The Big Beast sells out public involvement
Posted: 31 July, 2011 by Andrew Craig
The Big Beast in the NHS jungle Sir David Nicholson has decreed that the new PCT “clusters” will take responsibility for public involvement in the “shared operating model” the Department of Health released on 28th July. ”Shared” in this sense means everyone doing things the same way. The operating model dictates that engagement work merge with “communications”. That’s bad news. Our work with PCTs that put PPI and comms together meant real involvement usually took second place to those controlling the party line and pulling the strings. This is going to happen across England quickly and with a vengeance. The Big Beast’s iron grip – he has to squeeze £20bn+ recurring “savings” out of the system by 2014 remember – means real commitment to patient and public involvement has been sold down the river. And all for the sake of opening up the provider market to “any qualified provider”
AQP coming to a place near you
By September this year the “shared model” says, “Clusters to have undertaken patient engagement and have determined services of choice for Any Qualified Provider”. That’s what this tightening grip from the centre on engagement and comms is all about. Each commissioning group will have to have three AQPs delivering community and mental health services by April 2012.
Make no mistake. This isn’t about grass roots involvement to find out what local people think should happen and what would be acceptable to them. It is about giving some legitimacy to the “any qualified provider” initiative. Did you notice there was a consultation about that? If not, read the government response to it here. It is moving at juggernaut pace. So much for things slowing down during the dog days of summer.
Opening up choice and competition
Here’s how it is going to work. By April 2013 all of these services will have been opened up to “choice and competition” - and local clinical commissioning groups can add to this list if they have more important local priorities.
• Musculo-skeletal services for back and neck pain
• Adult hearing services in the community
• Continence services (adults and children)
• Diagnostic tests closer to home such as some types of imaging, cardiac and respiratory investigations to support primary assessment of presenting symptoms
• Wheelchair services (children)
• Podiatry services
• Venous leg ulcer and wound healing
• Primary Care Psychological Therapies (adults)
The iron grip tightens
It gets worse. By October this year, we are commanded to “Establish regional communication and engagement hubs in line with SHA Clusters in October.” For London this means, it will all be done by NHS London.
This goes hand in hand with establishing interim management of the locally delivered, nationwide shared service in the Autumn. “ So that by April 2012 we will have a nationwide shared engagement and communications service, locally delivered.
What this really means is faceless people in a communications department at the “cluster” – or even more removed at the SHA - telling us what those even higher up at the National Commissioning Board – of which the Big Beast is to be the CEO – want us to hear. If you think that’s engagement, much less involvement, you need your head examined.
No involvement means no legitimacy
The “single operating model” means clinical commissioning groups (no longer called “consortia” remember) will not have their own involvement and engagement staff. We suspect GPs who are leading these CCGs and local councillors keen on Health and Well Being Boards aren’t aware of that yet. Many will not be happy when they wake up to it.
So where will the local knowledge and sensitivities about interacting with diverse local communities come from? Co-production? Community development? Shared decision making? You may well ask.
Sold a pup?
“Nothing about me without me” sounds more like being sold a pup as each day passes and we find out more about what the ”reformed reforms” really mean.
If there is no meaningful local involvement in decision making, there can be no legitimacy for the commissioning decisions that are taken. That is not a negotiable point.
It would be a terrible irony if patient and public involvement became a casualty of the unseemly rush to expand “choice”, but that is the way it looks like going.
The Big Beast and his political master may end up paying a high price if the wheels come off his “shared operating model” because it has no local support.
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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Your blog is mostly correct.
‘Public and patient engagement’ work will be incorporated within a national communications fuction. The prime directive of this ‘shared service’ will be to protect the reputation of the Commissioning Board and the NHS brand.
David Nicholson has done this because the last thing he wants is individual CCGs, upset about the effect of the cuts, taking the side of their patients and holding public meetings, firing off press releases etc.
