In the latest episode of Making Complaints Count, our Policy and Public Affairs Manager Anna Davies is joined by Dr Tony Dysart, Senior Lead Clinician at the Parliamentary and Health Service Ombudsman.
They discuss the launch of Tony’s new patient safety blog series and:
- how his work at PHSO informs his work as a GP
- the biggest patient safety challenges facing the NHS and how these can be overcome
- what culture changes are needed to improve patient safety
- how the NHS Complaint Standards can drive improvements.
Listen below, or find us on iTunes, Spotify or your preferred podcast provider.
Anna Davies: Hello and welcome to Making Complaints Count, the podcast from the Parliamentary and Health Service Ombudsman, where we explore the power of complaints and how organisations can use them to learn and to improve.
My name is Anna Davies. I work in the policy team here at PHSO and I'm your host for today's episode. We're going to be discussing patient safety, and we're joined today by our senior lead clinician at PHSO, Dr. Tony Dysart.
Hi, Tony.
Welcome and thanks so much for talking to us today. Now, this isn't your first time on the podcast. I believe you were a guest about four years ago, and during that you told us a bit about your life growing up in Blackburn, your career, where you started out.
For those of us who missed that episode, can you tell us a bit about your early life and your career and particularly, I guess what led you to PHSO?
Tony Dysart: Yes, certainly. So yeah, it's a few years ago since I've had the pleasure of speaking to Rob Behrens, the previous Ombudsman, and we did talk then about what had brought me to PHSO.
I've been in the NHS now for over 30 years. I've worked in various roles within the NHS. So the organisation the NHS is very close to my heart and they've got a lot of commitment and lots of loyalty to the organisation.
I started off as a nurse, so I trained as a general nurse in Blackburn, which is my home town and worked in about ten years in various roles. And throughout that period I was always quite interested in issues around quality. I guess the term patient safety hadn't really been coined back then, but quality pretty much aligned itself to the issues around patient safety.
So I was very interested in that even from that early stage in my nursing career and I think my nursing background gave me a good insight into care, you know, the delivery of kind of basic level really on a ward and later on in life I worked on the intensive care unit.
So that was my background. But then as I progressed through my nursing career, I came to a bit of a turning point of not really knowing what I should do next.
At that point it was very much that you moved into a more managerial position and away from patients, away from the ward. And I didn't necessarily want to do that. I thought of other career opportunities and thought about studying to be a doctor, which is something that had never crossed my mind before.
No one in my family had been to university or certainly no one was a doctor. So it was something that I never thought about.
But then I started to think about it. I had some good role models in my work, some support from certain people in my workplace. Certainly one consultant was very supportive in my application, and so I applied and was successful in getting into Manchester University. I had to do a six year course because at that point there was no fast tracked routes into medicine.
Having almost ten years’ experience as a nurse and a post-registration degree I still had to do an extra year because I didn't have the science background. And I did that. And then through the six years at medical school, I still carried on nursing. It was quite a nice way to earn a little bit of extra money.
I finished the six years. I'd done GP placements and was pretty sure that I was going to be a GP. I was a bit older than my contemporaries, and so that seemed like a sensible option for me. And also it was something I was really interested, I really enjoyed. I really enjoyed the continuity, that idea that you saw people throughout their life really from being kids to seeing them as adults. And so it was kind of a nice career opportunity for me, I think, because it just gave me the things that I thought were really good in the job.
And that's kind of panned out in my career as a GP. I've been a GP since 2007. I worked at various practices, but I'm currently working in a social enterprise, so as a salaried GP. It’s a slightly different kind of model to the traditional but again that suits me and it suits my work-life balance, but also my work balance with my job at PHSO.
What brought me to PHSO was that continued interest in improving quality of care and improving patient care, putting things right where they may have gone wrong. When I saw an advertisement for the job 11 years ago now, I had not really heard of PHSO before. It's an organisation that I was interested in, the values of the organisation seem to link in with my values about improving public services and certainly improving things in the NHS that had gone wrong and things that might not have gone quite right for patients.
So I applied for a job at PHSO. There wasn't a job available for GPs at that point, but six months later the organisation got in touch with me because an opportunity did come up and I applied and got that job. That was in a nutshell what brought me to my current position. I've worked at PHSO for about ten years now. I still do clinical practice, but that's just one day a week now.
Anna: Thanks Tony. It's really helpful to hear where you come from. I always find it really interesting to hear people's background.
As you said, you've combined your work as a GP with your role with us at PHSO where you're assistant director of clinical advice. Can you tell us a bit about how you find that balance? I imagine the two roles inform one another quite a lot. Interested to hear how you find that.
