Health and Sport Committee

Meeting date: Tuesday, January 17, 2017

Official Report 538KB pdf

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Scottish Public Services Ombudsman

Agenda item 6 is a session with the Scottish Public Services Ombudsman. With us we have the ombudsman, Jim Martin; Niki Maclean, who is the director of the SPSO; and John Stevenson, who is the head of complaints standards. I thank you for your attendance.

The ombudsman has agreed not to make an opening statement, so we will start with questions. I will begin. Can you briefly explain your role and experiences over the past year or so?

The Scottish Public Services Ombudsman is the last port of call for people who have unresolved complaints about public services in Scotland. We have a very wide remit: we deal with the national health service, Government, local government, prisons, Scottish Water—and so it goes on.

We deal differently with the health service from how we deal with the other public sector areas that are within our remit, because in relation to the health service we have the power to look at clinical judgment. That means that I have to take advice from professionals in all the disciplines in the cases that come to me. I do not have such a power in relation to local authorities, higher education, further education and schools, for example: I cannot look at academic judgment and that kind of thing. In health, I have a particular power.

As the committee will have seen from the papers that we have given you, over the past year we have had a significant increase in the number of health service complaints coming to us. It is maybe worth our while to say for people who are unfamiliar with the SPSO that people normally only come to the ombudsman once they have been through the complaints process for the public body concerned. If someone comes to us early, we call it a premature complaint and would normally signpost them to the appropriate place and have them take their complaint through the process there. Once a complaint has been through the process at local level—general practice, dental practice or health board level—if the complainant is still dissatisfied with the outcome, they can bring it to us. Last year, we had about a 9 per cent increase in the number of complaints that came to us. Since I became ombudsman in 2009, health complaints have increased by about 75 per cent. There are lots of reasons for that, which I am sure the committee will want to discuss.

For most public services in Scotland from which cases come to me, the uphold rate—the rate of cases that we investigate and find that something should have happened but did not happen—is currently running at about 50 per cent. For health, the figure is about 56 per cent. The worrying thing about that is that those cases have already been investigated at the local level and, by and large, the complaints have not been upheld and have then been brought to me. In that situation, we investigate; in more than half the cases, we have found fault.

A complaint is sometimes upheld at the local level but not to the full satisfaction of the complainant. If we find that the case has not been investigated properly, we look at it. If we find that it has been investigated properly and there is nothing more that we can do for the person, we tell them that and that closes the matter.

The proportion of health service cases that we see has increased over the period. Health service complaints is the fastest growing area of complaints that come to my office and is now the second-largest area, behind local government. If the rate continues to increase in that way, I anticipate that health might well be on a par with, or overtake, local government in two to three years.

The cases that we are seeing now are more complex than those that we saw in the early stages. More and more often we have to send away for advice, perhaps from two or three specialisms, when we consider a case.

This is beginning to sound like an opening statement, convener, so I am sorry about that. However, you will see in our submission that we have a problem with provision of clinical advice. The Parliamentary and Health Service Ombudsman, which deals with health service issues in England, has decided after 23 years that it feels that it can no longer give us access to its clinical advice. I will say more about that later if someone asks me the right question, but it means that we are having to create our own bank of clinical advisers. Over the past year, we have seen an increase in health service complaints and the uphold rate is still quite high. We are also having to rethink how we get advice to investigate cases.

Further, we have been working alongside the national health service to help it to put in place a new complaints handling procedure, which will go live in April. That will introduce the same standardised procedure in the national health service as exists in the rest of public services in Scotland. We have argued long and hard that if we are to have health and social care integration, we need to have one complaints procedure for everything. Therefore, the social work complaints process will also be brought into line with the procedure from 1 April.

From 1 April, we should have a user-centred standardised complaints process, which will enable local authorities and health boards to work together to solve problems when they arise. It should also give the committee better information about the number and nature of complaints that come forward in the health service and in the integrated health and social care system. That will place the Scottish Parliament in a better position—certainly, better than any other Parliament in the United Kingdom and, I would argue, any other Parliament in Europe, in that we will be able to look across the whole of our public services to see what is happening with complaints. We will be able to see what areas are leading to complaints from the public, how complaints are being managed and how health boards, local government bodies, universities, housing associations, prisons and other bodies deal with them. I hope that, in the future, the committee will mine the raw information that it will have at its disposal to get underneath what bothers the public in provision of public services.

