There has been only a couple of articles on our blog since the last newsletter – one was a review of Christine Hogg’s up to the minute history of public involvement in the NHS. I have bought my copy and would urge you to do the same if you are trying to make sense of the structures and techniques you need to do public involvement better and to understand why you are finding achievement so elusive. I read it to get some thoughts going for a training course for GP practices and their staff on understanding and engaging with customers.
Citizen vs Consumer
The point that struck home for me with my background working for Which? and other consumer bodies is the one where Christine argues that health is a more complex business than the consumerist model can accommodate. The example she chooses to make her point is that of mental health services users whose rights as citizens are more important to them than their role as a consumer of health services. Their choices are few and in some cases, they have to rely on their rights as citizens to exit the system or refuse treatment. She goes on to see a situation where expert patients and others who care for themselves ‘break out’ (in Christine’s words) out of the role of patient and become providers. She sees that service that is truly user-centred is the one where the users work with equal status with professionals.
Health is Different
This is a radical and ambitious view that goes well beyond the conventional consumer model of market influence where user and producer interract but remain separate. Christine’s view takes into account the fact that health is different from other things that people want. Jonathan Miller has written “Of all the objects in the world, the human body has a peculiar status: it is not only possessed by the person who has it, it also possesses and constitutes him. Our body is quite different from all the other things we claim as our own. We can lose money, books and even houses and still remain recognisably ourselves, but it is hard to give any intelligible sense to the idea of a disembodied person. Although we speak of our bodies as premises that we live in, it is a special form of tenancy; our body is where we can always be contacted ( Miller J The body in question Random House 1978 quoted in The World Health Report 2000 Health Systems: Improving Performance so ably edited by our Associate Angela Haden ) So being a consumer of health is different from being a user of a PlayStation®. We do not live inside something made by Sony – not yet anyway.
Better Customer Care
The reason for this revisiting of this debate is to explore my idea that the tensions embodied in the arguments about differences between being a user of a consumer good or service and being a consumer of health impact on complaint handling. A couple of the many things we have failed to blog about recently are the latest initiatives on complaint handling from the Department of Health and the Health and Public Services Ombudsman. The Better Guide to Customer Care represents a great leap forward in its simplicity, clarity and freedom from an obsession with process. There is an explicit overlap with the work of Ombudsmen and the six principles of good complaint handling. One of the unacknowledged things that make complaint handling – never easy – more difficult in the NHS is the difference between the complaint about health-related service received and the one about your electronic gizmo. As we have written before, emotion is the driver and the emotion involved in complaining about the place ‘where we can always be contacted’ is of a different order and magnitude than a complaint about an object external to us. The only example in the world of consumer goods and services when the emotional temperature came close to rising into the health temperature range in my complaint consultancy experience, was men complaining about repeated quality failures in their Range Rovers. The letters and calls made Jeremy Clarkson look like the soul of reasonableness.
While the Treasury’s advice about financial redress is worth reading, the question of money while it can no doubt help resolution, is not the clincher – recognition of how close to home any complaint about our health and the body we live in remains the best route to resolution.
Owning and Using Data
And if our body is our own, we argue in Andrew’s blog on Real Patient and Public Power, so is the data that we give the NHS by filling in questionnaires and being available to be measured and counted is data which patients and their families should be able to understand and use in any initiative to improve health and social care services. We would like to see the definition of expert patient extended to include an expertise in how user data can be put to work and create action for improvement and change.
We are reminded how open to interpretation, questions on a checklist can be in one of the final publications of the Healthcare Commission as it morphs into the CQC – Listening, Learning, Working Together? The question mark indicates uncertainty about some of the findings – what the Healthcare Commission calls ‘mixed evidence’ about the standards of patient and public engagement. 98% of healthcare organisations claimed in their annual health check returns that they met core standard 17 which is the one about taking the views of patients and others into account when designing services. The snag is that there were a lot of negative comments from patient forums, voluntary organisations as well as the relevant local government committees (OSCs) that trusts were failing to seek the views of patients and public. Mixed not to say contradictory evidence indeed. Which is the correct view?
Management – Delusions, Comfort and Safety
Christine Hogg tells us that it is a mistake to ‘believe that user involvement can be managed and voices captured’. She is worried that participation ‘seems to be a management tool to be disposed of when it does not produce the goods’. Actually it is not being ‘disposed of’ that is the problem and of course the activity has to be managed – it costs money and involves resources so how else would organisations behave? No – what we have to be wary of is delusion. And the delusion amongst public and patient involvement managers is that the performance of the function – attended 10 meetings, produced 4 newsletters and ran a stand at the local fair or whatever and printed 5000 leaflets on topic X – is enough to tick the box. Delusion of this sort is after all a much more comfortable and safer place for managers to be than copping the comeback from relaying rude and disruptive comments from outside, uncensored and un-deodorised – a terrible assault on the sensitivities of one’s superiors whose lives are difficult enough without this vulgar din.
Thank you and farewell Health Commission – we knew you when you were still CHAI. How short institutional life is in the NHS, we Partners muse.