Tony: I think my current role is slightly different from where I started. I started as a clinical advisor providing advice for GP cases - and it absolutely helped my role as a GP. I was given the opportunity, I worked a day a week, to really sit down and look at cases but also look at the current guidance on certain treatments, on certain things that I was doing in regular practice but wasn't able to actually get the time to look at where things were being updated regularly.
So it gave me the opportunity to look at things that kept me up to date in my clinical practice. It also allowed me to take back to my clinical practice things that I was finding at PHSO. There were many times you would see a complaint and it would resonate with things that I've seen in my clinical practice or things that I've heard colleagues talk about.
And so I was able to share the learnings that we were taking from the complaints within the organisation back with colleagues in clinical practice. This helped to improve, not my own practice only, but their practices as well.
That was really a real bonus for the job. And I think it's still a real positive for any of the clinicians who work at PHSO. They have that headspace to give them the opportunity to look at things that are changing because guidelines and standards change very rapidly, and it's often hard to keep up to date with the changing guidelines.
This role gave me the opportunity to do that, to keep up to date. But then I could take the opportunity to take that back to my clinical practice and to share that with my colleagues.
As my role has developed within the organisation, and I moved into more of a management role that has changed. I do less clinical advice. I still get involved in cases and help caseworkers with more of the trickier cases or sometimes with serious cases like potentially avoidable deaths. I'll be involved in those cases with our caseworker looking at advice, looking at how we're using that advice.
I'm still involved, but in a different capacity, I guess, than I was when I was giving advice. But still working here and working clinically helps with this current role because when we talk about this a little later, we do quite a lot of external work with external stakeholders in the patient safety space or within the NHS, and just having that clinical background, but also having the experience and knowledge and the evidence that we get through our complaints about things not going quite right helps me in those conversations that I have externally.
Anna: I think just from our point of view in the policy team as well, because we work closely with you, knowing that you have that kind of frontline experience as well and helping us to think about how things might land is really beneficial from our point of view.
I think it's a great dual role setup. We want to focus today particularly on the topic of patient safety. And I know that's something that you’re really passionate about. So to start us off, I wonder if you could just share how exactly would you define patient safety?
Tony: Fundamentally, I think it is what it says on the tin, really. It's about keeping patients safe in whatever environment they are. So if it's the primary care, the GP practice,are we doing all that we can to make sure that our care is safe?
If it's in the hospital, again, do we know that what we're doing is keeping patients safe?
So fundamentally, it's that.
But I think it's an interesting concept and one that isn't just one-dimensional. It's not a binary kind of concept. It's multifactorial in my view.
And so, for example, you think about where we deliver patient care. Are the facilities, is the environment, is the building safe? Or actually, is the roof falling down, or is there no running hot water?
Things that are just practical things that we often take for granted and think should be present in a healthcare setting might not be. So that kind of raises concerns about patient safety.
Who's delivering the care? Is it a capacity issue? Do we have enough doctors and nurses? I think we feel that that's absolutely something that we need to improve upon.
But then if we don't have the capacity, we don't have the resource in our staff, how can we then guide safe patient care?
And there's this idea of recruitment and retention of staff. So, you know, does the environment help us to attract people to work in the NHS?
Does the environment help us to keep people who are here already within the NHS? Do they want to stay with us?
It’s very interdependent, I think. And what do we do? Do we have the right skill mix to provide care and treatment for all?
Are we asking people who aren't necessarily qualified to do the job to do something that the resource and the constraints maybe put them in a position where they might do that, but they shouldn't because they're not suitably qualified or suitably trained?
But there's a pressure there within the system that's asking them to deliver that care, and this often means people need to take a step back. That’s outside of my remit, I’m not qualified to do that, but that is the strain, I guess, of the stress asking us to still deliver that care.
So this is multifactorial again, and I think that's probably why it's not an easy fix to ensure patient safety is something that we can all sign up to.
Obviously, we all feel passionate about that. We all want patients to be safe, there's no doubt about that. But to achieve that often requires looking at things in a non-binary way.
Anna: As you say, as you framed it, it's pretty wide-ranging and comprises lots of things about how the NHS works.
We know it's a really challenging time for the NHS at the moment.
What do you think are some of the biggest patient safety concerns that you're seeing, and have you got any thoughts particularly on how those can be best overcome?
Tony: So yeah, it's a big question. What are the things that we can do to make sure patients are safe in hospitals, in GP practices?
I think it is a challenge. I think the things I mentioned earlier on about what patient safety is, are things that we need to fix.
Something as basic as just valuing and investing in people, investing in staff to make sure people stay with us.
We've got a massive workforce of really dedicated, highly skilled clinicians who want to go in to work to do a good job, and most of us do that.
We can see that there's a stress and a strain on individuals providing the care.
A really good example at the moment is the idea of providing corridor care, and nurses being recruited to provide corridor care.
For me, 30 years ago as a student nurse and then as a trained nurse, this was something that was just inconceivable.