John Stevenson, who is the architect of most of that stuff, will happily answer questions on it, and Niki Maclean will do the stuff with the numbers. I just do the blarney at the front.

Thank you for your non-opening statement.

You have said that 56 per cent of the health service cases that you looked at were upheld after having already gone through the NHS complaints system. Is that an indication that the NHS system is broken?

In its 2014 report “Making It Better: Complaints and Feedback from Patients and Carers about NHS services in Scotland”, the Scottish Health Council expressed a few concerns about the way in which the health complaints system was working, and it asked the health service to work with us on a better process for handling complaints that would give us a new national complaints-handling procedure. As for areas in which I think the health service is improving but could go further, I am not convinced that management of complaints is given the weight that it should be given—in particular, in health boards. Indeed, I am absolutely convinced that that is the case with regard to general practitioners.

In his report on Mid Staffordshire NHS Foundation Trust, Robert Francis highlighted his discussions with the chair of the trust, to whom he had put it that many of the issues that had led to the deaths of so many people had been flagged up in the complaints system but had been neglected by the chair, the chief executive and the board of the trust. Essentially, the chair said, “There’ll always be complaints. We know that, and they don’t really add anything.” Francis’s view was that if you take that approach you miss out on early warning and learning.

I think that the national health service is getting better at understanding that when complaints are brought they should not necessarily be looked at on the basis of potential reputational damage—when I came to office, one or two health boards definitely saw my office as a threat to their reputations.

Moreover, in my view, this is not a matter for lawyers. Over the past couple of years at least, we in Scotland have been moving away from lawyers saying, “For goodness’ sake, don’t say sorry or admit anything just in case that 0.4 per cent, or whatever, of complaints end up in court or litigation.” The health service is getting better at such things and at knowing that it has to investigate complaints.

I hope that once the new processes and procedures are in place, and with the work that Niki Maclean is doing with health boards and others on learning from complaints, the uphold rate that I have been seeing—or which my successor will see, given that I am leaving office soon—will fall. I see a willingness on the part of the national health service to grasp and learn from the issue, but sometimes it looks to me as though the machinery of the national health service has been oiled with treacle, given how long it takes things to come through. In this case, it is moving relatively quickly on the complaints-handling procedures—although it is still slow—and I hope that from 1 April we will have a better system in place.

In my experience of representing constituents—practitioners and patients—I have felt, with regard to the attitudes that prevail among very senior managers in the NHS, that there often appears to be a culture of closing things down and denial rather than of acceptance that there are problems. There is also the ability at the very senior level of the health service to claim that white is black and black is white. Do you think that that culture existed in the past? If so, is it still there, or do you sense that there is an opportunity for real change and that the health service is grasping it to ensure that it learns from mistakes and complaints, and that it is open about them?

10:15  

It is wrong to suggest that all health boards are the same: their cultures are different. If you had asked me about that in 2009-10—I will not name names, if members do not mind; I will say why later—I would have said that a couple of health boards would nearly fit that description and that their first port of call would have been to say no, or to say that there is nothing to see here, so please move on.

This is paradoxical and will sound really silly, but the national health service has been unprofessional in some cases in the past in not being good at closing things down. Five years ago, I would have said that consultants in hospitals, for example, had far more power over what happened to complaints than they ever should have had, and that investigations, particularly of the work of consultants, in many health boards were not up to scratch. On the other hand, in some cases in which it would have been in the best interests of everyone—including the family—to close something down, the health service would attempt to go the extra mile and would drag a process out without coming to a conclusion, which would lead, for example, to a family coming to me to say that the board had been investigating the case for over a year. However, when I looked at the detail, I could see that it had not; it had investigated the case and had reached the point at which it could take a decision, but had instead tried to help the family by getting more information, thereby not providing closure.

The handling of complaints has been a curate’s egg across the board, with the health boards. However, I think that that culture is changing, and the Scottish health council deserves a lot of credit for putting its foot on the ball—as we used to say where I come from—in 2014 and asking, “Hold on a minute. What are we actually doing here?” That has enabled boards to look at what their complaints process should be, how they should investigate complaints, and what the status of the people who handle complaints should be.

Post the Francis report, NHS Education for Scotland and the boards got together and asked us to help them with master classes so that non-executives in health boards could understand the central role that complaints play in governance in the national health service. Over the past two years, there has been pressure from the boards down and a move towards improving procedures, which I think will lead to a change in culture.

