MAC’s Eight New Laws of LINks – and an acknowledgement to Dr Einstein

Albert Einstein defined insanity as doing the same thing over and over again and expecting different results.  It’s a curse the new Coalition Government must avoid when it gets around to considering its plans for Healthwatch in England and what it intends doing with Local Involvement Networks (LINks).  Scotland, Wales and NI should be free within their devolved administrations to retain, improve or amend their own arrangements for user engagement, complaints and redress processes.  There is much to learn from each other about how to do engagement and participation better across public services.

MAC takes the opportunity in advance of the Health White Paper due in early July to contribute its ideas to the developmental process.  We have ideas about what LINks should do in future and about their relationship with Healthwatch and its functions.  Healthwatch funding should be entirely separate from LINk funding and the latter must not be raised or top sliced to create Healthwatch in England.

Some details are emerging about what the Government’s model for Healthwatch for England might be and what relationship it might have with Local Involvement Networks (LINks), now into the final year of their three year contract.  We have no doubt that LINks must survive and be developed to take on a more robust role across health and social care.

Now read on.

1. Integrated statutory framework.  Healthwatch England and LINks must operate within an integrated statutory framework bringing together involvement of service users, carers and the public and also embodying their rights including complaints and redress.  We are not talking about tinkering with the current fractured system in which most people don’t know how to have their views listened to or how to make a complaint about health or social care their receive.

2. Accountable to Local Authority. We wonder what  the proposed Healthwatch role about providing “leadership to LINks” might mean?   It should not be code for performance management.  Each LINk should be accountable to its sponsoring Local Authority according to a national contract and with sufficient funding to carry out its role in the local area.  Possibly it means Healthwatch taking on the function of the short-lived National Centre for Involvement?  That would be a positive move, by promoting and sharing good practice.

3. Brands  spanning health and care. Healthwatch needs renaming because it is too narrow and sounds like a regulator. “Carewatch England”, though not ideal, would be our choice, because care in its broadest sense encompasses both what the NHS does and what the social care system does. What matters more than a name is this -  the body must not take a medicalised approach: people using health and care services are about much more than being patients (maternity services users for example).  Members of the public have an equal claim to have their voice heard: patient experience is one thing; public involvement quite another and LINk can and must do more of both.

4. Statutory health and care remit.  LINks already have a statutory health and social care remit – that is right and it must be strengthened.  Above all, LINks must not be pruned back to a health-only remit or even one that focuses only on the NHS.  In a pluralistic economy, LINks must continue to be able to enter and view any and all facilities and services being used by publicly funded users – they must go where users go.  Their relationship with the inspecting bodies, particularly the CQC, also needs revisiting and smoothing out.  LINks should have synergistic relationships, not competitive or duplicative.  Enter and view should be sufficient powers for LINk – they are not meant to duplicate what the inspectorate(s) do but can already respond to concerns raised by members and from the public by making visits including unannounced ones.  There needs to be good practice enter and view models that all LINks can follow, including what happens to issues which LINks uncover and then refer to their Council’s OSC for action.  Evidence about this is lacking and Healthwatch should have a remit to uncover, assess and publicise what is happening and raise LINk standards.

5. LINks and OSCs.  LINk in many areas has a good working relationship with the local authority’s overview and scrutiny committees.  In many areas health and social care are combining into a single Adult Care and Health scrutiny body.  It should be taken as read that the LINk as a statutory body will have rights to receive all papers, attend all relevant meetings and speak at health and social care OSC meetings in addition to their existing rights to refer matters to the OSC.  But that needs to be spelled out in guidance or it may not happen in many places.

6. Bring coherence to complaints across health and care.   Since April 2009 there has been an integrated and (at least in theory) simplified complaints system operating across English health and social care.  But this is one of the best kept secrets we know of. Many NHS bodies are complacent about complaints handling and consistently miss targets for providing responses and resolving issues. The complaints and redress system must be made more coherent. But this does not mean that LINks should become involved with complaints handling or advocacy services, though of course they can and should signpost people to where they can get such help.  Complaints handling can easily turn into confrontation.  Healthwatch England’s proposed role to “investigate and support complaints” needs very careful elaboration. We do not want the old intermediate tier of complaint handling undertaken by the old Healthcare Commission revived.   Users got a poor service and the handlers drowned in the paperwork and procedures.