It wouldn't even be a thing that would have ever happened, and it would never be allowed to happen. And all of a sudden, we've just moved to a place where it's almost accepted as normal.
When you're a nurse or a doctor providing care in a place that's not the right place to provide that care, that can be quite stressful—very stressful—because you can see firsthand that it's not a safe place necessarily for a patient to be managed.
That is quite difficult for a clinician to continue to do, it’s a moral injustice. We weren’t trained to deliver care in a place like that. We were trained to deliver care in an appropriate and safe environment, and that's not necessarily the case on hospital corridors.
That is something we need to look at, how we can fix that, because if we value our staff, we don’t put them in a position where they may feel compromised in delivering the care they were trained to deliver.
So, pretty basic things like that I think we need to start to fix Looking at how we work with patients in terms of how we help people manage their own health in a different way. How do we manage people's expectations? What can they expect from the healthcare system that we can deliver?
It’s interesting, a new government, with the ten-year plan and PHSO has been involved in those initial discussions, it feels like there’s an opportunity for the NHS and the Department of Health and Social Care to really try to fix this.
Investment in patients, listening to the patient's voice, investment in the interface between secondary and primary care, and real investment in how we use digitialisation to improve patient safety. —Those are the three things that will hopefully help us transform not just the health service, but also patient safety.
Anna: All right. Thanks, Tony. That’s a really good overview. I think, as you say, it's a really challenging issue with so many different facets to look at.
We often see culture discussed in relation to the NHS, particularly around media reporting and the risks of poor culture and what that can mean for the safe delivery of care.
Can you say a bit about that issue in terms of the importance you place on culture and any thoughts you have on the changes we’d like to see?
Tony: Yeah, thanks Anna. That’s a really good question. The examples of cultural issues that I’ve seen in the NHS often come from my work with complaints.
Often, complaints highlight cases where things could have gone differently.
We may uphold a complaint, and sometimes the engagement from the NHS shows a defensive response to our findings that something went wrong.
Organisations can be very entrenched in their position, asserting that they didn’t do anything wrong and refusing to accept our findings.
When we uphold a complaint, it's usually because it wasn't resolved at the trust level, which is why the complaint was brought to us.
If we find failings, it’s often at odds with the trust's own investigation and findings. That mismatch is a challenge.
Within our organisation, caseworkers facilitate conversations with trusts to explain our findings and how we reached them.
Unfortunately, we still see many trusts being quite defensive in their response and unwilling to take our views or investigation findings on board.
This resistance stands in the way of learning from complaints, which is at the heart of what we're trying to do.
We’re moving toward encouraging organisations to learn from complaints and change that narrative.
We should talk about complaints in a positive way, if something went wrong and we identified it, what can we do to fix it?
All of our clinicians currently work in the health service, so we provide real-world context.
We understand what it's like to work in a busy medical admissions unit, an emergency department or as a GP in the current climate.
We’re not removed from the realities of the NHS.
That context allows us to engage with trusts and say, “We found these failings in patient care. We understand staffing levels might not have been ideal, but this still happened to this person, and we want to engage with you to improve the system.”
It might be that we can then use our complaints to build a report where we can then come up with various recommendations that we might present to the NHS or to the Department of Health.
And an example of that is our recent Broken Trust report, which looked at several potentially avoidable deaths, and we use them to form a report that came up with several recommendations that we were able to present to the NHS and to the health department to try and see how we can help them to fix the issues that we identified that had led to these potentially avoidable deaths.
So culture is important, and the culture is led from the top of an organisation.
We have positive engagement with trusts. Of course we do. And we've got a very active stakeholder engagement team who foster those positive relationships with trusts. And we see the difference in that response when we have a positive engagement with the trust, we see them welcoming the engagement with us. We see they're willing to take on our findings, and they will put together a plan of how they can respond to our recommendations.
That is a narrative, I think, that we want to see more and more across the health service. We want to be seen as an organisation that's not there to blame. We're not about finding blame in individuals.
What we want to do is look at how we can learn from complaints so that we can make sure that what happened to the person who brought that complaint to us doesn't happen to somebody else. Because we know from our own internal research with complainants that that's what people fundamentally want. They want what happened to them to not happen again to somebody else. And that's what we want to try and help trusts to do.
Anna: Yeah, it's a really important balancing act for us, I think, to call out what we see but also to play that really supportive role and to be forward-looking, as you say, to try to make sure the failings that we see don't happen again.
You've spoken quite a lot there about the role of complaints and how they relate to patient safety.
I wonder if you could just tell us a bit about PHSO’s own NHS Complaint Standards and the role that they play.
Tony: Yes, really good question Anna, thanks for that.