However, I agree with the convener that there is still a bit to go in many health boards. In the convener’s area, for example, we recently had to say to Lothian NHS Board that we were not happy with how it was managing the complaints process generally. If members look at that board’s minutes, they will see that it is now grappling with how it can improve that. Five years ago, there might have been a fight, but now—I give some credit to the chair of the board for this—the board will say, “We really need to get this fixed in the interests of patients and their families.”

I have two questions. First, what are the reasons behind what appears to be a very significant rise in health-related complaints over not just the past year, but the past five years? You mention that in your letter. Secondly, it seems that the number of clinical and hospital complaints regularly far outstrips other complaints. That is mentioned on the second page of your letter. What are your observations on that, please? Will you explore that for the committee?

I am happy to deal with that question.

The rising volume of complaints that the SPSO sees very much mirrors the increase in complaints that are recorded in health boards. We have to be careful not to presume that an increase in complaints is in itself necessarily a bad thing; it can, for example, mean that there is increasing confidence in a complaints system. My colleague John Stevenson might want to say a bit more about that and the role of the complaints standards authority in the SPSO. The SPSO certainly sees a reflection of what is happening in NHS boards.

Donald Cameron is absolutely right in his second question. We see a relatively low number of complaints about, for example, general practitioner services, relative to the number of people who access the services. That is partly about access to complaints processes: small practices might not receive high volumes of complaints. Processing of complaints within health boards is more established. There is, potentially, underreporting of complaints in areas including the GP sector.

You have to remember a number of things. The Patient Rights (Scotland) Act 2011 came in. We can argue about how much was in that act and what it changed, but it raised awareness that people have rights.

In 2011, Parliament gave my office the right to publish decisions—we were the first in the UK to do that. We now see newspapers reporting that decisions have been upheld and so on. I am particularly pleased that we can see that in local newspapers because it encourages people to come forward, which is important.

As John Stevenson will tell you, when we start to look underneath the numbers, it becomes difficult. I always ask committees to remember that I see only the tip of the iceberg. The cases that come to us are but a small portion of the total number of complaints, so you have to be careful about reading across from what we are seeing.

This is fascinating. I want to touch on a number of issues around the process. I was going to ask about how many complaints were hidden, but you have answered that—I get the feeling that you do not really know.

The 56 per cent of health complaints that are upheld first go through a process within the health boards and then they come to you. Do you have data about what is happening in the health boards, how many complaints they see and the metrics around how many they deal with, how many they do not deal with and how many come to you?

We have data from the Information Services Division of the NHS that shows how many complaints are received and recorded in a year. It is fair to say that there was a rise year on year until the past year, when there was a slight decrease.

One of the issues that the Scottish health council’s report “Listening and Learning: how feedback, comments, concerns and complaints can improve NHS services in Scotland” looked at was the consistent use of performance information and information about complaints handling. The report’s main recommendation led to the development of the new procedure that Jim Martin spoke about, and another recommendation was that the datasets that are being captured and recorded by the ISD should be looked at afresh to bring them up to date with the information that is being recorded across the wider public sector and to make sure that that is done in line with the new complaints procedure.

Moving forward, we will have a more detailed and better understanding of the complaints that are being recorded by boards and primary care providers, what they are about and what the learning from them is. In my work with professionals from the NHS and in looking at performance reporting, I was encouraged that those professionals identified learning and improvement from complaints as a key indicator. You will find that the new complaints procedure that will come into place from April highlights that, in performance reporting, the number one issue to report against is learning from and recording complaints. It is fair to say that, moving forward, we will have a far better understanding of the number of complaints that are being received, what they are about and what the outcomes are.

Ivan McKee mentioned hidden complaints. In the NHS and across the public sector, there has been a concern about complaints not being recorded as complaints. In the past, when someone expressed real dissatisfaction with a service that has been provided, there was a tendency to resolve the issue professionally without recording the fact that it had been raised. If such issues are not recorded, we lose the opportunity to learn. There has been a change in the NHS, and that might partly explain some of the rise in the number of complaints. However, there has also been a change across the wider public sector towards rigidly applying the definition of a complaint—that is, an expression of dissatisfaction—and recording complaints so that the organisation can learn.

At this stage, you do not have any data on how many complaints have been made to health boards, how many of those are dealt with satisfactorily and how many come to you.

