MAC’s initial response to the patient and public involvement (PPI) aspects of the Health and Social Care Bill introduced on 19th January is positive. The preamble describes it as a Bill whose purpose includes “to make provision about public involvement in health and social care matters”. That’s top billing for PPI in a mammoth piece of legislation. The inclusion of areas beyond the NHS like social care is very welcome.
The Bill provides an enabling framework to build on locally to achieve co-production and shared decision making. More than that, it significantly uses the term “involvement” and not the weaker “engagement” to describe what is required.
This is not just semantics.
You may ask “what’s in a word?” In the case of ”engagement” vs “involvement” the answer is rather a lot. “Engagement” implies a process of enquiry initiated by the NHS when and how it chooses. “Involvement”, in contrast, implies a sustained, continuous and co-created process. Without involvement we can’t have any meaningful accountability. It isn’t that engagement is wrong, just that it is insufficient on its own for the purpose of influencing decisions. Sustained involvement is the key to this.
Commissioners need to develop processes to ensure they listen to patients and the public as they shape ideas for new service delivery models. Otherwise, how can they be assured that service users, carers and the public are with them on the journey of service re-design as they develop service specifications, consider tenders, and monitor contracts? If they do not do this, they are at risk and cannot demonstrate their accountability to the moral owners of the NHS – that’s you and me.
Involvement from top to bottom
The Bill describes related PPI duties applying to the NHS Commissioning Board, to GP-led commissioning consortia and to local government. At the top, the Commissioning Board is required to “promote the involvement of patients and their carers in decisions about the provision of health services to them.”
As the Board will be authorising commissioning consortia, it is logical that the PPI duty is seen as part of that. More detail about PPI will come from NCB and guidance about how to discharge involvement duties will be mandatory on consortia.
For commissioning consortia, the involvement duty does not stand on its own, but is closely related to the duty to reduce health inequalities and to promote user choices. In exercising their commissioning arrangements, consortia are required to
reduce inequalities between patients with respect to their ability to access health services;
reduce inequalities between patients with respect to the outcomes achieved for them by the provision of health services;
promote the involvement of patients and their carers in decisions about the provision of health services to them;
enable patients to make choices with respect to aspects of services provided to them as part of the health service.
This is the right linkage. Involvement is only a means to an end after all — and that end is power sharing in decisions affecting people.
Involvement from the outset
The Bill is clear that involvement must start at the beginning of all commissioning processes. Here is the key passage:
The consortium must make arrangements to secure that individuals to whom the services are being or may be provided are involved (whether by being consulted or provided with information or in other ways )— (a) in the planning of the commissioning arrangements by the consortium, (b) in the development and consideration of proposals by the consortium for changes in the commissioning arrangements where the implementation of the proposals would have a significant impact on the manner in which the services are delivered to the individuals or the range of health services available to them, and (c) in decisions of the consortium affecting the operation of the commissioning arrangements where the implementation of the decisions would (if made) have such an impact.
Of course, as there is now in respect of Section 242 duties, there will be argument about what “significant” means and whether a management change behind the scenes constitutes a change in how services are delivered. But at least these involvement provisions are now “on the face of the Bill” and it is likely they will remain there.
It will be up to Pathfinders to work out what they mean in practice. Local patient and community groups should not be reticent in saying what they think should happen. Don’t wait to be told.
Read it for yourself
We will be considering public involvement in relation to local government in the Bill separately in a future blog and also discussing what the Bill says about governance. In the meantime dip into the Bill for yourself, all all 360+ pages!
The House of Lords is already practising having all night sittings and we suspect that parliamentarians in both houses will be having more than a few late nights before this mammoth piece of legislation finally reaches the statute book.
The Moore Adamson Craig Partnership supports user and public participation, trains lay representatives and develops responsive health, care and education organisations. We are ready to work with and support all those who want to make sense and a success of the new structures of patient and public engagement within the new arrangements for health and social care commissioning and providing. Feel free to contact us to discuss the opportunities.