The people who will be allocated to enage with populations on behalf of CCGs will be junior staff. The senior staff will be specialist they never meet. GPs can expect less than 1 full time equivalent post each – staff who will be working in the best interests of the Commissioning Board and the Secretary of State, not CCGs or patients.
Although CCGs will be legally responsible for the legal duty to involve, they will not employ those who engage on their behalf or directly control the amount of involvement done on their behalf or the approach taken.
The interim Director of Communications and Engagement Nationwide Shared Service, Stephanie Hood, has admitted “engagement professionals in the commissioning side of the NHS system have already fallen by 46 per cent” yet the plan envisages even further scope for reducing costs.
So how much capacity will there be from experienced people who know localities and have strong relationships with patients and the public? Considerably less than PCTs had it would seem. And this much reduced resource will be spread over an increasing number of commissioning organisations, supposedly with an expanded scope for consultation.
So you are right, the public (and GPs) have indeed been sold a pup. Nothing about me without me is a BIG LIE.
This is a triumph of DH spinmeister Colin Douglas over Paul Staines and the still developing field of public involvement. From October onwards, Public Engagement in the NHS will mean Public Relations.
There was nothing in the white paper or future forum reports about communications – it was all about public involvement. And yet a rearguard action by Mr Douglas and the SHA Directors of Communications put the frighteners on David Nicholson. Did he really want all those GPs running round actually asking people whether their local DGH should be closed?
So now we are headed back to where we were before World Class Commissioning – when patients just got ill and got better and weren’t expected to have a view about clinical priorities, reconfigurations or anything else.
The whole thing has been a sham.
Well done for raising the alarm Andrew. Pondering at National Voices what we do about this. Jeremy
I am very angry about this if it is true.
I sit on the Board of a CCG which has made a very public commitment to enagage our patients every step of the way. Partly because it is the right thing to do, but also to be honest because without public support things could get rather ugly.
Now it turns out we will not even be able to use the management fee to employ someone to do this. The people engaging on our behalf will actually be working for someone else, to their agenda. So all the promises we have made are worth nothing.
I haven’t had the opportunity to discuss this with the Board yet, but as far as I am concerned this is a deal breaker.
Dr No.
I don’t think this is anything to do with AQP. Its about the Commissioning Board keeping an iron grip on CCGs dialogues with the public. And doing it as cheaply as possible.
This is seriously depressing – the PCT I knew best was struggling years ago to understand the difference between comms/PR and engagement and still was when it uttered its dying breaths a few months ago. The usual model: individual services doing little bits and pieces here and there to engage with patients but not a clue about how to bring it all together or do it consistently well across the piece. So many people with the word “engagement” somewhere in their job title or job description and so little real engagement to show for it. Comms made sense to them because they employed a comms professional from outside the NHS to do it for them and tell them what it meant. Engagement was a mystery. So what is happening here is just more of the same. In the absence of any understanding about what it is or why it matters, just stop doing it and save yourself some trouble. Nothing that a sexy little leaflet can’t solve surely.
I think that’s a rather unfair generalisation Caroline. Public involvement was one of the success stories of the World Class Commissioning Programme which forced PCTs to raise their game. The progress can be measured in the improved results between years one and two. There was a lot of good practice of “continuous and meaningful engagement” taking place.
But I agree with your general point about communications. PR is a mature discipline with developed career pathways, formal qualifications, even a chartered institute; wheras engagement was the young upstart with minimal lomng term evidencem, no canon of literature and no real career pathway.
The NHS was late to pick up on engagement compared to other public bodies and it never really got properly embedded with advocates who had operational experience ascending to high places. The PR old guard at the DH and SHAs saw that the future for them was to jump on board the “nothing about me without me” bandwagon.
As you say engagement will now be a website, an iphone app or if you are lucky a leaflet through the door. I wonder what Steve Field and Geoff Alltimes are thinking now – Lansley has made fools of them.