We have raw numbers. We know that, in 2015-16, about 21,000 complaints were made. We can also tell you how many complaints came to SPSO.

It was about 1,500.

Yes.

That means that 90-odd per cent of complaints are dealt with at the health board level.

Yes. As Jim Martin said, what comes to the SPSO is the tip of the iceberg.

It may be worth considering that number for a minute. I have concerns about how robust the numbers are. The number of health complaints was about 21,000, and the number of local government complaints was 62,000 over the same period. I do not know how that feels to you, but it suggests that, each day, we see 60 complaints about health and 180 complaints about local government.

I hope that, once we get everybody on to the same system, we can begin to look at the numbers a bit more scientifically. You will then have better data with which to begin to advocate policy changes.

You said that about 56 per cent of complaints are upheld. I assume that that is spread across health boards. I do not want to use the word “sanction”, but is there any league-table measure or way of kicking the health board to say, “Your percentage is too high. You’re not dealing with this stuff upstream well enough and you’re letting too much of it come downstream to us,” or is it accepted that complaints will be upheld and that that is just the way things are?

I have intervened in a couple of health boards, one of which, as I mentioned, is NHS Lothian. We look at three things. The first is the rate of upholds—the issues that they and we have looked at and on which we have come to a conclusion. The second is the volume of complaints and whether, in relative terms, given the size of the health board, it is what we would expect to see. The third is the level of premature complaints—when people come to us who should really have gone to the health board in the first instance. We then do a wee algorithm and come up with a figure. If, over a period, I uphold 70 per cent of complaints against a health board, I will have an informal chat with the board. If the number does not come down, I will have a formal chat with the officials. If the number still does not come down, I will have a very formal chat with the board.

That is good. My background is in consultancy and manufacturing. That stuff is done to death in that field: continuous improvement is a way of life, because if you do not do it, you do not survive. This discussion is like a throwback to where we were in that environment 30 years ago.

You are saying all the right stuff about where the system needs to go in terms of process improvements. I am interested in how many complaints result in the implementation of process improvements. Language is important, too. We tend to talk about “opportunities for improvement” or “improvement suggestions” and so on. Does the process allow people to say whether the system could be better and to suggest how to improve it, or does it just allow people to make a complaint? The complaints process looks at whether somebody did something wrong, rather than at whether there is a process that we could fix.

On process improvement, it is important to remember that the ombudsman was initially established to consider individual redress—that is at the heart of the ombudsman service’s work. Fundamentally, our first priority is to try to put things right for that individual and their family. That said, 60 per cent of the recommendations that we make through our casework are improvement related. Increasingly, that area is where we should focus our attention, so that we make sure that people get as much value for money and as much improvement as they possibly can from our recommendations.

Obviously, it is very much up to health boards how they use the recommendations to drive wider improvement. However, some of the work of our learning and improvement unit is very much about encouraging and supporting health boards to ensure that they get maximum benefit from our recommendations.

We do not have systemic powers to follow complaints and investigate more widely. We are seeking more powers so that we can share the information that we hold on learning. That would be of real benefit.

In my experience of working with NHS professionals over the past year, they aspire to have an NHS that is an open and learning organisation and which values all forms of feedback.

You asked whether there are other processes. Within the 2011 act is a requirement to record all forms of feedback, including comments, concerns and complaints. You are right that complaints have a certain connotation, but I know that boards and primary care providers are also recording concerns, comments and other feedback and are using that information to improve services.

Thank you.

10:30  

Good morning and thank you for coming to see us. I am very grateful for the existence of your office. I have referred a number of constituents to you when they have reached the end of the line with complaints, particularly about NHS Lothian and health-related issues.

I would like to pick up on Ivan McKee’s last question, which was about the application of learning. Yesterday, a constituent—Dr Patrick Statham, a neurosurgeon at the Western general hospital in Edinburgh—came to see me. He is very concerned about the level of cancellations in his ward as a result of the unavailability of beds because of the lack of ring fencing in the neurology department. He said that his morale and that of his fellow surgeons is plummeting, because they keep having to turn people away. That is clearly a systemic problem, which will undoubtedly lead to complaints to your office. It is clear that there is a mix of system-related complaints and complaints about individual practice or care.

