• You are here:
• Home /
• Publications /
• Presentations

Presentations

Presentation to the Oireachtas Joint Committee on the Strategic Management Initiative, 26 June 2001

Submission by the Ombudsman in relation to Quality Customer Service in the Healthcare Sector

Introduction

Thank you for inviting me here today to outline the experience of the Ombudsman and his Office in relation to quality customer service in the healthcare sector. My presentation covers the health boards and the Department of Health and Children. I also refer to the Public Voluntary Hospitals which are not yet within my jurisdiction.

As you know we are strong supporters of the QCS concept and we have actively participated in initiatives concerned with its promotion such as briefing the QCS Working Group and developing the use of complaints to the Ombudsman as a performance indicator in this area. As recently as two weeks ago we hosted a seminar in my Office for the civil service QCS Officers' Network with particular emphasis laid on QCS aspects of Ombudsman case studies.

I propose to address the following areas in my presentation:

1. Complaints against the Department of Health and Children and I will express some general views on the Department's strategic role as seen from my perspective.
2. Complaints against the health boards and the key areas of continuing concern.
3. My Office's involvement with the health sector generally and some recent, and I think, positive developments which have taken place.

Complaints against the Department itself are relatively small as one might expect given that the Department's functions are concentrated in policy areas rather than in the direct delivery of services. In 1999 we received 34 complaints which dropped to 16 in 2000.

Two points of interest emerge from an analysis of these complaints. One, almost 60% of complaints were made against the General Registrar's Office, with delay featuring in over half of them and, two, in the remaining 40% delay was a feature in almost one third.

It seems to me that the Department, despite its non-involvement in service delivery, exhibits all the signs of a Department under pressure. This conclusion is supported by my experience as Information Commissioner and the Department's performance under the FOI Act, a subject, Chairman to which I will be returning at my meeting next week with your Committee. I am conscious that the Department is a controlling Department and in that regard demonstrates similar symptoms to the Department of Education and Science in the extent of its involvement in the administrative control of its agencies. Given the high amount of expenditure in the health and education sectors for which these two Departments are responsible, it seems to me that it should be a huge priority for Government - and indeed in the interests of the Department of Finance - to ensure that they operate in a way which ensures strategic management of the respective sectors with particular emphasis on the effectiveness of the delivery of services. The Cromien report on the Department of Education and Science will, I think, make a major contribution in that sector. But I have a feeling that the Department of Health and Children needs greater support from the centre if it is to develop its strategic role. In drafting my recent investigation report on Nursing Home Subventions, I became particularly conscious once again of that perennial problem that still bedevils many Government Departments. Ken Whitaker put it succinctly over thirty years ago when he said that the greatest challenge facing senior civil servants in the future would be how to extricate themselves from day to day operational matters so as to give proper attention to policy planning and development. However, thirty years on, the business of Government has become more complex and this has brought fresh challenges as to how the civil service should be managed.

Specifically, the interdependence between planning and operational matters is now recognised. Planning must inform operations but equally operational matters must inform strategy formulation. In a sense, the debate has moved on. It is no longer about separation of policy and operations but, rather, it is about the issue which is central to any strategic management process viz, helping Departments to think in terms of what they should be trying to achieve and what they really should be doing rather than what they are now doing. To put it simply, it is not just a question of how to do things "right" but how to do the "right things". Quality customer service initiatives - although important in their own right - always carry the risk of leading a Department towards a static or "doing things right" view of its operations. The real challenge for a Department is to use initiatives such as QCS initiative to inform its thinking on the core question of what business it ought to be in.

The central Departments - the Department of Finance and the Department of the Taoiseach - also have an important role to play in the process of supporting line Departments - such as the Department of Health and Children - in redefining and redeveloping their core competencies and in exploring why some or all of their existing functions and activities are currently undertaken and whether they might be more appropriately undertaken by other agencies. I hope that issues of this kind will be fully explored in the process now underway to develop a new National Health Strategy.