Everybody working in localities on band 8a or above will be made redundant by next April. They will simply be too expensive to be afforded. Their links, relationships etc. will be lost to the system.
The people at the front line (‘account managers’) will be junior PR types gaining experience and working from a highly prescriptive manual. Their key task will be protect the reputation of the NHS.
Post 2013 this shared service will be spun out of the NHS as a social enterprise and then other private sector providers will be encouraged to bid for work against it. It will then die a slow death as new market entrants eat away at its income until its ‘hub and spoke’ model is no longer viable.
Then it will go the same way as the COI.
Felicity – there may have been a lot of good practice around but my point was precisely that, there are/were pockets of good practice (perhaps even MANY pockets of good practice, though I remain to be convinced) but nothing which really brought it to the mainstream of NHS management to the extend that hearing and responding the voices of patients and public became a top managerial priority. In the PCT I was talking about we got the declaration of intent high up the top ten priorities in some document somewhere for several years but I have to say it simply never got translated into any sort of reality. And if you had asked them to demonstrate how and where the voice of users had really made a significant impact to the way the organisation was managed they would have been hard pushed to give you any evidence.
Agree that `patient at the centre` rings increasingly hollow and `consultation`, in my experience means telling people what you are going to do and ignoring any feedback that suggests a different approach. However, the Pathfinder Clinical Commissioning Group within Wandsworth have committed themselves to patient and public involvement and working in partnership with local LINk/Healthwatch. We are involving hard to reach groups and will be launching a strategy in the Autumn.
I won’t attempt to defend every PCT Caroline but the fact is WCC was leading to real improvements. Given another couple of years, we could have seen some really exemplary work.
However, no matter how bad PCTs may have been, at least they employed engagement professionals with links to local people. What is being proposed is a massive step backwards.
Very interesting discussion. Thank You Andrew for hosting. From our experience in the field I would agree with Caroline’s observations that some good practice may have been happening in some places, but NHS management were not able to translate these into any meaningful whole system strategies. This I think has less to do with leadership and much more to do with people; people trusted by people either not willing or not able to bring to the table the level of drive and energy and expertise that is needed to sustain and embed change processes. This in turn not being facilitated by the inert culture often inherent in very large institutions like the NHS. So good practice lived and often died on their own merits with no added value achieved and no real learning being shared, owned or understood. A real pity this as some good people did and are doing good work and this is not being valued in the way that it should be (with the resulting loss of motivation… and hope).
I think that Felicity is also right in that WCC was beginning to smoke out what needed to be done and was beginning to put down some really useful benchmarks for direction of travel around community engagement. Alas, it was never allowed to mature and what a shocking waste of resources and energy and learning that was. As others have observed, I think that the “system” has become very good at reeling out terms like “patient and public involvement” and “involvement of hard to reach groups” and able to get away with saying that they are being successful by the mere fact that they have got a few people, even better if they are from BME communties, in a room to talk health and well being! When the hard fact is that real and meaningful community involvement in ways that builds community capacity and understanding is a long game and requires a much more nuanced and deeper excavation of community and social infrastructures and interactions, backed up by a long term commitment of resources-professionals, funding and otherwise- which currently does not seem to be available at the level that is required or seems coming over the horizon any time soon. The net result of this is and will be an increased marginalisation of groups already marginalised (with the resulting rise in poor health trajectories- in obesity, in CVD, in childrens health etc) and a further isolation of at risk individuals (with the resulting increase in long term conditions and mental health amongst other far more worst case scenarios). It seems that the NHS PR machine will be setting itself up to whitewash and screen out any chance of this type of evidence “contaminating” their brand.
I think what we can do, whilst this juggernaut rolls on, is keep alive the conversations around what is and what could be and continue to build alliances and relationships across sectors and communities amongst those who “get it”. My experience has been that the tide will change. Whether when it does, we will still have standing enough people around with the commitment to give it another go remains to be seen.