The role of the Ombudsman on the one hand and local resolution on the other should not be weakened. But we believe much could be done to publicise the system and to facilitate people to find their way through it.  Healthwatch could be the independent body which commissions and manages complaints advocacy services (ICAS) for consumers.  The local or regional presence for Healthwatch has not yet been specified; perhaps the White Paper in July will throw light on this.  We note that Mr Lansley himself, unlike Earl Howe, didn‘t mention complaints in connection with Healthwatch in his Bromley by Bow presentation, but the issue cannot be ducked.  The current complaints processes are disjointed, difficult to access and not meeting the needs of service users or anyone else.

7. LINks should be host free.  LINk host bodies are coming to the end of their three year contracts.  This model should not be renewed.  The new model for LINk should be “host-free” because introducing intermediary bodies simply obfuscates governance and accountability.  LINks are statutory bodies and should be established as budget holders and employers in their own right, accountable to their local authorities for their performance against national standards and compliance with a national contract.  This means each LINk should hire and manage its own officers and get the service they need to carry out their roles, something most of them are not able to do at the moment because the Host stands in the way. It also means that LINks will need premises, something that should be negotiated with the sponsoring local authority.

8. Relationships between LINks and Healthwatch. The boundary between LINk and the local presence of Healthwatch will need careful thought so that unintended consequences do not result. The relationship should be additive and synergistic, not competitive. Otherwise consumers and inspectors will be confused.  LINk as a membership body is primarily about involvement, engagement, listening and communicating views as well as being eyes and ears about quality of services and user experiences.  Their relationship to the OSC is an essential one to develop.  This is quite different from what Healthwatch might do as a non-membership body, though clearly there is scope for collaboration.   Equally there is scope for developing relationships between LINk and Foundation Trust Members and Governors and between Healthwatch and Monitor’s expanded role as well as the CQC as the principal inspectorate for health and care.  A matrix of consumer focused activity would be a positive outcome.

Doing these things will avoid Einstein’s curse.  We will get different – and better – results from doing things differently.  LINks and Healthwatch have the potential to develop into a synergistic relationship but not one where one controls the other. For LINks, the accountability buck should stop with the sponsoring local authority.   We hope the Coalition Government has the vision to enable that to happen.

Some background for policy wonks

During the 3rd June debate on the Queen’s Speech in the Lords, the Government spokesman Lord Howe said: “We are going to give the public a strong and independent voice through Health Watch, which will be a statutory body with the power to investigate and support complaints.”

No more details were given, but we can extend Earl Howe’s statement by looking at a reply Hull LINk received to its query on what relationship there would be between Healthwatch and LINks in England.   Here is what they were told:

“ There have been three different mechanisms for patients and members of the public to engage and involve themselves in the development of NHS services in less than four years.  We believe that mechanisms for engaging patients in their health services need to endure so that confidence and brand awareness increase over time, and the experience of those who operate these mechanisms is retained.  We have therefore committed to avoid unnecessary organisational upheaval and retain LINks as the foundation of our policies for patient and public involvement in health at a local level.

However, we are concerned that LINks in their current setup are too weak and will have too few powers to command the confidence of patients and the public.  We will therefore give LINks additional powers of inspection, and the ability to act as advocates for patients who complain about NHS services.

We will also establish a national consumer voice for patients: HealthWatch.  HealthWatch will provide support to patients at a national level and leadership to LINks at a local level.  It will also incorporate the functions of the Independent Complaints Advisory Body.  Health watch will have a clear statutory right to be consulted over guidelines issues nationally concerning the care NHS patient should receive, and over decisions which affect how NHS care is provided in an area. “

A third take on this comes from the question and answer session Mr Lansley made following his first speech as secretary of state at Bromley By Bow Health Centre, East London, on 8th June.   Mr Lansley thanked LINks for all their work thus far and said he was not going to reject people who have been involved in LINks as part of his intention to shift power down through the system and put patients in the driving seat.  He said Healthwatch England would channel more power to local bodies so that there could be more independence, more power and greater opportunities to influence the NHS and social care.  He said the Healthwatch model would be made stronger as the policy details around Healthwatch were sorted out.