A personal view by David Czarnetzki

10th July 2025

Since its release on 3rd July 2025, I have read through the 10-year plan in its entirety. The document consists of 143 pages, supplemented by 272 endnotes which annotate the references. Aspirations run high throughout the document, but I have concentrated on the area of most concern to readers of PHSO The True Story – the complaints system and the role of the Ombudsman.

The first reference I came across was on page 13, which read:

“Reform complaints process and improve response times to patient safety incidents and complaints. Review how to improve patients’ experience of clinical negligence claims”

Page 77 of the document tells us,

“There will be a failure regime to bring poor performance up to standard”. 

On the very next page, it is declared that the existing seven NHS regions are to continue with responsibility for performance management and oversight of providers.

The seven regions are:

  • East of England
  • London.
  • Midlands.
  • North East and Yorkshire.
  • North West.
  • South East.
  • South West.

It is therefore clear that the document accepts these regions already have responsibility for performance management and oversight. We can but hope these responsibilities are ‘beefed up’. It is my view that they should also have responsibility for independent investigation of complaints made by patients and whistleblowers, with serious complaints investigated by a team from a different region. Unlike PHSO, operating out of its paper-sift silos in Manchester and London, the regions are close enough to the action to have real impact provided they are given the right powers and freedom to properly and independently investigate. This would have an added bonus of freeing staff within NHS settings from carrying out internal investigations, leaving them to manage rather than firefight and thus reducing the opportunity for the ‘cover up’ culture identified in the short extract from page 85 of the report below

A whole chapter of the report is given over to the title “A new transparency of quality of care”. The chapter is worth reading in its entirety.

“The Mid-Staffordshire scandal is, tragically, far from an isolated incident. The NHS’ history is blighted by examples of systematic and avoidable harm: the needless deaths of children undergoing heart surgery at the

Bristol Royal Infirmary (1980s to 1990s); serious failings in maternity care at Furness General Hospital (2004 to 2013); Shrewsbury and Telford (2009 to 2019), East Kent Hospitals University NHS Trust (2009 to 2020) and

Nottingham hospitals (2022 onwards); neglect and poor care of patients under the care of mental health services, including Essex inpatient services (2000-23), Tees, Esk and Wear Valleys NHS Foundation Trust (from2017), the events leading to the tragic killings of 3 people in Nottingham (2023); and the Infected Blood Scandal (1970s to 1990. The failures that underpin each are consistent: incompetent leadership, toxic culture, rampant blame, workplace bullying, and a failure to learn from mistakes. There is also a fundamental lack of transparency, which means low quality or neglectful care does not come to light quickly; that the response is not fast or decisive enough; and that patient, staff and public attempts to sound the alarm go unheard. It is time for the NHS to learn.

We will usher in a new era of transparency,”

This is, then, official recognition of the problem and the government’s ambition for the brave new world the NHS will move into. The penultimate sentence focuses on learning and ignores accountability. Just four pages further into the report, on page 89, we get an inkling of how this is to be done – On the NHS App!

“Direct patient feedback will be core to our new approach to quality. Patient feedback is already collected by NHS organisations, but it is too often very high-level and pales in comparison to the granular, highly actionable feedback collected in other service industries. As outlined in Chapter 3, the App will give patients the option to leave feedback on the care they receive. This will be viewable by others, nationally collated and translated as actionable recommendations to providers and clinicians to support continuous improvement.

The NHS complaints procedure is far from where it needs to be. In our engagement, patients and carers expressed confusion about where and how to complain and told us about their struggle to get responses to their concerns. The number of formal complaints referred to the ombudsman for healthcare is nearly 7 times higher than for railways. This cannot be right.”

It is something of an understatement to say the NHS complaints procedure is far from where it needs to be. It is broken and ineffective. What I found particularly curious is that the report makes a comparison between complaints to the Health Ombudsman and those to the Railways Ombudsman. Why him? Why not make comparisons with Ombudsmen in other parts of the United Kingdom, dealing with health complaints or even international comparisons? The comparison, in endnotes 193 and 194 of the report, makes no sense to me.

Towards the conclusion of the document is this little snippet on page 132

“We have asked David Lock KC to provide expert advice on the rising legal costs of clinical negligence claims, ahead of a review by the Department of Health and Social Care (DHSC) in the autumn.”

From my perspective, it is a given that too much clinical negligence arises from a variety of factors as identified in the inquiries mentioned on page 85. However, it is right that those harmed by clinical negligence are properly compensated. At the moment, we have no information on the start date of this particular DHSC review, what its terms of reference will be or, indeed, what the real objective of the review is. 

In conclusion

The Public Administration and Constitutional Affairs Committee (PACAC) last subjected the Ombudsman to scrutiny over his 2022/23 report and PACAC’s findings were published on 27th February 2024. PACAC’s recommendation, rejected by the then Conservative Government, is reproduced below.

“The PHSO reiterated its support for legislative reforms. Previous proposals have included consolidating ombudsmen schemes into a single Public Service Ombudsman and changes to the powers of the Ombudsman. The Government has rejected reform of the Ombudsmen structure, arguing that the issue is not an urgent issue. We disagree, thinking that legislative reform has been neglected for too long and further delay is no longer tenable. We recommend that the Government should reconsider its position, consult with a wide range of stakeholders, and set out its plans ahead of the general election. All political parties should include in their manifestos a commitment to early legislation in the next Parliament to enact legislative reform.”

Remember, this was a cross-party select committee report. Since the July 2024 election, most of the MPs who signed up to it are no longer in Parliament. However, there is one notable exception.

Karyn Smyth MP was a member of the committee which produced the report and is now Minister of State for Health in the current government. Perhaps she would now like to use her position in government and take the lead on removing this failing Ombudsman service from its responsibility to investigate issues relating to the Nation’s health.