In terms of the application of learning and the recommendations that you make, can you explore how much you look to other health bodies that have solved such problems in the past? I say that because Patrick pointed to St Thomas’ hospital in London, which had exactly the same problem with its neurosurgery department. It brought in a management consultant, KPMG, to look at how it could better deploy the beds. KPMG came up with the simple idea of ring fencing beds for neurosurgery. That did not really impact on the rest of the hospital, but it meant that people got seen for elective surgery. Can you give us your reflections on learning from other places? These problems are clearly not unique to Scotland.

First, I think that it is fair to say that the complaints that we see are not about systemic issues. Secondly—and I know that this also does not address your question—we do not see a high volume of complaints about neurology.

Our recommendations stem from the use of clinical advisers who are in practice. They refer to relevant guidelines from the Scottish Intercollegiate Guidelines Network, the National Institute for Health and Care Excellence and other areas of good practice. We assess the reasonableness of the actions of clinicians and medical experts against national guidance. That is where we take our advice from.

I would add a little to that. We were at the Local Government and Communities Committee the other day to discuss my annual report, and I used the opportunity to suggest ways in which the powers of the ombudsman might be augmented to enable better sharing of information, so that issues can be picked up.

We see things that occur frequently. For example, a few years ago, we were concerned that, at one hospital—it was in Fife, I think—a number of radiography cases had come through with the same flaw. Technically, I could look at each of those cases on its own, come to a decision on each case on its own and, presumably, make recommendations about each case on its own, but clearly there was a systemic issue.

Enabling my successor to share information with regulators—which the Scottish Public Services Ombudsman Act 2002 precludes us from doing—would enable us to take a more joined-up approach across Scotland. Where the ombudsman saw issues arising, those could then be tackled. If we were to operate simply to the letter of the 2002 act, we would not be allowed to do that. That is something that various committees of the Parliament might want to think about when—as I hope—the Local Government and Communities Committee takes forward our suggestions about information sharing.

Thank you. My second question is about the split of complaints that you handle in real time—they are live situations that are still happening to people—versus complaints that are made after the fact.

Before the meeting began, I was talking to the convener about the fact that, on a number of occasions, I and a number of parliamentary colleagues have had to raise individual cases on the floor of the chamber and embarrass ministers and the First Minister in order to get action. That action is then taken the next day. I do not think that that is the way to run a health service but at the moment it is working for us. What can your office do in that respect? I am thinking of a case of bed blocking and delayed discharge in which a gentleman had to remain in hospital for 150 nights after being declared fit. He had got nowhere with the health board. Can you tell us what you could have done to help in that situation and then address the question about the split between real-time and after-the-fact complaints?

You have to remember a couple of things. First—and this is very important—the ombudsman is not a regulator. As Niki Maclean said, the primary role of the ombudsman is to deal with cases that require individual redress. John Stevenson’s work with the national health service on the standardised complaints process should mean—I say “should”; we will see how it works—that complaints are defined, investigated and concluded earlier, which should allow issues to come to the ombudsman earlier. One of the things that frustrates the team in my office—and I have a lot of good people who get very frustrated from time to time—is that we see cases late and the fact that it takes a long time for things to get through the system before they come to us.

However, we are not there to do the job of the health board or Healthcare Improvement Scotland. As I have said, at the moment we are precluded from looking at systemic issues. We could have looked at and come to a conclusion on the case of your gentleman who had to remain in a bed for 150 nights—perhaps even while it was still happening—but it would have been far better for the appropriate management routes to work effectively.

While I am on my high horse, convener, I just want to point out that the one thing that my office is about is naming and learning, not naming and shaming. I think that one of the barriers to learning in the health service in Scotland has been people’s fear of being named and shamed and the reputational damage that comes with publicity of “failure”—and I put that word in inverted commas. I hope that this Parliament, which I think is, in many ways, far more mature than your colleagues’ Parliament down south, will move towards understanding that, although it is good to highlight the things that have gone wrong, what is most important is to get the learning and ensure that those things do not happen again. The first thing that the vast majority of people who come to my office say is that they want to understand what happened and to ensure that it does not happen to anyone else ever again. If you want some advice, I do not think that naming and shaming advances learning.

But sometimes it gets our guys out of hospital.

On that note, I want to ask a little bit more about the learning and improvement unit. Is a systematic approach being taken to feeding into the bigger governance picture the themes that you are seeing from the complaints that you handle such as near misses, Datix and so on?