Within the Department of Health and Children there already have been some noteworthy recent developments. But it is, perhaps, too early to evaluate the benefits for the Department of the setting up of the Eastern Regional Health Authority and its role in relation to the voluntary hospitals as well as the Office for Health Management and the Office for Health Gain but I would hope it would be a positive one.

Turning now to the area of complaints against the health boards themselves, the number of complaints reached a peak of 482 in 1998 and declined to 304 last year probably reflecting the changed approach of the Department to nursing home subventions following my Office's intervention. However, already this year complaints are 100% up on last year as a result of complaints relating to the entitlements of elderly people with medical cards. As I dealt with that matter in some detail at a meeting last week with the Joint Oireachtas Committee on Health and Children, I do not propose to go into this issue today. Almost 35% of complaints last year related to Supplementary Welfare Allowances, 18% to hospital services, 11% to health services generally and 6% to delay. I have to admit that I have always been surprised since I became Ombudsman at the low level of complaints against the health sector relative to those against local authorities which reached a high of 787 last year. There have been very positive developments in recent years in the handling of complaints by health boards (which I will return to later) and this is obviously a factor. But the low level of complaints undoubtedly reflects the fragmented nature of my jurisdiction in relation to hospital services which has resulted in a low level of awareness by the public of complaints procedures within the hospital system. The public voluntary hospitals and a whole range of health bodies are now within my jurisdiction as Information Commissioner but despite repeated announcements by different Governments since 1994 no progress has been made with bringing the same bodies within my jurisdiction as Ombudsman. I just don't understand, Chairman, what the problem is. As I have pointed out to the Department of Finance if amending legislation is not seen as a priority, bodies can still be brought within my jurisdiction by Government order.

The inclusion of these bodies within my jurisdiction as Information Commissioner is, however, beginning to have a positive spin off in raising awareness of my role as Ombudsman and indeed highlighting the anomalies in relation to my jurisdiction. There is evidence that people are becoming more aware of my role in relation to complaints against hospitals and I recently completed a major formal investigation into a complaint against Tralee General

Hospital. I think it might be of interest to your Committee if I gave you some information on this because it highlighted many areas which require improvement.

A family wrote to me outlining that their father had been admitted to hospital complaining of severe pain in his lower back and legs. During the following days he was examined by various doctors from the Orthopaedic department and had blood samples taken from him. Throughout this period his pain and discomfort increased with no relief and he became increasingly agitated. His family became concerned and distressed over this period and as his agitation developed they sought explanations from both nursing and medical staff as to the cause of their father's pain and discomfort. The family considered that the attitude and response to their expressed concern by a particular doctor was very unsatisfactory. They described his attitude and demeanour as dismissive and stated that he refused to give them information on their father's condition and proposed treatment. The family became so concerned with their father's condition that family members remained with him in the hospital. Their father was subsequently the subject of an emergency transfer to another hospital where he died shortly after his admission as a result of a ruptured aneurysm.

The family were at a loss to understand the standard of medical care he received after having raised concerns. They were particularly aggrieved that they were not informed of the nature and severity of their father's condition which they considered had remained untreated until his emergency admission to another hospital. They were also very upset at the way the complaint they made after their father's death was handled. I should stress that the family's primary concern was to get an explanation of what had happened and what, if anything, had gone wrong. Because of that I took the somewhat unusual step of sending the family my full investigation report suitably anonymised because I felt that was the only way they could get the type of redress they wanted. Normally, I would only send a copy of my findings and my recommendations as provided for in Section 6 (4) of the Ombudsman Act, 1980.

I think that the recommendations I made in that case will illustrate very well for you the deficiencies I uncovered and which I have reason to believe occur on a more general scale.

