"The NHS will last as long as there are folk left with the faith to fight for it"
Aneurin Bevan

Tuesday, 15 February 2011


Today the Parliamentary and Health Service Ombudsman released a report of care of the elderly in the NHS. It has got a lot of press, and the BBC on their normally sensible Radio 4 news bulletins report that these highlight the need for "a complete overhaul of NHS". So let's have a look at the figures.

The report says:

"The complaints were made about NHS Trusts across England, and two GP practices"
So it is not just hospitals, it is GPs too. Remember this when you read articles based on this report, this BBC report, for example, does not mention GPs at all.

"the results of investigations concluded by my Office in 2009 and 2010"
So it is over one year.
"Of nearly 9,000 properly made complaints to my Office about the NHS in the last year, 18 per cent were about the care of older people. We accepted 226 cases for investigation, more than twice as many as for all other age groups put together. In a further 51 cases we resolved complaints directly without the need for a full investigation."

So out of 9000 cases referred to the Ombudsman 1620 (18%) were about the elderly yet of these, only 14% (226) did they feel that they had to investigate. In any 3% of complaints the Ombudsman recognised that there was an issue, but resolved it without investigation. This means that the other 83% (1343) were rejected for some reason or other, why? Would this suggest that 83% of complaints escalated to the Ombudsman should not have been? The Ombudsman says that it performs the following tests and if they fail the complaint is "declined for investigation":

Preliminary assessment

  • Is the complaint within the Ombudsman’s remit?
  • Has the complaint been properly made to the Ombudsman in writing (as required by legislation)?
  • Has the complainant completed the local complaints procedure?
Further assessment

  • Is there some indication of maladministration or failure in service?
  • Is there some evidence of injustice or hardship arising?
  • Is there a likelihood of a worthwhile outcome to an investigation?

It appears that the 1383 complaints that were not investigates were declined for one of these reasons. The Ombudsman gives data from 2009/10 that suggests that 29% of complaints are "not properly made", 29% were "premature" (ie have not complained locally, or has not waited for the local response), 27% were "discretionary" (for example the Ombudsman thinks the NHS has acted correctly or that the complainant was offered reasonable redress) and 9% were "withdrawn by the complainant". The Ombudsman suggests that just 3.6% of the complaints were within their remit and suitable for investigation or intervention.

This raises the question of why the complainant decided to escalate the complaint to the Ombudsman.

The Hospital Episode Statistics online website says that in 2009/10 there were 14,537,712 Finished Admission Episodes. So out of 14m episodes, the Ombudsman gets 226 complaints upon which the BBC say that we must have a "complete overhaul of the NHS". Perspective?

OK, so the Ombudsman is the last chance of complaint. If there is an issue with NHS care and a complaint is not handled locally to the satisfaction of the person making the complaint, they can take the complaint to the Ombudsman. This would suggest that the 226 is a "tip of the iceberg" that there are more complaints, but they have been resolved locally. The NHS Information Centre collate figures about complaints. NHSIC says that in 2009/10 there were 101,077 written complaints from NHS Trusts (ie hospitals), there were 48,271 written complaints about General Practice (including Dental).

Of the NHS Trusts written complaints, 1,168 were about "Elderly (geriatric) services", (Table 3). However, 7,667 were for A&E Services and 31,046 were for Inpatient Services, and so a proportion of these will be from elderly people. Some complaints will be about administration, appointments, food, cleaning etc, these are not the sorts of complaints that the Ombudsman is referring to so we need to separate them. Table 5 lists the reason for the complaint about NHS Trusts and 42,727 were for "All aspects of clinical treatment". Similarly Table 9, for General Practice, lists that 16,300 complaints were Clinical complaints (a proportion of which will be about care of the elderly). The problem is that these are very wide criteria. We do not know the severity of the complaint. We do know (from Table 1) that in 2008/09, 1935 (out of 89,139, 2.1%) complaints were not resolved, this would suggest that in the vast majority of cases the complainant was satisfied with the result.

There is also the "mustn't grumble" argument, that is, most people in this country do not complain. It is very difficult to get estimates about the level of this. There are some suggestions from American customer satisfaction ("for large ticket items ... 5-10% of complainers escalating to local management or corporate" suggesting that, at worst, the NHS complaints figures twenty times less than they should be), but these are for consumer goods (eg cars) and not about life-and-death issues, which one would expect the complainant would consider much more important. The NHSIC does suggest that complaints are rising slowly: complaints in 2009/10 for "All aspects of clinical treatment" increased by 0.8% from the figures of 2008/09. Whether this is due to patients being more willing to complain, or to a change in the quality of care. The Ombudsman does say that
"In April 2009, a new integrated system for handling complaints within the NHS and adult social carewas launched."

that is, we cannot make comparisons with previous years because they used a different system.

Having gone through all these figures I conclude:
  • There are roughly half as many complaints for GPs as for hospitals, whereas GPs have 51% of patient contacts and hospitals have 18% of patient contacts.
  • 226 cases out of 14.5 million episodes every year is very small, it is statistically insignificant
  • 98% of NHS complaints are resolved locally
  • 96% of the complaints received by the Ombudsman should not have been escalated to them
  • There is no accurate information about how many people do not complain when they should
  • There is little information about the severity of complaints in the NHSIC reports
The danger of this Ombudsman report is that people will extrapolate, and the BBC has certainly done this painting a picture of the NHS that is far worse than it is in reality. The Ombudsman even suggests that people are complaining when they shouldn't by rejecting 96% of the complaints they received.

People read this report from the Ombudsman and think "this could be my mother" rather than the actual case which is that these are truly exceptional cases. Until we have real, accurate studies, we cannot use this report to make conclusions like the NHS needs a "complete overhaul".


  1. Good work.

    Also worth noting that the universally poor reporting of this story has failed to grasp the very simple point that the ten cases collated together were collated because they were severe and had recurring themes.

    As someone who has to know how to intepret evidence, this immediately rang alarm bells for me. That is not to say that these cases are not horrific. They are. These are things that should never happen. However the idea that they are representative is more than a little ridiculous. 10 cases from the 226 investigated from the millions of patient episodes.

    It does feel like there is a conspiracy of silence about the NHS - in terms of the positives. And a massive organised movement to exaggerate the negatives.


  2. Perhaps now that we can offer more technologically and chemically sound care, we are deliberately balancing the help given, with the rotten treatment of large numbers of people, so that the balance of life and death remains undisturbed?

    If so, shouldn't someone tell us all?

    Then we could choose to die in our own good time, with no treatment, nor interference, nor mistreatment.

    Rolling into the gutter on a very narrow trunk road, would produce better treatment than some people are currently receiving in this benighted country.. and it would be quicker and less distressing.... and more honest.

  3. I suspect a single complaint may be enough to show the inadequacy of, in this case, a public service. As is pointed out the Ombudsman is the last port of call, after local complaints procedures have failed. Hence a single case can be sufficient to show an endemic weakness in the procedures.

  4. @michaeldubitante

    No, how can one case say anything meaningful about the entire system? We are all different, you know.