It is important to remember that previously the ombudsman service has not been resourced to undertake that wider analysis, but we have secured funding for this year and into the coming year to set up a very small unit of just three people to undertake some analysis. As we have said, the number of complaints that we actually see is very small relative to the whole of the health service, but I think that there are opportunities to identify some of the thematic issues, and one of the things that that unit will do is publish themed reports across the whole public sector. In March, for example, we will publish a report on informed consent and some of the issues in that respect.

We are looking for areas in which there is space for us to add our voice and make some comment that is unique with regard to what has already been said. Another example might be end-of-life care, on which a lot of research and investigation has been carried out and on which guidance has been produced by other bodies, and we need to think carefully about how we use our resource to ensure that we genuinely add a unique voice and picture to such areas.

Other pieces of work that we are pursuing through that unit involve, as we have said already, working with a small number of public bodies that attract high volumes of complaints and where there are high uphold rates. For me, that very much involves supporting organisations at that later investigation stage, where things become complex and intractable. That is where there is a skills gap and organisations genuinely need support, education and guidance.

Can you tell me a little bit more about how you give out feedback? Do you feed information back to health boards rather than to the place where the complaint originated?

When we arrive at a decision following an investigation, we report in one of two ways. One way involves our issuing a decision letter that goes to the body—a board, a practice, a dentist, a pharmacist or whatever—and the person who has complained. That letter contains the decision, the reason for the decision and recommendations for improvement.

If we find a matter that we regard as significant, either because it is in the public interest or because it offers a significant learning opportunity, we will issue that report individually as a separate report to Parliament. I think that we issued 38 health reports to Parliament last year. Every month, we publish summaries of all of the decisions—there are around 60 a month. We draw the matter to the attention of the board, and NHS Scotland draws all our decisions to the attention of all the boards and, where appropriate, GP practices and others. By doing that, we hope to ensure that learning from every decision that we take gets into the system. As an ex-teacher—although I was not a very good teacher—I can tell you that you can have all the teaching materials in the world, but if you have a bunch of kids in front of you who do not want to learn, you will struggle. I have been taken with the work that John Stevenson has done over the past couple of years, because the Scottish health council and the health service seem to be approaching complaints from the point of view of learning. In order to get learning through, you have to create an environment and a culture that accept that learning will come about from situations in which things go wrong. That means getting to a position in which, when things go wrong, you do not just shoot people.

The whole thing is a continuum, and the work that Niki Maclean and John Stevenson are doing is meshing together to help the national health service to learn from the experiences that we see people having with that service.

In the analytical work that you are doing, have you identified a correlation between complaints and, for instance, budget pressures, demographic change, socioeconomic factors and so on?

You have to remember that the learning improvement unit has been in existence for—how many months?

Nine.

Nine months.

Oh, that is plenty of time.

We are looking across all the sectors. It is interesting that, whenever we go to places and talk about the learning improvement unit, we are asked whether we could consider the correlation between various things. I keep saying to people that we have three people and have a budget for one year that has been extended for another year, and we do not know whether that budget will be extended for a third year, so we have to cut our cloth in the first instance.

As I said earlier, the health service will be required to publish data on its statistics but, because the volumes that we see are small, I am not sure how useful that analysis would be. I think that the analysis has to be of the wider health service complaints data that the committee will have available to it. As Jim Martin says, there is a fantastic opportunity for Scotland, because we will be the first country in Europe that will be able to analyse this data across our public services. The data will be made available.

First, let me say that I wish you well in your retirement, Mr Martin.

I want to put this discussion in context, so that we do not paint a bad picture of the health service. I think that, for every health service complaint that you get, you get three complaints about local government. Is that correct?

No. We receive probably a couple of hundred more complaints a year about local authorities than we do about the health sector.

I think that we said that across the NHS we are looking at around 20,000 complaints—

Compared to 62,000—

But that is the number recorded by the sector, not the number of cases that come to the SPSO.

10:45  

That is the point that I want to clarify. You said 21,000 for the NHS and 62,000 for local government.

Yes.

Every complaint is important—I certainly agree with that. I have one complaint sitting with you already. Yes, unlike Mr Cole-Hamilton, I only have one with you just now. However, if we take on board the fact that the NHS has at least a million appointments a year—maybe we will get that figure checked out—is the number of complaints that you get high in proportion to the number of activities that take place in the health service? I want your honest opinion.