I recommended

1. that a member of the senior management of the Board and the hospital visit the family to apologise for the shortcomings identified in the report and to explain what action would be taken on foot of the findings and recommendations contained in the report. The hospital had already sent a written apology but, if anything, this had only added to the family's dissatisfaction. A "disembodied" so to speak written apology is often preferred by public bodies but in particular cases, it is just not good enough.
2. that the hospital, in cooperation with the health board, review its procedures to ensure i) that entries on the nursing records created by nursing staff accurately reflect the contacts made with medical staff for the purposes of patient review and the reason that the contact was made; ii) that all significant observations on a patient's condition that are made to members of the medical team by the nursing staff are recorded on the nursing notes. I have spoken publicly a number of times about the importance of adequate record keeping especially medical record and nursing notes. I would like to see this becoming an absolute requirement.
3. that they also review their procedures to ensure that a patient's medical notes are updated at the earliest possible time following a medical examination carried out on a patient, in particular, where such an examination is requested by nursing staff because of their concerns about the patient's condition.
4. that they review complaint handling procedures and ensure that (i) complaints from patients or relatives and /or next-of-kin of patients are properly considered and (ii) appropriate training is given to all medical, nursing and administrative staff. In particular, the review should address the role of the consultant in dealing with complaints and the importance of good communications procedures in responding to the concerns of complainants.

I also recommended that the Board take action to ensure that all the hospitals under its control meet the standards outlined above.

Finally while recognising that I am precluded from examining matters of clinical judgement I identified one particular issue for joint consideration by the management of the Board, the hospital and the Medical Staff. I asked for consideration to be given to greater clarification in the respective roles and relationships of junior and senior medical staff. In particular, consideration should be given to an administrative protocol outlining the circumstances in which a junior member of a medical team should consult with his or her consultant when a patient's condition gives cause for concern, and the corresponding obligation on consultants to be accessible for such consultation.

The Board has accepted my recommendations.

Turning now to the last area I mentioned, I'm glad to report that there have been many positive developments in recent years. Any Ombudsman Office has to ensure that it not only enjoys credibility in relation to the general public but also in relation to the public bodies within remit. The latter requires not only that the staff develop expertise in particular areas of the public service with which they deal but that they are seen to act fairly and impartially when dealing with complaints. I think it would be fair to say that there is a good professional relationship between my Office and the Health Boards.

When I was appointed to the Office of Ombudsman I identified a lacuna in the relationship between the Office of the Ombudsman and the health boards i.e. the absence of a forum whereby officials from the Office could meet, on a constructive basis, with the individuals who are delivering the public health service at the coal face, to explain the role of the Ombudsman and how we see the interaction between our various organisations I believe that such dialogue is a prerequisite to improving procedures and practices generally. With this in mind I have engaged in an ongoing series of meetings at intervals with the Chief Executive Officers of the Health Boards. While we might be at odds on occasions we can learn for each other in order to facilitate a better service to the citizen availing of our services. As a result there have been a number of quality of services initiatives as well as complaint handling initiatives.

Quality of Service Initiatives

Over the past number of years officials of my office have delivered presentations to staff employed in the health boards on the work of my office and quality customer service. One particular example was a presentation to key officials in the Western health Board in which Ombudsman case studies were utilised to explore issues of quality service. I welcomed the emphasis which most Health Boards are now putting on quality customer service in their operational plans, the publication of quality service standards, the provision of clear, accurate and timely information and commitments to deliver services with timeliness and courtesy.

I have had a similar proactive role with the health boards in my capacity as Information Commissioner. The enactment of Freedom of Information (FOI) legislation was identified in the 1996 report "Delivering Better Government" as a major plank in the SMI process. FOI is playing a crucial role in enhancing quality customer service. It helps to improve the standard of public administration because public bodies now know that, apart from some exceptions, their decisions are open to public scrutiny. For their part, clients of public bodies now have a legal right of access to information which, formerly, was only available -if at all- on terms dictated by the public body.

