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.

For many people the NHS is like marmite, but whether we love it or hate it, we all end up using it one day, one way or another.

Students are one of the most outspoken, actionable social groups around, so when asking a number of them for their opinions on health services – an outspoken answer was what I got.

It has been an interesting few days hearing student’s thoughts on their health services. Below is a film the students I met, sharing their views – but not everyone was happy to be filmed, and as you’ll read below, there were quite a range of views!

International students, on the whole told me that they thought the NHS was great. When asked why, they mostly replied, ‘because it is free and available to all’. Interesting, a majority of the international students I spoke to also felt open minded to the idea of reforms and privatisation of the NHS.

In comparison, British students were a little more sceptical. But, overall they also agreed that the NHS was a great thing, although they did say that there are improvements to be made – all of which can be done with the help of patient feedback.

Elizabeth Etheridge who is studying French at the University of Sheffield, told me how her Nan had recently been in hospital but she felt the only reason ‘things were being done quickly’ was because her mum ‘knew the right people and could pull a few strings’. However, when speaking of the University health service, she could not speak highly enough, ‘fantastically well run, great service and really pleasant doctors.’

Interestingly, when I asked her about her thoughts on Patient Opinion, she said, ‘I’ve never heard of it but I think it’s a great idea. Change always starts from the bottom.’

One group of students I have been eager to speak to are medical students. Fortunately, I did manage to speak to a few outside the University Information Commons on Wednesday.

Although they didn’t wish to be filmed or be directly quoted, they did speak to me and pass on some really intriguing information. One male student who was in his fourth year of medicine told me of how he was intending to leave the field before he had even started because of ‘all of the bureaucracy’. His course mate told me she would be sticking with it but was sceptical of her future as she said, ‘the NHS isn’t what it used to be’. She also told me how all the medical students she knew were in uproar over the current proposed changes.

Speaking with students about their experiences of health services and their thoughts on the NHS, has made me see that students do care about their services and would like to see change. What is more important I think now, is that a site such as Patient Opinion try and expand its reach to students. Students are the next generation and with their strong political ideologies and desire for change, their work and interaction with PO could be surprisingly influential.

Two weeks ago we held a very lively North of England stakeholder event in Sheffield. And, in the course of what was a very stimulating and enjoyable day, there was one brief exchange between a speaker and a participant which really made me think.

Jane Danforth, involvement manager at Nottinghamshire Healthcare NHS Trust, was speaking about the impact of Patient Opinion in the trust. And Helen Forrester, the manager of B50, one of the trust's adult mental health inpatient wards, talked about how using Patient Opinion had changed the culture of her ward. (Their slides are available.)

One of the participants asked how many stories the trust received through Patient Opinion. Jane pointed to the figure on the slide - "259".

"Oh, so 259 per month?"

"No", said Jane. "259 since we started."

The questioner - and one or two others - looked rather taken aback.

And that was the moment the proverbial light bulb above my head went on. That was exactly the point: it wasn't that Helen had seen significant changes in her ward culture despite there being only 259 stories across the trust. It was that just 259 stories (and many fewer specifically about ward B50) on a public web site had been enough to help her change the culture in important ways. That was all it took.

Of course, everyone (including me) is used to thinking that we need thousands of responses to surveys to tell us anything reliable. But here were worthwhile changes in culture and practice in the wake of a much smaller number of stories.

The point was underlined later in the day, when Steve Eastwood, a commissioner of drug and alcohol services in the North West, talked about how the stories they had received through Patient Opinion were helping them commission better services. (Slides available.)

How many stories? 78.

So there's the question: how many stories is enough? And, of course, we know the answer: enough for what?

It all depends on what you want to achieve. What are your objectives? Why do you want to hear the experiences of patients and carers?

If your objective is to measure (as it so often is in the NHS, where "listening" and "measuring" seem to be used almost interchangeably), and compare those measures between times or places, then yes, you will need a lot of responses to gain the precision and certainty you need.

But if your objective is to change culture, empower patients, prompt staff reflection, or improve services, then on the evidence of Jane, Helen and Steve it seems that a very much smaller number of stories - coupled with an understanding of how to use them - may be more than enough.

At last, I'm starting to understand why we talk about the power of stories.

Good to have some evidence about what we’ve long suspected – that patients know what they’re talking about when it comes to the quality of hospital services. Researchers at Imperial College have shown that hospitals that  rated highly by patients on public feedback sites are indeed better that those that are rated badly by them.

Not surprising but very worthwhile to have the academic evidence. Thanks to everyone at Imperial who did the hard work.

If you had to choose being able to see the name of the person who sent you an email or its title which would you choose? Well the evidence is pretty clear that most of us go for the person not the title. The messenger has always been more important than the message when it comes to getting stuff into our consciousness.

This is important when it comes to writing a good response on Patient Opinion (or any other social media platform). The more personal the responder is, the more feel they feel OK about being visible as the messenger, the easier it will for the reader to hear them. So here is a great response from Epsom and St Helier

We're glad your husband's injury wasn't serious and we'll pass your kind comments on to the team, including - importantly - the 'niggle' about having to give the full medical history twice. As you'd expect, there are procedures in place for staff to check and double-check some elements of a patient's medical history, but you shouldn't need to repeat the full history in such a short space of time.

It’s good because the writer has obviously read and appreciated the original story. And it’s written in a friendly style that makes you think there is someone pretty human at the back of it.

But it could be even better. For a start the author is simply ‘Epsom and St Helier University Hospitals’ which is about as impersonal is it gets. It would be great to know who it was who was saying this stuff – not just their job title but preferably their full name. And it would be even better if we could see what they looked like so its great when people add their photographs to responses just as Jane Danforth at Nottinghamshire Healthcare Trust does .  (it’s really easy for Patient Opinion subscribers  to upload a photo to personalise their responses).

And the worst kind of response that we see? Well that’s easy - it’s the cut and paste job from someone who doesn't appear to have even read the original posting and doesn’t give any details of themselves except their job title. Even worse is where every response from the organisation is identical so that anyone scrolling through a few can immediately see that the worst kind of ‘tick boxing’ is going on.

People are pretty savvy about user feedback nowadays. They are used to reading TripAdvisor and Amazon reviews. They know that some reviews will be from when the organisation – or maybe the author - was having a bad day. They read a few and come to their judgement. But the responses – well now that's real data direct from the horses mouth itself. So judgements may be quicker and harsher -  ‘Look at this - a cut and paste job for this posting that says terrible stuff happened? How heartless can these guys be?’

 On this reading the response to a posting – especially negative ones - may be more important in shaping the public’s perception of a trust than the critical story itself.