John Kell

Head of Policy

An independent report was published last month on the value for money offered by the Parliamentary and Health Service Ombudsman (PHSO). This met a recommendation by the House of Commons Public Administration and Constitutional Affairs Committee.

Changes to PHSO's role and powers
Discussing the findings of the review in an interview with the Health Service Journal (paywalled) the Ombudsman, Rob Behrens, outlined that following the report he will be making a case for new powers for PHSO. These will include the ability for PHSO to launch investigations without formal complaint (‘own initiative’ investigations, which are commonplace in other ombudsman services).

A role is further proposed for PHSO as a Complaints Standard Authority, in line with the Scottish ombudsman: this would allow PHSO to direct bodies in scope of its work to improve their complaints processes in line with a framework set by PHSO. Mr Behrens also emphasised that he wants to start this complaints improvement process in partnership with NHS Trusts, without a formal power to compel, as most organisations will not need compulsion.

Our position statement on PHSO, published in June this year, says the following:

PHSO has recognised the scale of both its problems and the action needed to correct them. It has set out a strategy for how it will improve its performance across a period of years. We have welcomed this, and the organisation’s new leadership as of 2016-17.

However, at present PHSO is only part-way through this change programme. It has not yet produced the transformation that is needed. […]

We recognise that achieving change on the necessary scale will take time, but we hope PHSO will be able to show progress as soon as possible, with reference to patients’ experiences of their service.

We will therefore judge firm proposals for new powers on their merits, as they are formally put forward. In doing so, we will consider PHSO’s track record in achieving improvements to its services for patients. As yesterday’s report makes clear, this process is not yet complete.

While it notes that PHSO makes more use of service user feedback than most ombudsman services (it highlights the Financial Services Ombudsman as probably the only ombudsman in the UK that is further ahead than PHSO in this), it also observes that this feedback highlights areas where improvement is still needed to ensure that complainants are assured that processes have been fair. The depth of investigations and the explanations offered about how decisions are reached are the key areas where improvements are needed. We would also like to see clear quality assurance processes in place to provide assurance of these improvements for patients.

So while the scale of change at PHSO has been significant, it has not yet fully borne fruit – although, as we make clear in our position statement, we would not necessarily expect it to have done so quite yet.

Possible new powers
The report and Mr Behrens’ interview provide insight into what these possible new powers might mean for PHSO. The most eye-catching ones are own-initiative investigations and the Complaints Standard Authority role. The second of these probably represents the biggest change for PHSO, and the own-initiative investigations might effectively be one tool in PHSO’s toolbox for carrying this role out.

We expect these investigations will be tightly focused on the processes of complaints, and not directly address issues of patient safety or clinical practice in their own right, as investigations of this sort would then potentially duplicate the role of the Healthcare Safety Investigation Branch (HSIB). In practice, delineating the different types of investigations undertaken by the two organisations, if PHSO does obtain these new powers, might prove quite a technical challenge. There will need to be clarity for patients about which body does what.

A role for PHSO as a Complaints Standards Authority appears to hold great potential. The slow progress made by the NHS to date in improving its complaints process and patients’ experiences of it are clear to us from calls to our helpline, as well as from multiple high profile cases. An independent body vigorously pushing the NHS to improve its performance in this regard could significantly improve the complaints process for patients.

The report also includes useful discussion of the work done by PHSO beyond its formal investigations. Its ‘assessments’ of cases are, it finds, substantively no different from its formal investigations, although the latter involve more procedural steps. It also identified roles for PHSO in signposting people to other redress mechanisms, for instance if they have not yet been through the NHS’s complaints process, and in bringing issues into public discussion, as part of a broader push towards change. It gives sepsis as an example of the latter, and we agree that it would be good to define PHSO’s role more fully here: the NHS is still not effective at learning from its findings, and still to prone to repeating the same mistakes.

The scale of change at PHSO
The report opens with an unflinching outline of PHSO’s recent troubles, characterising them as both an organisational crisis and a loss of trust. It also makes clear how far-reaching the changes within the organisation have been – rather than being incremental or piecemeal, they have happened at scale and pace. This has included moving most of the organisation’s operations to Manchester, a reduction in staff numbers overall as well as both redundancies and recruitment as part of the move, major changes to internal processes, and the development and introduction of a new training programme.

It concludes that the cost-per-case of PHSO will be broadly in line with other ombudsman services, once the transformation programme has been fully implemented – although it cautions heavily, and persuasively, against the use of such a crude benchmark in isolation. The key test of success must remain the difference that PHSO is able to make for patients, so that in future they will know that their concerns have been listened to and investigated properly.