Dorothy Armstrong's thoughts on apology generated a real buzz at our recent Glasgow event.  We're delighted that she's agreed to write this blog.

‘We are all human – we can all make mistakes.’

This quote is from a man whose son died. He brought his complaint to the Ombudsman, he said, to ensure that he was listened to, lessons were learned and to receive an apology.

In my role as Professional Adviser to the Scottish Public Services Ombudsman (SPSO), I hear first hand from patients, relatives and carers about negative experiences of healthcare. The most common emotion expressed is of vulnerability, helplessness and humiliation.

When I read the stories shared on Patient Opinion, the themes are very similar to our experience at the SPSO. We see poor communication, behaviour and attitude as the most significant factors in the complaints we receive. In many cases, people feel that they have not been listened to. They feel patronised and powerless. If only staff involved in a mistake or wrong doing, had been honest and open and provided an apology at the time, they would not have continued to complain.

‘An apology is the superglue of life. It can repair just about anything.’ 

New South Wales Ombudsman, (2009).

As children, we are programmed to say sorry for our mistakes, but, in our working lives as adults, saying sorry is a real challenge. When used well in the NHS setting, an apology can be both very powerful for the patient and empowering for staff.

Sorry made easy - The 3 R’s

You can use this tool at work and at home. I’ve found it particularly effective with my teenage children – take a deep breath and try it too!

Regret

It is important to recognise that something has gone wrong by acknowledging the wrong doing, even if you are not at fault. Saying sorry, in a meaningful and sincere manner, is crucial. Often this first step is enough to de-escalate the situation.

Reason

Even if you feel criticised and hurt, it’s really important to provide a reason (if there is one) for the mistake, but to avoid being defensive. Make sure you are clear that the wrong doing was not intentional or personal, so try to keep to the facts. It can help to put yourself in the complainant’s shoes and step back from the situation. Stay objective.

Remedy

Try to resolve the mistake there and then, if you can. Ask the complainant what they would like to happen and take responsibility to investigate, if required, and to provide feedback to them as soon as is practicable. Encourage colleagues to be proactive too.

Dr Dorothy Armstrong is Professional Adviser to the Scottish Public Services Ombudsman.

The SPSO’s Guidance on Apology sets out what an apology is and what you can do to make it meaningful.

During my regular mid week date with One Born Every Minute last week, there was a moment that got me thinking about what part love plays in health care.

Shortly after giving birth to a baby boy, one of the new mums seemed flustered when the attending midwife reached over and embraced her with a kiss on the cheek, telling her that she was proud of her. It was intimate, warm and loving and not something I've seen happen during any other labour featured on the show. It’s certainly not something you'd expect from other health care professionals, a kiss and a cuddle from the surgeon who'd just removed your kidney stones would be fairly unusual.

This may not fit with everyone's definition of love, but in my interpretation it is without doubt a loving and affectionate gesture and behaviour that falls outside of the standard role of the midwife. I’m sure it’s more a reflection of the midwives personality than the circumstances, but it got me thinking about the part that love has to play in health care.

People often talk about their professional personas and how much they differ from the personalities they express outside of work. Acting 'professionally' has connotations of suppressing the softer side of your character and portraying a more corporate, task focussed demeanour. But in a world where teachers are warned that hugging a crying child who has fallen in the play ground is acting outside of 'professional boundaries', are we forgetting how important it is to be human at work?

In the report we released this time last year, it couldn't have been more conclusive that the attitudes of staff and a lack of care and compassion were the most frequent causes for complaint or concern for patients of our health service. The same is true for compliments; what people are most thankful for when receiving health care is feeling like the staff cared about them.

So people certainly notice and appreciate kindness, affection and loving behaviour but is there any evidence to suggest that this has any impact on health outcomes?

The King's Fund Point of Care programme(2009) noted that:

'Research evidence suggests that compassion affects the effectiveness of treatment. For example, patients who are treated by a compassionate caregiver tend to share more information about their symptoms and concerns, which in turn yields more accurate understanding and diagnoses (Epstein et al, 2005).

'In addition, since anxiety and fear delay healing (Cole-King and Harding, 2001), and compassionate behaviour reduces patient anxiety (Gilbert and Procter, 2006), it seems likely that compassionate care can have positive effects on patients' rate of recovery and ability to heal.'

It's clear that experiencing compassionate care, and in this context love, from health care staff matters enormously to patients, both in shaping their impression of health services and in their recovery.

For staff, showing compassion to people at their most unwell or vulnerable is often at the heart of their motivation for joining the NHS. It's my impression from reading the stories we receive that the majority of staff are striving to show patients the affection and kindness that makes all the difference, but that staffing issues sometimes get in the way. So how can we help to ensure staff always feel comfortable and capable of delivering this level of care?

The King's fund paper goes on to suggest that:

'In the practical circumstances in which staff caring for patients feel under pressure, and experience themselves as having very little time, it is often difficult to do just that one thing for the patient that makes her or him feel cared for. Enabling staff to feel and be compassionate towards patients in their care, at all times, requires action on multiple levels.

One of the most powerful resources that healthcare professionals consistently cite is patients' stories.

Every day here at Patient Opinion we continue to make available stories from patients that detail how it feels when compassion is lacking and what truly compassionate care looks like. I'm reminded of a beautiful quote from a story we received some time ago which recorded a moment between a member of care staff and the author's nan:

'One day I heard one of the staff, Tracy, talking to my nan as they were bathing her. Tracy was lovely with her and so caring and sensitive - I can't imagine it's easy to bathe a grown person. Tears came to my eyes, I was touched by the care and respect demonstrated. No one knew I was close to the bathroom door and could overhear what was being said, this wasn't a demonstration put on for my benefit.'

