Tuesday, 2 September 2014

NHS Wales : Who watches the watchers?

Welsh Labour might've been concerned about Ann Clwyd MP giving
evidence to an Assembly committee, but the inquiry produced
productive and sensible proposals for the NHS complaints system.
(Pic : BBC Wales)

While there's a lull in Assembly activity until AMs return from recess, it's worth returning to the committees and what has become one of the more high-profile and contentious inquiries of the Fourth Assembly due to the dirty laundry it aired and embarrassment caused to the Welsh Government.

The Assembly's Health & Social Care Committee undertook a short inquiry on the last day of the Assembly year (16th July) into the NHS Wales complaints system. As a result, Committee chair David Rees AM (Lab, Aberavon) sent a 17-page letter (pdf) to Health Minister Mark Drakeford (Lab, Cardiff West) on August 5th outlining the key issues raised during their investigation.

The inquiry made headlines for more than one reason, the most notable headline being that Labour MP for Cynon Valley, Ann Clwyd, accepted an invitation to give oral evidence following well-publicised personal experiences of patient care at Cardiff's University Hospital.

It was doubly pertinent as the complaints system was one of the main grievances arising from the Andrews Report into care standards at the Princess of Wales Hospital and Neath Port Talbot Hospital in Abertawe Bro Morgannwg Local Health Board (Abertawe Bro Morgannwg : Trusted to care?).

The Key Issues

Fear of reprisals against whistle-blowers and inadequate resources to deal
with complaints were just a few of the concerns thrown up by the inquiry.
(Pic : Daily Mail)
Insufficient independent regulation of complaints – The police, for example, have the Independent Police Complaints Commission (IPCC), but there's no similar body for NHS complaints. The need for such a body was highlighted for those cases where complaints handled by local health boards (LHBs) don't result in any concrete actions. LHBs accept the need for an independent regulator, while the Welsh Government have launched a review of the functions of Healthcare Inspectorate Wales (HIW) as a result of a previous committee inquiry. The Committee recommended that independent complaints regulation be considered by the Health Minister if LHB governance arrangements are "inadequate".

The role of Community Health Councils (CHCs) – This was another area picked out for criticism in the Andrews Report and I've often said myself that I consider CHCs to be largely useless; both as a mechanism of accountability for LHBs and as a result the paralysis caused by a Welsh obsession with setting up committees instead of coming up with new policies. The performance of CHCs was "variable", and there were calls for improved training, improved leadership and greater public awareness of what CHCs are supposed to do (represent patient's views).

Accountability & Leadership – There were two parts to this. The first part dealt with local health boards and trusts. It's said there've been insufficient resources made available to improve management, and a "gap" had developed between the complaints process and boardrooms. Ann Clwyd agreed that the responsibility ultimately lay with LHBs, calling for more openness in how they operate and use of easy to understand language. LHBs have taken steps to improve matters down the years, such as : "ward walks", proactively encouraging patient and staff feedback, meeting with complainants etc. This was welcomed, but the Committee recommended that LHBs take complaints more seriously.

The second part looked at the Welsh Government's role. It was agreed that complaints handling should be considered alongside financial and clinical targets when evaluating the performance of individual LHBs.

Sharing best practice – Due to the variation in performance between individual LHBs, the importance of sharing examples of good complaints handling was flagged up. LHBs said they were keen to learn from each other, but there were concerns that the structure of NHS Wales prevented quick sharing of new ideas.

Staff concerns – UNISON warned that complaints handlers were "under-resourced" and subsequently "under immense pressure". Staff need to be highly trained due to the complex situations they deal with, ranging from dealing with bereaved relatives to co-ordinating complicated clinical information. Cardiff and Vale LHB were, therefore, open to the idea of a national complaints team to deal with the most complex cases. Poor communication from front-line staff was also flagged up as a reason for complaints relating to poor customer service.

Primary care complaints – The current complaints system didn't adequately cover GPs and dentists. LHBs and the British Medical Association (BMA) said that the focus was often on secondary (hospital) care and was therefore not useful enough for primary care. The Committee asked for reassurances from the Health Minister that recommendations from various reviews will apply to all levels of the NHS.

Recording of incidents and complaints – Ann Clwyd said many minor complaints could be "resolved by the bedside". It was also said that lots of minor complaints could be a symptom of bigger issues that could lead to "catastrophic disasters" down the line. The BMA, however, added that logging every minor complaint would be "burdensome". The Committee recommended comment books as a way to log smaller complaints.

Staff support – It's said a "blame culture" in the NHS makes staff afraid to speak out when things are going wrong, with nurses said to be reluctant to fill out incident reports or give their names. Abertawe Bro Morgannwg LHB have subsequently instituted a "See it, say it" campaign to encourage staff, patients and relatives to report issues. Ann Clwyd added that honesty was important so everyone feels they're empowered enough to speak out if something is wrong. Staff should also be able to raise issues openly, but it's said 44% of staff would think twice before whistle-blowing for fear of reprisals.

Complaints data – There's little analysis of complaints data at an all-Wales level and such data is rarely made public. There was support for making complaints data available to the public via the My Local Health Service website – as long as individuals can't be identified.

Response times to complaints – LHBs recognise their response times (there's a 30 day target to issue a final response to a complaint) simply aren't good enough. However, they say quality of response is as important – if not more so – than speed. Face-to-face contact with complainants was said to be important too, as well as maintaining communication with complainants throughout the process. In Powys LHB they've tried to do this by contacting complainants as soon as a complaint has been received to tell them it's being dealt with.

Time for an Independent NHS complaints regulator?

After the committee's recommendations, has the time now come for a national
NHS complaints system to help prevent sad scenes like this being repeated?
(Pic : Wales Online)
The Health Minister hasn't responded to the letter yet, and I presume he'll respond to the committee once the Assembly returns from recess. Most of the recommendations and suggestions from the inquiry are common sense and it's depressing and frustrating that a lot of this hasn't already been done. It could've saved the Welsh Government, AMs, LHBs and families a lot of trouble.

The Public Services Ombudsman is supposed to act as an independent regulator (of sorts), but I suppose we should consider whether all but the most minor NHS complaints need to be dealt with independently at an all-Wales level - perhaps as part of Healthcare Inspectorate Wales' remit. I don't think LHBs and CHCs can be trusted to deal with complaints anymore as too many people have been let down by the current system and there's too much variation between health boards. It's also putting too much pressure on front line staff.

All that was hinted at in the inquiry, and having a team of fully-professional complaints handlers and analysts might take the heat off front-line staff and make it easier to notice trends and patterns which indicate deeper problems at specific hospitals. Making senior charge nurses (aka. matrons) the single point of contact for minor complaints on each ward might make things easier too.

Hopefully it would all feed in to a single transparent complaints system that people know won't be bogged down and shuffled around on bits of paper in board meetings, will be independent of LHBs and won't victimise either staff or complainants.

If the Welsh NHS can start to deal with complaints with candour - and, more importantly, actually deal with problems no matter how small - maybe it'll begin to rebuild the trust that's been lost over the last few years.


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