The transition from a culture of secrecy to one of openness does not happen overnight and my Office was very happy to respond to requests from public bodies which sought my Office's assistance in their preparations for FOI. In the health board sector, access to medical records was a major concern and medical consultants and health board staff had expressed a number of concerns relating to access to such records by public patients. In order to discuss these and other issues arising under the FOI Act, most of the health boards organised seminars for their medical consultants and administrative staff which were addressed by me or by the staff of my Office together with Dr Denis Cusack of the Legal Medicine Division of University College, Dublin who was very supportive of the Act and of the work of my Office. In the months following the application of the FOI Act to the health board sector, my Office again made a number of presentations to health boards on the practical application of exemptions in the Act to particular requests for information. To their credit, the health boards put a lot of effort into their preparations for FOI and I was happy to assist them in that process.

Complaint Handling Initiatives

As you know I am a great supporter of bodies having their own internal complaints systems and I produced a guide to such systems with my 1997 Annual Report. The health sector has reacted positively in this area. My Office has encouraged a number of initiatives as a contribution towards the promotion of quality in complaints procedures in the healthcare sector. Members of my staff have engaged with the Risk Management Forum Group within the Dublin Voluntary Hospitals in relation to complaint procedures, with the Irish Society for Quality in Healthcare in relation to the establishment of quality benchmarking in complaints procedures in Acute Hospitals, with the Royal College of Surgeons in Ireland in relation to the concept of complaints and complaint handling as a module on the Higher Diploma in Quality in Healthcare, and with the Eastern Regional Health Authority in the establishment of a working group to review existing procedures and protocols in complaint handling. There has also been a deal of interaction with individual health boards in relation to the development of their individual complaint handling systems. My Office also hosted a seminar on quality complaint handling in a hospital environment, which was attended by representatives from wide range of hospitals, public and public voluntary. The purpose of the seminar was to promote the essential features of quality complaint handling in a hospital environment, and to highlight the need for hospitals to be aware of the requirement to develop quality management practices in relation to complaint handling. Most recently I had occasion to participate in the presentation of awards to officials of the Mid Western Health Board on their achievement in obtaining the ISO Quality standard in respect of their appeal system.

Engagement of Medical Staff in the complaint handling process

However, complaint handling is very much dependent on the goodwill and cooperation of medical staff in the heath sector. It has been my experience that health professionals, particularly doctors and consultants do not engage wholeheartedly with patients' complaints. In some cases complaints are seen as a consequence of irresponsible dissemination of information by the media. This, when allied to a reluctance by patients to complain, usually because they are very dependent on the system, makes for a very unsatisfactory situation. Complaint handling is invariably seen by medical staff as very much a matter for the administrators, even though the kernel of the complaint might well involve particular doctors or consultants. In several recent complaints made to my office, I observed a marked reluctance on the part of the relevant consultant to engage in the complaint process. I was taken by the lack of a procedure which obliged the consultant to engage fully in the process. In the United Kingdom the NHS has a process of independent reviews of the handling of complaints, whereby an independent panel is constituted in appropriate cases, with the authority to seek expert advice of a clinical nature if deemed necessary. As I have already mentioned I found it necessary in the Tralee General Hospital case to recommend it should address the role of the consultant in dealing with complaints and the importance of good communications procedures in responding to the concerns of complainants.

Complaints and the National Health Strategy

In relation to the development of the new National Health Strategy, I have indicated to the Minister that the Consultative Forum, in its consideration of the rights of patients and service users, might find it useful to consider the establishment of a statutory system of complaint handling, to include the concept of local resolution and independent review. I have also indicated that I would be pleased to nominate an official of my Office to liaise with the Forum in this regard.

Finally and in conclusion, Chairman, I welcome the opportunity to address your Committee today on quality customer service in the healthcare sector. Last week, I addressed the Joint Oireachtas Committee on Health and Children in relation to my report on Nursing Homes Subventions. I look forward to meeting you again next week to discuss the report of my investigation into the FOI practices of public bodies. I favour interactions of this kind between my Office and Oireachtas Committees.

Back to contents