Thinking back to the midwife on One Born Every Minute, her attitude, warmth and willingness to give a little bit of herself makes me hopeful. The interaction between her and the new mum on the bed depicted everything that I know to be the right way to treat a person and I'm reassured to see that either in line with or in spite of policy, treating a patient with love prevails.

We are getting ready for the big switch over to our new site here at Patient Opinion HQ. Want to see a screenshot of what our front page look like? Well here it is...

 

Watch.UsNow is a great video about how the web lets people take things into their own hands and just get on organise stuff. There’s Clay Shirky, Charlie Leadbetter, William Heath, Lee Bryant plus mums from netmums and many others all talking very good sense. Well worth a quick watch (and thanks to Jonty  at Demos's Progressive Conservatism project for bringing it to attention).  

But looking at it I realised that Patient Opinion doesn’t quite fit. And the reason is that we don’t ‘do community’ in the same way that netmums or Facebook or Couch Surfers do it. For them the community is the whole point – they are about giving people a place where they can do what they want in ways that they are passionate about. This is what Web 2.0 has been all about up to now and it’s releasing a wave of mutual help and support that will, for sure, change the world in just the ways that the Watch.UsNow video explains. 

You can easily imagine similar communities building around Patient Opinion with people discussing services for endometriosis or hospitals  in Wolverhampton. And of course we’ve talked long and hard about whether Patient Opinion should do this. Our worry is that such groups would quickly turn into moaning arenas or gravitate to the ‘let’s go beat them up’ approach. But perhaps we’re doing everyone a disservice by such assumptions and we should trust people more and go test it out. 

But there is also another reason why we don’t quite fit into the standard web 2.0 model and that’s because we’re focused on changing services whereas most of the standard bearers for  ‘web 2.0 is a revolution’ are focused (rightly) on their members interests. So netmums is about mums not primarily about services for mums. And Couch Surfers is about finding congenial  people to stay with for free in new cities, not about improving travel services.  

Patient Opinion together with sites like MySociety are doing something different – we’re trying to engage the service, to get busy staff to act in new ways. This is very different from setting up a community of users ‘outside’ the system and who are all too easily perceived by staff as being critical. So it is possible that vibrant communities of users might indeed make our  core task – improving services – harder not easier. 

This isn’t an either/or of course – sites that focus on mutual support or benefit and sites that want to change the system are both really worthwhile. But Patient Opinion’s task of changing the system by engaging many thousands of staff as well as  tens of thousands of users, is distinct for two key reasons. Firstly it creates a different sort of public value to groups focused on mutual support. Second if we are successful, it opens up different revenue streams beyond the old stalwart of advertising that everyone and his dog is trying to make a living from on the net. After all if we could help patients and carers initiate 10,000 service improvements a year this will create significant value for the NHS. If we could find ways to extract this value and feed it back into more patient-initiated change - now that would be exciting. Then there really would be money in them there pills!

Sitting on a working party the talk was all of governance, protocols, making sure that ‘the lessons are learned’. Life was proceeding as it has in the NHS for several decades on the general assumption that if control is good, more control is better.

This might be called the One Last Heave model of service improvement: having implemented  the 137 recommendations made by Lord Laming following Victoria Climbie’s death, and being faced by the appalling case of Child P, the system homes in relentlessly on ‘further lessons that must be learnt’, another inquiry, yet more checks and controls. One Last Heave will get us to Nirvana where bad things can’t happen. 

Such is life in an environment where systems are tightly coupled. And sitting there not doing full justice to my working party, I realised that’s been the major characteristic of the last 20 years of my life as a clinician in the NHS. We’ve been busy using the power of newly digitised practice to build ever more tightly coupled systems. More and more is governed, linked, joined up, defined, evidence-based. Variation has been driven out, and following agreed practice is valued over the exercise of judgement and discretion. 

The dream behind building tightly coupled systems is that they will lead to control, equity and cost-effectiveness. Which may be so in the short run but in the longer term tight coupling leads to rigidity, risk aversion and declining innovation. Tightly coupled systems deliver decreasing returns – every additional goal, policy, organisation, partner or issue leads to less return.  There are two reasons for this. Firstly because variation is seen as the enemy: noise, randomness, error and failure are all things to be engineered out where as in fact they are often needed to make the system work. And are an important source of insight and innovation. Second the coordination costs of tightly coupled systems rise non-linearly as the number of things to be coupled increases.  So ‘joined up government’ quickly becomes toxic.   

And now we are faced with an economic situation that gets ever more uncertain. It is unlikely that the ‘one more heave’ philosophy of tightly coupled systems will work in a severe recession. Being risk averse, relying on protocols, KPI’s and micro-management will fail in the newly austere state because such approaches deliberately exclude the variation from which the new solutions will emerge.

The answer to all this? Look for systems that have increasing returns. Google, Wikipedia, e-Bay, the web itself – all deliver increasing returns. The more people use, edit and review Wikipedia the better it becomes. Such systems are almost always loosely coupled. No body is forced to use Google, no one accredits e-Bay buyers, and there was no government roll out plan to teach teenagers to use SMS text messaging. Is it possible to build increasing return systems that help improve health? Don’t know yet, but if it is I know they will look more like the net than NICE, more like Wikipedia than Whitehall.