The throttling season

The dog days of August have been anything but torpid, and not just on the streets.  In the policy arena the Department of Health continued to tighten its grip around the throat of any meaningful patient and public involvement.   It’s the throttling season.  The most recent example was the launch by Mr Lansley of 75 Local Healthwatch “pathfinders” on 3rd August into a scorched earth funding landscape, but more of that below.

Test drive the new diagnostic commissioning tool for “EwPC”

Amid all the excitement, the Department of Health sneaked out a “diagnostic tool for commissioners”  on 4^th August in the form of a bright and shiny Excel shreadsheet.  It is well-intentioned, but alas, far too complicated for GPs who probably won’t ever see it anyway though it is aimed at their Clinical Commissioning Groups.   I took it for a test spin, but found it wouldn’t fit on my screen unless reduced to 90% and it still felt very crowded to use.

I browsed the commissioning tool’s content for EwPC = “engagement with patients and community”  and – for me at least – learned a new acronym. What was wrong with PPI or PPE I wonder?  But never mind, because, surprisingly, the tool is very positive on this subject. Whoever wrote the tool understands that effective commissioning can’t happen without local public understanding and user/carer support for redesign and different ways of doing things together.

Can’t quibble with that.  But here’s the point: the new tool is likely to be a futile exercise where PPI, PPE EwPC or whatever acronym for meaningful engagement is concerned.

Reasons for futility 

Why futile? Two main reasons.  First, CCGs can opt out of using the commissioning tool (and many will to avoid its rigour),  but more importantly because the death knell for local and meaningful engagement with patients and the public sounded on 28^th July in the form of the “shared operating model” for clustered PCTs.  No one can opt out of that and its centralising grip is getting stronger.

It means that CCGs aren’t going to do their own engagement work in the “shared model” as it will all be integrated with “communications” controlled from much higher up the hierarchy of command and control – extending right to the Big Beast himself as CEO of the National Commissioning Board.

We’ve had our say about this throttling of PPI at the hands of “communications” and it clearly struck a nerve with readers because more of you left comments than we have ever had on a subject before.

There’s a second reason the new commissioning tool is likely to be DOA.  The throttling of real engagement continued in early August when Mr Lansley launched the 75 Local HealthWatch pathfinders, but failed to provide any resources to get from here to there and no ringfencing for budgets when LHW go live, leaving it to the discretion of each local authority.

The launch press release had these honeyed words -

“These new learning networks will champion patients’ views and experiences, promote the integration of local services and improve choice for patients through advice and access to information. Local HealthWatch will provide a collective voice for patients and carers, and advise the new Clinical Commissioning Groups on the shape of local services to ensure they are informed by the views of the local community. “

Withering pathfinders in scorched earth resource environment

It is a great aspiration, no doubt about that.  But it will be merely wishful thinking if the Local Healthwatch pathfinders wither and die because starved of resources between now when they are still LINks and October 2012 when the Local Healthwatch bodies are supposed to go live.

Malcolm Alexander and the National Association of LINks Members (NALM) has rightly sounded the alarm loud and clear about what this means.  Councils will get money for Healthwatch, but you may see more holes filled in your road as a result.  Ensuring adequate funding of LINks and their transition to a viable Healthwatch is a different matter.  There aren’t many votes in public involvement across health and social care.

It’s systemic

Why is all this happening to choke off the possibility of public involvement at local level at a time when government’s engagement rhetoric and championing of “localism” has never had a higher profile?  To find the answer, search no further than David Gilbert’s insightful analysis for the Commission for Healthcare Improvement (CHI) back in 2004 that involvement was not in the “corporate bloodstream” of statutory services.  A prescient metaphor.

He said then: “… PPI needs to be made part of everyday practice, or ‘mainstreamed’. Unless this happens, PPI will be a passing fad, and a unique opportunity to ensure better quality care, treatment and decision making would be missed.” 

With some notable exceptions the “mainstreaming” we all hoped for hasn’t happened. PPI and co-created, user-focused intelligence aren’t centre stage in most decision making processes – certainly where commissioning is concerned –  because most “professionals” don’t want them to be.  They threaten the prevailing culture of control, especially in a cold climate with short rations.

And for that reason, we conclude, the “reformed reforms” have a poor prognosis.

When the dust settles 

When all the dust settles, assuming it ever does, our conclusion is that “liberating the NHS” has produced not logical reform but confusion characterised by organisational drift and indecision, increased cost pressures, network dislocations, unplanned staff changes and confusion and needless anxiety in service users and the public.  ”Nothing about me without me” has been throttled in that climate because, lest we forget, the “Nicholson challenge” is still to save £20bn+ by 2014 and we are still miles from achieving that. That is why the iron grip is tightening from the centre.

It is a huge disincentive to involvement. As the old saying puts it, “If you wanted to get to there, I wouldn’t start from here.”

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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