. My Office has been operating since 1984 and has dealt with over 90,000 complaints to date.
I am not an advocate for either party and I do not act as a representative of the complainant against the public service provider. Each complaint must be objectively examined on its individual merits and, in doing so, my staff and I must be fair to all the parties concerned. However, in carrying out our daily work, we are often struck by a certain power imbalance when a member of the public is in dispute with a public service provider. I think this is never more true than in the health sector when this power imbalance is compounded by the fact that, for most people, they are at their most vulnerable when they or their loved ones are ill or are dealing with the sorrow of bereavement. For these reasons, it is very important that all of us find ways to ensure that the voice of the patient (and their relatives) be heard.
It is the nature of my role as Ombudsman that I almost always only hear about activities within the health sector and hospitals when something has or is perceived to have gone wrong. I am well aware that that is not a wholly true or complete reflection of the reality in Irish hospitals. There is no doubt in my mind that tremendous work is being done in every hospital across the country by passionate, talented and committed clinicians and staff in often very challenging circumstances.
However, that being said, in terms of the health sector, my role is to examine and, hopefully resolve, complaints. The complaints which come to me can speak volumes about the way a service is being provided and a measure of how well the system is working. For example, although I am currently excluded from looking at issues of "clinical judgment" (the judgement used to diagnose a condition or decide on a course of treatment), the examination of hospital complaints nevertheless serves to shine a light on instances of poor patient care and poor communication between patients and healthcare professionals.
Experience has shown the value of complaints and the importance of an effective complaint handling system in helping to provide safe and high quality patient care. By highlighting shortcomings in patient care, health service providers can learn from past mistakes and take corrective action where necessary. When I think of the tragic and distressing events concerning the Midland Regional Hospital, Portlaoise, I often wonder whether these could have been avoided if the complaints that were made about the maternity services were dealt with properly and fully in the first instance. After all complaints are one of the most effective "early warning" systems of possible failings within hospitals and other health services. Ignoring them, as was the case in Portlaoise and further afield within the Mid-Staffordshire Health Trust in England, invariably leads to poor practice persisting and, sadly, even lives being lost.
Notwithstanding this, however, from the start of my tenure as Irish Ombudsman, I was struck by how few complaints my Office received about the care received in public hospitals. For example, complaints to my Office about all aspects relating to healthcare (and not just care received within a hospital setting) represent approximately 20% of all complaints received. This is very low compared with other jurisdictions such as Northern Ireland (over 60% investigated) and the UK Parliamentary and Health Services Ombudsman (80% of cases investigated). I wanted to know why this was and so I began an "own initiative" investigation. This was the first 'own initiative' investigation undertaken by my Office since it was established over 30 years ago. At the end of May last year I published the results of this investigation - a report entitled Learning to Get Better.
The investigation was the most extensive investigation carried out by my Office and involved a survey of all public hospitals, site visits to a sample of hospitals (including a maternity hospital and mental health facility), interviews with front line and senior hospital staff and consultations with regulators, medical and nursing schools and health sector and advocacy groups. We also conducted our own patient surveys in so far as we asked members of the public to share with us their experiences of complaining (both the good and the bad). In addition, we conducted a small number of focus groups with members of the public and past complainants.
Some of our focus group participants also very kindly agreed to participate in a short film detailing their experiences for the launch of the report. This short film is available online on our website - if you can spare about 7 minutes out of your undoubtedly very busy days, I would recommend that you take the time to watch it as it is a very powerful and eloquent piece.
The investigation discovered that many users of hospital services:
In view of this, my investigation team paid particular attention to how easy or otherwise it was to make a complaint to a hospital or indeed to give any kind of feedback at all, positive or negative. While all hospitals visited as part of the investigation had Your Service Your Say signage and posters/leaflets, in some cases this was limited to being displayed in just one or two public areas. There was little evidence that the materials displayed were reviewed to ensure that the information was still correct or relevant. Only a minority of hospitals visited had comment boxes close to the relevant signage and leaflets despite the fact that these comment boxes are a very convenient and safe way for a patient or relative to provide feedback.
Most hospitals told us that information regarding their feedback and complaints process was also available online. As part of the investigation, my team therefore checked each hospital website and found that the information provided on these websites was far from uniform and, in some cases, simply incorrect. Only a small number of hospitals provided direct links to feedback facilities, whether email addresses or comment boxes. It was particularly striking that few hospitals actually use the term "complaint" when providing information on how to share experiences of hospital care.
Only a small number of hospital staff interviewed as part of the investigation were aware of changes and/or improvements made as a result of patient feedback or complaints. We found little evidence that hospitals publicised these outcomes even though making these outcomes known can only help to promote public confidence in the value of giving feedback and sharing experiences. It would appear, however, that this is now being recognised. For example, one hospital was able to give an example of providing information in their staff newsletter on changes brought about as a result of patient feedback. Another hospital displays You Said, We Did posters in public areas within the hospital to highlight which has be done as a result of patient feedback.
At this point, I should say, that my investigation also highlighted many other good practices in hospitals across the country. I am pleased to say that some of these good practices initiated in this hospital. For example, I learnt that it is usual for hospital board meetings to begin with a "Patient Story" , be it a complaint or indeed a compliment - after all it is worth remembering that feedback is not always negative. Your patient advocacy unit was also pleased to tell my investigation team about their participation in the annual outreach Health Fair. This Health Fair is held in a local venue and all members of the community are invited to attend to share their experiences of care in Tallaght Hospital. Both of these initiatives are to be commended. I am also struck by the fact that these initiatives and this patient survey project have a lot in common and, in particular, the focus on putting the patient first and listening to their voice.
As a result of the investigation, I made a number of recommendations, which were accepted in full by the HSE. In particular, I have asked that the HSE and each hospital to put a robust complaints system in place to ensure that
I have also suggested that learning from complaints could usefully sit alongside other sources of information such as litigation, serious incident or even "near-misses" to ensure that there is a comprehensive approach to learning from mistakes. I can see no reason why the results and outcomes from patient surveys such as this one should not be included as another very valuable sourcing of learning.
I understand that the HSE is currently developing an action plan in order to implement the recommendations contained in my report and I am in ongoing productive discussions with the HSE about this. I intend to monitor progress on implementation over this year.
All too frequently, feedback is seen as not to be encouraged and, especially when it is negative, can be perceived by some as an attack on the "status quo" that has to be defended at all costs, regardless of the merits. I am therefore heartened by the recent announcement by the Minister for Health to establish a National Patient Advocacy Service which, although funded by the State, is intended to be independent of the HSE and the Department of Health. As I understand it, this service's role will be to ensure, as with this project, that patients' reported experiences are recorded, listened to and learned from.
I would like to conclude by encouraging hospital service providers and staff to continue to find a place for the patient's voice, to maintain an open mind as regards feedback and complaints, regardless of the content or source and see it as a potentially very valuable source of learning. Again, I am delighted to be here today to hear about the patient survey project and wish it well for the future.