Our Complaint Standards have been a really important piece of work for PHSO, developed largely by our stakeholder engagement team and relevant across other public sector organisations that we investigate.
And really, the main intention of the Complaint Standards is to support organisations to help them provide a much quicker, simpler, and much more streamlined approach to complaint handling.
There is a strong focus within the Standards on really looking at early resolution and empowering and training staff who deal with complaints well.
We want all staff, particularly senior staff (this is relevant to NHS staff that are involved in care and treatment that may be being complained about) to be involved in handling and responding to the complaint.
We know that doing that will help with the learning that we want to see coming from the complaints that we handle.
We also want to see how this is going to be implemented. The Standards ask organisations to let us know how they're going to look at improving services and learning from complaints, really making complaints matter within the NHS.
The Complaint Standards do all of that in terms of helping to support organisations and services in how they approach complaint handling.
But I think the really key thing in that for me is the involvement of clinicians in responding to those complaints.
It allows people to have the opportunity to explain their involvement in the care and treatment that is being complained about, but it also allows lessons to be learned from that.
And I think that's really important.
So, a really crucial piece of work for us over the last few years, which has really helped us to raise the profile of complaints within organisations, raise the profile of complaint handlers within organisations, and help to place this on a firm footing within many organisations.
We want these to be adopted more widely.
We want them to be seen in a more formal way in terms of how every trust should respond to complaints and use the Standards that we've developed to help them do that.
So, yes, that's still a work in progress, and we're still working with organisations to encourage them to use the Standards.
Anna: Thanks for that overview on the Standards, Tony.
And if anyone's listening and is interested to find out more, there's loads of information on our website about NHS Complaint Standards and how you can get involved in training and resources for that.
Tony, I know you've got something new planned in terms of how we communicate about our patient safety work.
Can you say a little bit about your new patient safety blog series?
I believe it's called Prioritising Patient Safety.
How did that come about, and why do you think it's important?
Tony: Well, thanks Anna. So, a plug for the new blog. The first edition has just been published.
The intention of the blog is to share good practice.
I really want to share good practice from the findings of our casework to help colleagues across the NHS use this to improve patient safety.
It's about, for me, trying to share good practice. Good practice in terms of complaint handling, responding to complaints, and demonstrating the learning that comes from them.
I think that learning is always best done from examples of good practice.
Far too often, we see lots of negative stories about the NHS, where things have gone wrong and people haven't done anything to put things right.
We see many examples of trusts working with us to put things right where things have gone wrong.
We know that’s what complainants want. They want things to be put right so that what happened to them may not happen to somebody else in the future.
So, through this blog, I want to share those examples of cases that show good practice.
But also examples where things may have gone wrong, where the trusts did all they could to provide the right care and treatment for that patient.
Through these blogs, I want to reassure complainants who bring their stories and complaints to us that if we find that something went wrong, it is taken seriously.
It might reassure them that once we've done a thorough investigation of their complaint, they will see that whatever happened to their loved one, it was the right thing, and nothing did go wrong with the care and treatment.
Their concerns have been taken seriously. Their voice has been listened to.
We've done a thorough investigation with our professional investigators, and they can be reassured that a robust process has taken place to look at the concerns they've raised.
That’s what I want to try to achieve through this blog.
The first blog focuses on a couple of recent cases, one about maternity care. We hear a lot about issues within maternity care, and this is a really brilliant example of how we've used mediation in the organisation to get a good outcome for the complainant, but also really positive outcomes for the trust in terms of what they did in response to the complaint.
The second case we look at in the blog is related to imaging.
This was a case where a patient had a scan, and the results of the scan were not communicated in full to the GP, which led to a misunderstanding and a condition being missed.
And in this case, we actually found something through our investigation that hadn't been complained about, and we flagged this to the trust.
That was around communication and communication with primary care.
The response from the trust was really positive. It took our findings on board very proactively and developed an action plan to try and remedy that.
It was a really positive response from the trust and these are the sort of stories that we want to share within this blog.
It's going to be quarterly.
The next one is due to come out in May, and we're probably looking at trying to include more of our stories and more of the complaints that we see.
We also want to use the blog to show how we're working with other organisations in the patient safety space, so the Patient Safety Commissioner for example,—just to show that we work together within this space to try and improve patient safety.
Anna: Yeah, it sounds like a really good initiative and part of us landing our message in the right way, to make sure that we get that engagement piece right, which you talked about earlier.
That was a really great discussion, Tony.
Really good to cover lots of different aspects of patient safety and how we work here at PHSO.
So thanks very much for your time and all of your insights.
I think that's all we have time for on this episode of Making Complaints Count.
If you enjoyed this discussion, please do subscribe to the podcast so you don't miss out on future episodes.
And if you'd like to receive Tony's Prioritising Patient Safety blog, please do sign up to our mailing list.
Thanks!