Liberating Primary Care

If you are not White Papered out already, we’d like to offer up our thoughts about patient and public engagement in primary care.  Our views on Local Democratic Legitimacy in Health, LINks and HealthWatch are here and here.  The focus now switches to GP consortia and primary care practices, the grass roots of any effective user engagement process.  The statements quoted below in italics come mainly from Commissioning for Patients part of the suite of policy proposals that make up Liberating the NHS.

Strategy we support

The strategy underpinning the White Paper stresses that  it is

“rooted in the Government’s intention to put patients first.”

It defines a patient-led  NHS as

“one that involves all patients in the development of services that meet their needs and takes account of their lifestyles, backgrounds and characteristics.”

And it is frank that addressing inequalities and insensitivities

“will require an understanding of, and genuine dialogue with, patients so that their needs are properly understood and addressed.”

MAC can certainly sign up to that.  The hard part is going to be putting it into practice against a prevailing NHS culture which does not value sharing power or decision making processes with patients.  That’s why liberation has to start with – and score its earliest and biggest successes – in that part of the NHS that most of us make use of more than any other – primary care.

Liberation must happen at the grass roots in the thousands of GP practices in England.  These are (almost without exception) the privately owned, small businesses which actually provide the services most people think of as “the NHS”. That’s where the culture has to change.  But it is also where patients are closest to the action and can potentially have the most influence.  The chances of sharing decision-making with patients will in our experience happen to the extent that the other party – PCT, GP, consultant – actually feels confident in their own powers of decision making. The more they feel in charge the easier it is to share. It is the decision making equivalent of fighting over the scraps that makes patients losers excluded from the foodchain. Empowerment is for everyone.

Let’s be clear. Experience suggests it is going to be a real challenge – getting GPs to agree on anything is hard enough and coordinating their behaviour is akin to herding cats, in the well-worn phrase.  But there is some significant leverage in the White Paper that everyone should know how to use.  It is about understanding how the chain of accountability for the duty of patient and public involvement could work.

PPI ducks in a row: NHS Commissioning Board  - commissioning consortia – constituent practices

The role of the independent NHS Commissioning Board in all of this is crucial.  It will hold purse-strings for primary care and provide leadership on commissioning for quality as well as promoting and extending public and patient involvement and choice.  Having set up the commissioning consortia, it will hold consortia to account and commission some services itself.

One of the things consortia will be held to account for is engaging patients and the public:

Consortia will need to engage patients and the public on an ongoing basis as they undertake their commissioning responsibilities, and will have a duty of public and patient involvement. [para 2.6]

Making patient and public involvement a duty on GP commissioning consortia, in other words legally enforceable, is a real step forward.  And it’s what happens below the consortia in the constituent practices that is also crucial.

The NHS Commissioning Board will hold consortia to account for their outcomes, for stewardship of NHS resources and for duties like PPI and local authority partnership.  Here’s the kicker:

In turn, each consortium will develop its own arrangements to hold its constituent practices to account [by working]  closely with the patients and local communities they serve, including through Local Involvement Networks (which will become local HealthWatch bodies) and patient participation groups, and with community partners. [paras 2.15, 2.19]

PPI chain of accountability

Like something built out of interlocking lego blocks, this arrangement describes a chain of accountability for patient engagement which works both top down and bottom up.  It connects each constituent GP practice (and no practice will be allowed to remain outside of a commissioning consortium), to its local commissioning consortium and in turn hooks all consortia into the NHS Commissioning Board for discharging the duty of patient and public involvement.   That, in our view, will be the most important linkage PPI has ever enjoyed (once it is enshrined in legislation through the Health Bill in the autumn).

Build on what exists already

In the White Paper, it is stressed that a principal aim of GP commissioning is

to make decisions more sensitive and responsive to the needs and wishes of patients and the public. Good communication and engagement with the public will, therefore, be vital.

Having a good “listening ear” at local level will be necessary to hear and respond to the stronger voice that patients, carers and the public will want to have about what happens to their services.   Government knows that it is not starting with a blank page here.

Commissioners are told to “establish and nurture new relationships” with

• Local Health Watch (formerly LINk);
• Patient Participation Groups “that GP practices are increasingly using to help make their own services more responsive to patient wishes”;
• Local Authorities “who will have a new enhanced role in promoting public involvement in decisions about service priorities and changes to local services and in responding to any public concerns about inadequate involvement”;
• local voluntary organisations and community groups, “who often work with, and represent, the most disadvantaged and marginalised patients and carers.” [para 6.3]

Go for patient participation groups as practice investments

Of these, we think the most potential for liberating primary care lies with patient participation groups (PPGs) in individual GP practices.  A PPG is an investment by the practice in itself as a customer-facing business.  A successful PPG is well worth the effort and can produce a quality return on the practice’s investment many times over.

Having a PPG also aligns the practice with the grain of coalition government health policy which strongly favours user engagement within practices. PPGs are singled out as ways to achieve better informed patients who can share in decision making – a key government aim.

Some clinicians may voice fears that as PPGs spread they will end up “professionalising” patients.  Maybe they will, but that isn’t a bad thing.  We believe most practices would rather have patients as partners, sharing decisions about their individual care and collectively helping think about how to make the practice successful.  Give us that over the deferential, grumbling, ill-informed and “done to” any day.