Just saying “no” won’t do

Yesterday about 85 people from around Wandsworth gathered with our pathfinder consortium leaders to discuss what good commissioning and meaningful patient and public participation could and should look like locally.  There is no doubt local people are keen to be involved from the outset in the changes happening to health and social care here.

We were ably led by Wandsworth LINk chair Jenny Weinstein.  One of the things she identified in discussion as essential when consulting was something that often gets left out when giving people feedback on what happens to the views they offer. When the answer is “no, we can’t do that”, it’s necessary to go further and to say why and what else would  or could be done instead. If this doesn’t happen, the “no” giver comes across rather like the character in the illustration and it may be the end of any further dialogue.

How right she is.  It is necessary to go further than just saying “no”, however politely it is dressed up.  Suggestions made in good faith must be treated with respect even if they cannot be acted upon.  Is it to do with money? Are there legal issues? Environmental barriers? What are the reasons? Participants have a right to know.  Otherwise consultation fatigue and alienation from engagement set in very rapidly.

Listening to the discussion on this point prompted me to dig out  a list of the patient and public involvement commitments that I wrote into the consultation document in 2001 which set up Wandsworth PCT.  I was then vice chair of Balham, Tooting and Wandsworth Primary Care Group.

Back in 2001, we said we were committed to giving patients’ views greater prominence in shaping NHS services and we identified five “tests” about this.

1. In practical terms, this means that the views of users and their representatives must be sought about priorities for investment and options and implications for service development.

2. We will therefore involve users and representatives and consult with them as part of planning service provision. They will be consulted in the development and consideration of proposals for changes in the way those services are provided, and on decisions to be made by the Primary Care Trust, affecting the funding and operation of those services.

3.  As part of its patient, carer and public involvement, the Trust will show that it has sought and taken account of such views, in return for the time and effort, which users and representatives have given them.

4.  We will be open about our decision-making and will acknowledge when public involvement has been responsible for change.

5.  Equally, when resources or other restrictions mean that well-informed views for alternative approaches cannot be implemented, the Trust will explain to those who have given their views why it is not possible to agree with them. It will also make clear the rationale and implications for whatever investment, service developments or other changes have been agreed instead.”

It is number five that really addresses the point that Jenny Weinstein made about “not just saying no”.  The new commissioning consortium  must do more than  just aspire to that, and we hope they will be able to avoid the pitfalls we encountered in PCT land.

However good the commitment, I think an objective observer would conclude that we failed the delivery tests on many occasions.  The reasons will be only too familiar: we were overtaken by events; “must dos” and targets rained down from above with ridiculous timescales and meaningless performance management; we endured reconfigurations; there were always personnel changes; and financial crises of course; you name it.

Dusting off the 2001 wording, its clear to me that “responsiveness” is the concept which emerges as the best test of “what good looks and feels like” in user and public involvement.  It’s a lesson we must hang on to in the current difficult times.  I think this sums it up:

“By involving local communities; the patients, service users, carers and residents of Wandsworth, we can gain a better understanding of how local services need to be changed and developed. By creating greater local ownership of health services we can improve the quality and responsiveness of those services and reduce health inequalities.”


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.




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