[this contribution is from one of our blog's regular readers who works in a national staff organisation]
We’ve always been concerned about the variety in quality of involvement and engagement across the NHS, and so a more co-ordinated approach could deliver better consistency of approach;
However, the combining of two separate disciplines (PR and involvement and engagement), which are often at odds with each other in terms of rationale, is incompatible with the principles of involvement and engagement.
For me, the biggest problem coming from the Bill in respect of PPI, and more importantly Nicholson’s grab of the new settlement, is that the creation of so many new bodies diffuses accessible power (as opposed to that held by the likes of the SoS and Sir David) so much that the PPI/E bodies that are part of the new settlement will be unable to really achieve anything meaningful.
So, we now have SHA clusters, PCT clusters, CCG; we will have the NHS Commissioning Board (with a member responsible for informatics and involvement, how does that figure?), a more powerful Monitor (with no involvement aspect, I think), and a CQC with a requirement to do more with fewer people and resources, but hosting the new PPI/E and patient accountability body, HealthWatch (which is most likely to have appointed members as it currently stands).
As for the comment about CCGs not being able to undertake their own PPI/E, some of them have already started, and so it will be interesting to see how they respond to this new instruction. An interesting debate is now taking place about where the locus of power should sit in relation to PPI/E around primary care; with some of the new CCG patient groups arguing that they should be the requisite bodies, and organisations like NAPP that it should stay with the GP patient groups (they produced a very good response to the democratic involvement consultation).
I think the use of the ‘choice mechanism’ by Nicholson is actually quite an interesting tack, since many patients do not get involved with PPI/E activities, but can easily be sold the benefits of greater plurality of service provision, especially in these times of increasing waiting lists and reduced availability of key services.
“As for the comment about CCGs not being able to undertake their own PPI/E, some of them have already started”
Who has been doing that for them? In the main PCT people who are about to disappear. CCGs will be left high and dry, saddled with a legal duty to involve but no staff and no money.
I agree with the analysis of the likely consequences. However why not a local and national fightback? Local activity mentioned by LINK….build it up fast so that local Primary Care Centres and the CCG cannot avoid local consultation. I am not suggesting that they want to avoid, but there may need to be some contervailing pressure which calls the proposals not only into question but to their unworkability. If Link could engage local voluntary organisations to seek consultation on subjects relevant to them and to local commissioning….there might be a system which could not be undone by the clustering approach of the DoH…and of course the forthcoming debates in both houses of parliament might, by the use of clever amendments, see some airing of the subject. The Health Select Committee might be interested. It’s OK to make a fuss…what’s needed is an organised fuss!
Peter, assuming this clears the Lords I think the one thing that will change this approach is a series of legal challenges where service changes are not adequately consulted on. Scores of simultaneous judicial reviews underway and being won would make this approach untenable.
Another possibility is that the private sector consultants, PR agencies etc, who thought they would be bidding for comms and engagement work as part of the marketisation of commissioning support, seek their own judicial review of the policy.
Or if they feel sufficiently strongly about it, CCGs may throw a strop. Doubt this though as the number who ‘get’ public involvement yet seem to be in the minority.
Andrew talks of challenges to the Big Beast’s decisions and Felicity hopes that private sector businesses or indeed CCGs may throw a strop. But will that make any difference in the absence of a working theory of accountability? Look at what we have put up describing Caroline Oliver’s approach to effective governance. We need an accountability system that does not depend on judgements based on the illusion that one man can know all that is going on. Accountability may still need a Malcolm Alexander to make it work but having a system in place certainly makes that job easier. People may despair of being run by a ‘feral’ elite but polling a citizens’ jury will not work without a decent working definition of accountability.
Felicity BK says:
August 3, 2011 at 11:49 am
……… I think the one thing that will change this approach is a series of legal challenges where service changes are not adequately consulted on.
Is the successful action by the Brompton using judicial review going to be the tip of the iceberg. Where did you buy your crystal ball from Felicity ?
Chair Camden LINk.