MEMORANDUM SUBMITTED BY THE HEALTH SERVICE
OMBUDSMAN FOR ENGLAND
1. In my Annual Report for 1999-2000 I provided
information about the activity of the office and work underway
to develop our practice. I also dealt with three key issues: themes
arising from cases, the handling of complaints in the NHS, and
recommendations and redress. Previously my Annual Reports covered
Scotland and Wales as well as England: following devolution I
now issue separate reports in respect of my Scottish and Welsh
responsibilities. The Annual Report for 1999-2000 therefore covers
England only although, where appropriate, I have also quoted figures
for Scotland and Wales for comparative purposes.
2. In April 2000 the Review of Public Sector
Ombudsmen in England reported. I await with interest the Government's
conclusions following the subsequent consultation process. However,
I have already made changes in the working methods of my office
in response to evidence submitted to, and views espoused by, the
review team, especially about the length of time taken to investigate
and the proportion of complaints investigated.
3. During 1999-2000, my office began a review
of its working practices, with a view in particular to eliminating
unnecessary delays, developing a wider range of approaches to
cases (focused on meeting the needs of complainants in a cost-effective
way), and making best use of internal and external clinical advice.
Our processes and systems are under regular review; and changes
have been made in order to speed up the investigation process.
For instance, with experience we have found that there are a number
of cases in which we can reach a satisfactory conclusion without
interviews, simply by examining existing documents, and where
the appointment of external clinical advisers may not be necessary
as appropriate advice can be provided internally. Such cases can
be completed significantly quicker than when interviews and external
advisers are needed. A Director of Clinical Advice has been appointed
and is pushing forward developments in the way we obtain and use
4. It had become clear that in clinical
cases complainants could not so easily provide prima facie
evidence of particular failings, as we had generally expected
them to do in administrative cases before we agreed to investigate.
We therefore shifted the presumption further towards investigation,
if we could not feel confident that treatment had been appropriate
and that complainants had had an adequate response to their concerns.
5. The effects of that began to be felt
during 1999-2000, when the take-up rate of investigable cases
(ie those which in principle I could investigate because they
were in jurisdiction and had exhausted the NHS complaints procedure)
increased to 19 per cent, from 12 per cent the previous year.
The proportion has continued to rise: for the first six months
of this year the take-up rate was 30 per cent. The outcomes of
the additional investigations suggest that they have been worthwhile,
in providing better information for complainants, and in identifying
failings which would otherwise have been missed.
6. This change in practice has inevitably
lead to an increase in the number of investigations in hand: from
97 at the start of 1999-2000, to 175 by the end of that year and
to over 250 by the end of November this year. the proportion of
investigated cases which are clinical, and therefore generally
more complex, has also continued to rise: in 1999-2000 it went
up from 52 per cent to 77 per cent. By 1 September 2000 83 per
cent of investigations in hand were clinical.
7. In 1999-2000 I completed 128 English
investigationsa significant increase on the previous year.
By the end of November this year I had completed 107; and my target
is to complete 210, an increase of over 60 per cent on last year.
This very large increase in investigation workload and output
is almost entirely attributable to the increase in take-up rate,
as the number of new complaints received has increased only very
slightly over the last 18 months.
8. Unfortunately, at the same time my office
has suffered from considerable turnover of experienced staff,
which means that at present we are actually handling the much
increased workload with fewer investigative staff than at the
same time last year. A major recruitment exercise is underway.
That will not only replace staff who have left but also lead to
the creation of two more investigation teams (in addition to the
present six) to help cope with the extra work. That will be essential
as, if we are not to develop an unacceptable backlog of work,
we will need to issue over 300 reports next year: more than doubling
our output within two years.
9. I have been extremely pleased by the
response of my staff to the large increase in their workload.