That point has been put to me for the past four or five years. It is a standard line—“We hear you Jim, but there are a million contacts.” Local government says the same thing to me, and it is absolutely true. If I was sitting where you are, I would say that that is a given. However, the health service’s own numbers—the numbers that John Stevenson was talking about—show an increase of 68 per cent over the past four years in the number not of complaints to my office but of complaints recorded by the ISD. Ivan McKee was explaining his business experience earlier. If I was running a business and I saw that complaints were going up at that rate, I would say that we had better look at it.

It is important to get the number in proportion. It is not an indication that the NHS in Scotland is failing or is on its last legs, or anything like that. It shows that the number of very serious complaints that are made both to the NHS and to me is increasing. Worryingly, I am upholding more than half of the cases that health boards have not upheld.

I am not teaching my granny to suck eggs, but if I was sitting on this committee, I would be asking this question: if the ombudsman is upholding half of the cases that come to him, how many cases were not upheld by health boards and what is the likely proportion of those cases that the ombudsman would have come to a different conclusion on? That would lead me to ask whether we are satisfied that, even given the small proportion of complaints against the total number of contacts, that the investigation of complaints is thorough, robust and of an acceptable level. Given the work that Robert Francis did in his report, and the risk identified in it—where the chair’s view was, “We always see lots of complaints and there is nothing that we can do about that”—I would argue that, although the number of complaints is not the only indicator that the committee will have, it is a very important indicator that might lead you to ask questions of the relevant people.

There is something that can be done about complaints—they can be solved before they are sent to you. That is why I asked you the question. In my experience of a discussion that I had with my health board, which is NHS Lanarkshire, I know that you can sit down with someone and look at the problem in depth. However, I agree with you that, all too often, organisations go, “No, there is nothing that we can do,” and then people come to us to put complaints in. I think that I have flogged that point enough.

You made an interesting comment about the European Union and Brexit in your submission. I am sorry to bore people with that word again. You say that Brexit

“is something of which we are currently mindful but we are not yet clear what the impact may mean for the direct delivery of services. We will be monitoring this carefully.”

Do you believe that when Britain—hopefully, it will not be Scotland—comes out of the EU, laws will be changed that will affect your service in some way? You may want to expand on that.

Or not, convener.

Or not.

I do not know what the Prime Minister is saying just now. She might be saying something that is of interest.

I doubt it.

As far as my office is concerned, the issues are what the public service in Scotland will look like post-Brexit and whether that is likely to bring complaints to us. Until we find out what happens, we will simply not know, but I am sure that my successor will keep an eye on this place and on what committees such as the Health and Sport Committee think about Brexit and the impact that it will have.

I have a small final question. We are all talking about budgets. What is the cost of your service at the moment? The level of complaints that you receive has increased right across the board. You do not deal only with complaints about the health service; you deal with complaints relating to other areas, including local government. Are you coping? Are you under pressure? Please be honest.

The budget that I have is just over £3 million.

Thank you for giving me the opportunity to rant—I will try to keep it short. Today, I have roughly the same number of people investigating complaints as I had in 2009, when I took office. At that time, there were cases in my office that were three years old and more. When I walked through the front door, we had 92 cases that were more than a year old and a significant number that were more than nine months old. We have turned that situation around.

We took on prisons complaints. At that point, I went to the Presiding Officer and said, “I think that my office has enough capacity to deal with that without increasing our staff,” and he said, “Well done—on you go.” We then took on water complaints, and I had the same conversation with the Presiding Officer and was told, “On you go.” Over that period, the number of complaints coming to my office has risen by about 40 per cent and productivity is up by 31 per cent, but when I go to the Scottish Parliamentary Corporate Body and say, “We now need more people,” the answer is no.

At some point, the Parliament must work out what it is going to do with bodies such as the Scottish Public Services Ombudsman and the Scottish Information Commissioner, which, in effect, provide demand-led services that are financed by the Parliament. We are funded as departments of the Parliament—in other words, we are funded as if we were a finance department or a human resources department with a fixed budget.

Over the years, I have spoken to the chief executive and others about different funding models. For example, the committee will see in the material that we have provided it with that we worked with NES to put together new training materials, which 19,000-plus people in the national health service have used. My argument was that we should license those training materials for use outside Scotland, where they are used for free. I suggested that we should look at polluter-pays systems because, at the moment, the Parliament is funding the budget of the final tier of the complaints process for local government, health, prisons and so on. If we introduced the polluter-pays principle, that would impose a sense of responsibility on the bodies concerned.

