EUROPEAN PRESSURE ULCER ADVISORY PANEL

EDUCATION - SHARING OUR EXPERIENCES
Can complaints change culture?
Hilary Scott, Deputy Health Services Ombudsman

Understanding the science, economics and therapeutics of pressure ulcer management is central to the programme for the Fifth Open Meeting, but implicit throughout is - what needs to be done to bring relief to those suffering from or at risk of pressure ulcers? I think that, by sharing my experience, I can make some contribution to the 'what needs to be done' question.

For the past two years, as Deputy Health Service Ombudsman, my job has been only to do with investigating complaints about the National Health Service, services provided by hospitals and family practitioners and ambulance services in England, Scotland and Wales. My colleagues have considered almost 6000 letters from people who are dissatisfied enough with their care to come to the Ombudsman's office. We have issued close to 400 formal reports of investigation in those two years, and resolved matters less formally in more than 200 other cases. For reasons referred to below, this can say nothing about the 'state of the NHS' as a result of that work - the sample is small and rather eccentric. But I can make some observations about the way NHS organisations deal with the complaints that we see, and what that may say about they way they go about dealing with shortcomings in services.

Before going trying to answer the question: Can complaints change culture? - what is the role and work of the Ombudsman?
The British Health Service Ombudsman is a special mandate Ombudsman, investigating complaints about the single institution within his jurisdiction - the NHS in England, Scotland and Wales. This sets him apart from his other European counterparts: Ombudsmen here - the Médiateur, Defensores Civicos have jurisdictions that cover several institutions. Another factor distinguishes the Health Service Ombudsman. Before 1996 his investigations were confined to matters of mal-administration in the NHS; a change in legislation then means that we now have five years experience of investigating complaints about clinical care.

The Ombudsman's Office is independent of the National Health Service, and of the government. The Ombudsman is appointed by the Queen on the recommendation of the Prime Minister, and reports to Parliament through a committee of the House of Commons. The office acts as a 'last port of call' for people who have a complaint and intervenes, generally, only when the NHS's own complaints procedure has been exhausted. The 'intervention' may be in the form of an investigation which leads to a report that will uphold, or not, the complaint and make recommendations for change as necessary and appropriate. The office has no power to require compliance with recommendations, but it is very uncommon indeed for a practitioner to refuse accept the Ombudsman's findings and recommendations.

About 3000 people each year contact the Ombudsman's office each year. More than half of them bring complaints that are without our jurisdiction (for example, to do with private health care, or an employment or legal matter) or come to us before they have approached the NHS locally. Of the others, a proportion of the matters complained about, presently about 25%, are investigated, and in some depth. We tend not to investigate if we think that as much as possible has been done locally to resolve the complaint.

Inevitably, many of the complaints that come to us bear evidence of poor practice, both in terms of clinical care and the way they were handled locally. But many illustrate, in fact, good practice - and particularly where a complaint has been taken seriously, investigated thoroughly and acted upon appropriately. It is important, at this point, to put the work that we do in perspective. There were 10.1m consultant episodes in acute hospital services in 1999-2000; there were 135,000 written complaints about all health services in the same year and slightly fewer than 3000 people coming to us. This is why we can say nothing about the 'state of the NHS'. That said, themes do emerge from our investigations - we have written at length about poor clinical record keeping; poor communication between professionals and with patients and carers; about inadequate support for and supervision of doctors in training and other junior clinical staff; about failures to manage care effectively, when resources are stretched; and failures to provide essential nursing care.

We do not, on the other hand, publish other types of themes that also emerge from our investigations in the same way. I think that if my 80-plus colleagues were asked: can you tell what distinguishes an NHS organisation that deals with a complaint well, from one that does not; one that has identified and made changes as a result of investigating a complaint, from one that has to be 'encouraged' to do so by us; they would say 'yes', and - more - probably that it's something to do with the 'culture' of that organisation.
What might they mean about 'culture'? They might say something about

• whether the original complaint was investigated thoroughly or not,
• whether explanations were given in terms that could be understood,
• whether the word 'sorry' only ever slipped out between gritted teeth,
• whether senior staff had an obvious interest or a hand in responding to the complaint,
• whether the staff they interviewed in the course of one of our investigations were defensive, or frightened, or guilt-ridden - or some of all three,
• whether effective action was taken as a result of the complaint.

I think it could be summarised as evidence of what is believed to be important in the organisation - i.e., what gets rewarded and what is punished; and the way people deal with patients, each other and those outside the organisation. And that does no justice at all to the massive literature on organisational cultures.
When 'culture' is thought of like that, a first response to the question - can complaints change culture - might be, no. A second response might come from your own experience of changing practice as a result of a complaint and lead you to qualify that and say no, not on their own. A third response is yes, if …
I want to suggest that there are some conditions that might lead complaints and complaint handling to have a recognisable impact on culture - the way organisations, professions and individuals 'do' things.

If you ask 'How are we doing?' in the first place and treat complaints as authentic and hard won responses to that question. Most people do not complain - partly because they don't want to be nasty to nice doctors and nurses, but often they think they'll be horrible to them to the point of doing harm and because they won't do anything different even if they do complain. And there's evidence to show that they are right on both counts, although the cases of real harm are rare. Asking the question and dealing with the responses honestly sets complaints in a reasonable and not a fearful context - 'we asked because we want to do something, if we can, about things you do not like, find unhelpful, or frightening. And we know that you may not mention it yourself'.

If speedy and open responses are made to complaints. If senior staff (most people both have senior colleagues and are senior to others) require and congratulate quick and open responses, it reinforces, or even sets, standards for communications in general. A recent complaint set out a sad picture - a doctor who did not speak in any detail with the patient or her husband, or with the nursing staff looking after her; nursing staff who made assumptions about the patient's prognosis in the absence of explicit discussion with the doctor or husband; and, as a result, a man who was totally unprepared for - and thus suspicious about - his wife's death the next day. The original response to the complaint? 'She was obviously ill and it would have happened whatever we did.' I hope that, next time, hospital managers will not make such a response. Apart from being unhelpful, it just reinforced the notion that inadequate communication between colleagues, and with patients and carers was, in some way, acceptable.