As can be seen from the information above, productivity has increased
significantly. Last year we exceeded our target of replying to
75 per cent of correspondence within 18 days, achieving 81 per
cent. So far this year, staff have still managed to hit a target
of 80 per cent. However, the rise in the number of investigations,
and an increase in complexity as shown by the increased number
of clinical cases, has inevitably had some effect on throughput
times. In 1999-2000 we nearly met our target of completing investigations
in 48 weeks, and set a more ambitious target of 43 weeks for this
year. For the first six months of this year the average was nearly
48 weeks: and we have to recognise that we are unlikely to achieve
the target. It is very difficult to predict the number of reports
we will issue, but it may fall slightly, but only slightly, short
of the target of 210 of reports issued. Next year will be a very
demanding time: existing staff will have to manage not only the
increased workload but also help train the cohort of new staff,
who will not become fully productive for some time.
10. One of the topics on which I commented
in my Annual Report was out of hours general medical services.
This arose from three complaints I investigated about Healthcall,
an independent sector organisation which contracts with GPs to
provide cover for their patients out of hours. Each of the complaints,
from different parts of the country, was upheld fully or in part.
They revealed some worrying features, including inadequately trained
staff dealing with patients on the telephone, and serious delays
in visits by doctors. Healthcall accepted the criticisms and assured
me that problems would be addressed. The concerns I identified
have also been taken into account in the recent report commissioned
by the Department of Health on out of hours services.
11. During the year the NHS issued additional
guidance to conveners: which took account of many of the issues
I have raised previously. The Department of Health's evaluation
of the NHS complaints procedure is now nearing completion and
the Government have already said that they will reform the complaints
procedure to make it more independent and responsive to patients.
I await with interest developments in this area, which could have
a significant impact on my work.
12. It is important that the public can
feel confident that recommendations I make will be implemented.
In 40 cases organisations agreed to take action to resolve complaints,
without a need for a full investigation. Many more recommendations
for action were made in reports of investigations, (and followed
up three months later). Those included: improvements in clinical
practice, record keeping and systems for complaints handling,
and also financial redress (in four cases where patients had suffered
13. In my role as Health Service Commissioner
I have not generally recommended financial redress more widely
(eg for pain and suffering), as I believe it is the responsibility
of Ministers and the NHS Executive to develop policy and practice
in this area. However, in a small number of very serious cases,
in which the more usual recommendations would have been inadequate,
my office has explored with the NHS body what additional redress,
not necessarily financial, might be provided.
14. It is important that both the public
and NHS staff should know about the recommendations I make. During
the last year I have changed the format and timing of publications
produced by my office. I now produce summaries of completed cases
three times in a year, rather than twice. The new format for this
publicationa slim volume of short reports and summaries
and a larger volume comprising the full text of selected caseshas
been welcomed. I understand that readers find the material more
accessible, not least because of the reduced costs involved. For
the first time this year, I produced an occasional newsletter.
Again, this was warmly received and from the feedback, seems to
have found its way to staff at all levels. I shall continue to
explore ways of making my publications accessible and useful.
15. I am not helped, however, by a change
in practice on the part of the NHS Executive. Until last year,
the chief executive of the NHS circulated my Annual Report and
reports of completed investigations to NHS organisations under
cover of a health service circular. Quite suddenly, and without
warning, that practice ceased. Although I have found other ways
of bringing the attention of this important audience to my publications,
I think that this change in practice sends quite the wrong message.
The NHS makes too little use of information about things that
go wrong already: to restrict circulation of material that might
encourage better practice seems perverse. I welcome a recent invitation
to discuss this further with the NHS Executive.
16. My office has continued to develop its
relations with clinical professions and regulatory bodies. Staff
have regular contact with the GMC and the Local Government Ombudsmen's
offices. Established contacts with the Mental Health Act Commission
have continued and relations have been developed with the Commission
for Health Improvement and the Data Protection Commissioner. We
have regular meetings with representatives of advisory and voluntary
Health Service Ombudsman
6 December 2000