I was extremely disappointed when, having said in my strategic plan for the next four years that we should consider such an approach, the response from the chief executives and legal officers of local authorities was that one of the ways in which we should control demand was by introducing a charge for people to access the ombudsman. That would only hit the most vulnerable, and I do not think that it is the way we do things in Scotland.

When my successor comes in, I hope that the Parliament will ask him or her, “What do you think you need to run your service efficiently?” I hope that Parliament will scrutinise that number and play hardball with them, but I make a plea for it to listen to them, because if we do not have the resource that we need, all that happens is that ordinary people—in many cases, families who are grieving—face inordinate delay in getting decisions that are of great importance to them. My parting shot as I go out of the door as ombudsman is this: for goodness’ sake, listen to my successor, and if you want an efficient ombudsman service, please be prepared to fund it and resource it.

Thank you. I wish you well in your retirement.

Congratulations. You took your opportunity with aplomb.

I thank the members of the panel. It has been very interesting listening to your answers to fellow committee members’ questions.

You kindly raised the issue of prison healthcare, which is what I wanted to ask you about. In your briefing, you say that there were 137 complaints about prison healthcare in 2015-16. You will be aware that the committee is looking at conducting a short inquiry on prison healthcare. Does that figure cover the entirety of prison healthcare? Does it cover all the services that are provided in that context? What are the most common complaints about the prison healthcare service?

Yes, it covers all prison health complaints. I do not have the details with me, but it is fair to say that the most common complaints are about prescription medication and whether things have been prescribed appropriately.

That takes me on to another hobby-horse of mine, convener, so I ask you to indulge me for a minute. If the committee is looking at the issue, I suggest that you might want to think about how the ageing prison population will be catered for. I am concerned about the ageing prison population and particularly the groups that are not the most popular, such as sex offenders. People in prison are getting older and all the things that happen to people who are not in prison will happen to those prisoners. We will have more problems with dementia and mobility and all the rest of it.

If we are to be humane in our treatment of prisoners, there has to be more close collaboration and strategic planning between the national health service and the Scottish Prison Service, particularly on areas such as hospice care for people who are in prison. I am pleased that the committee is looking at that area, and I hope that you will test people’s strategic thinking about how they are going to deal with that issue, which I think is a little time bomb.

I can follow up on the numbers of prison healthcare complaints. It is notable that prison healthcare complaints have gone down as a percentage of all NHS complaints received in the past year. The number of prison healthcare complaints coming to the SPSO has gone down slightly, as has the number that we uphold. From working with NHS Tayside and NHS Lothian, for example, I know that there are some good initiatives in prison healthcare settings to try to resolve complaints quickly and early and at the point of contact. Perhaps some of that work is coming to fruition.

I was going to move on to that point, because the ombudsman previously provided information to the committee that, after the healthcare responsibility was transferred to the NHS from the Scottish Prison Service, there might be have been some barriers to prisoners making complaints. What have you done to make it easier for prisoners to access your service when required?

In the early days of the transfer of responsibility from the Scottish Prison Service to the national health service, there was a patchy response across the health boards in dealing with complaints from prisoners. The health boards had different interpretations of the Scottish Government guidance on how to manage prisoner health complaints. We had a lot of informal chats with the Government about what we were seeing, because we did not think that things were working.

Eventually, in, I think, Ayrshire and Arran NHS Board, we saw an interpretation of the complaint guidance letter from the Scottish Government that we just could not match with what was happening elsewhere. That led to discussions on what the guidance actually means. For example, in one case that I can think of, people in a prison were told that they could not make a complaint until they had formally given feedback on a form because that was the way that it was meant to be and the way that the Scottish Government wanted it to be, whereas that was not an issue in other board areas. In some health boards, there were questions about the role of the Scottish Prison Service with prisoners when they were receiving healthcare advice, and that kind of thing.

The issues have largely been sorted out and we are now in a better place. I see fewer things coming through that I think are systemic faults. We will see the occasional thing that goes wrong—that happens in prison and elsewhere. In the early stages, it took a bit longer than it perhaps should have to get over the teething problems, but I think that we are now largely over them.

As there are no other questions, I thank our witnesses for attending. I wish Mr Martin well when he moves on to pastures new. Thank you very much for your evidence.

I suspend the meeting briefly before we begin the next panel.

10:59 Meeting suspended.  

11:03 On resuming—