15 November 2017
I am delighted to have been invited to speak to you today as part of the launch of the new health complaints process. We all have a shared commitment to improving 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 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 true or complete reflection of the reality in Irish hospitals. I am well aware of the tremendous work that's 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, for example, 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 within the Mid-Staffordshire Health Trust in England, for example, 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. I published the results of this investigation - a report entitled Learning to Get Better, in May 2015.
The investigation was the most extensive investigation ever carried out by my Office. We surveyed every public hospital, we visited a sample of hospitals (including a maternity hospital and mental health facility), we interviewed front line staff and senior hospital staff and we consulted regulators, medical and nursing schools and health sector and advocacy groups. We asked members of the public to share their experiences of complaining with us (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 - and I know that many of you have watched it and have used it in training. 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. While thinking about what I might say today, I looked at an entirely random sample of hospital websites. It was not straightforward on any to find out where to complain, and people were asked to submit a complaint in writing if they could not resolve it with front line staff. I didn't find any on-line complaint forms.
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. For example, in one hospital, 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.
As a result of the investigation, I made a number of recommendations, which were accepted in full by the HSE. In particular, I asked the HSE and each hospital to put a robust complaints system in place to ensure that:
I 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.
Today marks a very tangible step forward in delivering the improvements required by Learning to Get Better. At the launch of Learning to Get Better, Tony fully committed to implement the recommendations and we have seen very considerable efforts being made to give effect to these commitments.
One of the key recommendations was that there should be a full review of Your Service Your Say. I am pleased that this launch marks the completion of that work.
Another key recommendation is the introduction of a standard approach to implementing Your Service Your Say across the hospital system. The new process launched today is designed to do just that.
The recommendation to provide a standardised recording system has also been addressed through the use of a standardised IT system. This should provide detailed management information on complaints enabling trends to be identified and corrective action to be taken. It's based on the National Incident Management System known as NIMS and from the New Year, it will not be possible to record a complaint using any other system.
The report called for multiple methods of making a complaint to be available. Not every service user will be able to put a complaint in writing, and it is important that complaints should be accepted whether made verbally or in writing, on-line, by phone or using social media. Not all of these routes are yet in place and my unscientific sampling didn't find universal access to an on-line complaint form. Some of the changes will need to await the revision of the legislation governing Your Service Your Say by the Department of Health but until that happens, the new process marks a very considerable step on the road.
The 5 guiding principles which are set out
My report focused on hospitals, but I am very pleased that this development will be put in place across the health service in all settings. I am very pleased to see that the CHOS have been actively engaged in developing and implementing the changes required. There are other aspects of the recommendations that will take longer to implement. I look forward to the delivery of the promised national advocacy service. I welcome the training that has already been rolled out including an excellent package for Review Officers with training for complaints officers soon to follow. I look forward to seeing training made available to all front line staff and complaint handlers, and welcome the progress which is being made in developing the new on-line interactive training module. I welcome the developments in identifying manager with responsibility for complaints in each of the Hospital Groups and CHOs. We need to see these and the dedicated complaints handlers all in place and operating effective.
In order to check progress, my Office will be running a follow up investigation to see what is happening on the ground. Some of the progress has been very tangible. In one hospital, the complaints office was very hard to find. Now, it is prominent in the main foyer when you arrive. It is pleasing to see such tangible outcomes and pleasing also to see the launch today of the template for complaints handling across the health service.
Developing a patient centred, learning health service requires that the voice of the patient be heard whether this is through surveys, through comments or through complaints. I hear many compliments about the way our health service is delivered, of the many little kindnesses, the highly skilled professionalism and the interventions which save or transform lives. Inevitably, in such a large and complex service, things can go wrong. Learning from mistakes is a key means of ensuring that they are not repeated. The launch today clearly demonstrates the commitment of the HSE to delivering high class complaints management and learning, and I am glad to have this opportunity to welcome this important step forward.