The new “when it’s less urgent than 999” service – NHS 111 – is rolling out across England. Here in Wandsworth NHS 111 goes live in late November this year. I have expressed reservations before about how well all the “non -urgent care” messages will be communicated to and understood by the public. Those doubts haven’t gone away. But 111 is going to happen soon and that means we have to face up to the challenge of how to ensure that its users are meaningfully engaged with it and able to say what they think about using it.
This posting is about what user engagement in 111 services might mean locally in our part of London. If it helps elsewhere, then feel free to use the ideas. I should stress that the views that follow are personal ones from my perspective as an engagement practitioner living locally; they do not necessarily reflect the Wandsworth 111 CG Committee’s views or anyone else’s.
User engagement essential to good governance
I’m the lay member on the Clinical Governance Committee for our new 111/out of hours service. The LINk is represented as well. What we don’t have – at the moment – is user input. That’s what we need to prepare for now.
The Wandsworth 111 service is complex. It’s much more than an “off the peg 111 service” which has been piloted elsewhere. Our service specification brings in “single point of contact” (SPOC) referrals to adult social services and community healthcare, end of life care (EoLC) pathways, as well as advice and self care, home visits if needed, ambulance call outs, and appointments made for people at urgent care centres (UCCs) and GP practices. It’s pretty much the mirror image of what happens “in hours”. That’s the way we drew up the specification for the contract.
The challenge will be to get engagement from users of this new service in ways that are easy and flexible for them, and whose outputs are meaningful for our ongoing clinical governance work. This is harder to do than to describe.
The panel which dealt with the tender – of which I was a member – wanted to put a user panel together as part of the procurement exercise to get interaction with the main bidders. But we were told by NHS London that we could not do this as we had to abide by the national 111 procurement template and that did not include any user input. That was, in my view, a great shame. It points to a potential weakness in the new initiative. I hope we can do something locally which will overcome this.
Regular users are advisers and assets, not representatives
I think the main points of what we need locally are clear.
1) We need a “111 User Reference Group” (“111URG” for short) whose participants are seen as advisers rather than as representatives. I don’t want to use the word “patients” either, because many 111 users will not be patients at all, but simply local people ringing for advice or information about themselves, family members or others. It is never going to be “representative” in the literal sense, but there is a specific role for users and carers accessing 111 to act as advisers in helping us all focus on the quality/safety of the user experience and the appropriateness and efficiency of the user journey if they are directed to specific services.
2) “111 URG” must be an integral and continuous process underpinning our clinical governance work. It should generate a pool of informed users (and “proxies” for users such as parents and carers). These local people will be “engagement assets“. Their input should enrich our quality monitoring of the service, inform and improve our communications about it, add to our learning from (anonymised) complaints, compliments and comments that relate to the service and help us make any necessary changes as we progress into this new way of working.
3) “111URG” should reflect the whole of the contract, not just the 111 advice and referral bit. Getting feedback is also essential from people who are handed on from 111 to Out of Hours for advice or home visits or who have appointments made for them or ambulances called for them, or who are handed on to social services or community healthcare through “single point of contact” or who have needs related to end of life care.
4) The 111 user “mix” locally is going to be diverse. The implication is that “111URG” will need to be managed most of the time as a “virtual group” (though getting individuals together for specific tasks from time to time might be needed too). It has to be someone’s responsibility at the new Wandsworth CCG to do this and it needs the right level of resourcing. It must be seen as an engagement investment.
5) “111URG” participants will be more on the “inside” than on the “outside” to use David Gilbert’s description of user participation. In that sense the new Wandsworth CCG should see them as critical friends seeking to work with and influence the system and decision-making and acting themselves as community channels seeking to articulate the interests of, and enable and communicate with others in the community. That is much more valuable than striving for “representativeness”.
Who might be regular users for our 111 service?
We won’t really know until the service is live, but my supposition at the moment – knowing our local population profile -runs like this.
- older people particularly those with complex conditions including being house bound;
- people with long term conditions of any age (and their carers, including people caring for those nearing the end of life);
- parents/guardians (for their children);
- people not registered with a Wandsworth GP practice, because they are new to the area or are mobile younger residents who are less likely to register anyway. We have a 30% population churn in some parts of the borough and an increasingly younger, mobile population
- any others who are making significant use/demands on the service once it is functioning. These could be from ethnic minority communities, “hard to reach” groups and vulnerable individuals, but we won’t know that until we get real time experience.
“111URG” as part of the WCCG’s Patient and Public Egagement Strategy
Wandsworth CCG is creating a “PPI Clinical reference Group”, chaired by the Board’s Lay Member for PPI. That’s an excellent platform for the “111URG” to stand on. Creating and supporting a “111URG” would address at least five big points in the draft PPI/E strategy – and the new CCG would learn a lot form the process:
• Developing new modes of engagement (including through technology)
• Ensuring engagement in pathways redesign and service changes
• Engaging hard to reach groups and vulnerable communities
• Promoting and supporting self-care and self-management
• Developing effective partnerships with HealthWatch
Capturing 111URG views – and then what?
How to get the “111URG”‘s views? Definitely not by trying to get them in a room somewhere unfamiliar on a dark, wet evening with promises of tea and sandwiches. We have to reflect the real lives of real users and that means making things easy, convenient and safe. That’s what 111 itself is supposed to be about, after all.
To start things off, I suggest that a short, pre-paid “fold up and post” questionnaire should be given to everyone who receives a home visit from the out of hours service after 111 begins on 20 November and for the next 6 months. After that, it could be done with a percentage of home visits. This would collect “how was it for you?” information about timeliness, attitude and communications of professionals and general satisfaction with what happened on the visit. This should be part of the “friends and family” approach – ie would you recommend the experience to someone you know or to a family member? This approach to measuring user experience is starting in the acute sector and A&E in early 2013, but I think it should be used in 111 as soon as we can do it.
Texting comments, Tweets and emails are likely to be high up on the “things that might work” list of how to get feedback from people who have used 111 and the services it can refer on to. I suggest that for the first six months, everyone for whom an appointment is made by 111 at an Urgent Care Centre should be sent a text with no more than five questions about their experience, which they can answer quickly afterwards and send back. Thereafter, a percentage of people in this category could be sent such feedback texts.
Receiving feedback from 111 users in particular means that someone on the receiving end has to log, collate and sieve all of this to turn it into intelligent information on which action – if needed – can be taken.
This intelligence needs to be mined on a regular basis and the nuggets that emerge have to be considered by the 111 Clinical Governance Committee, which where there must be a direct line to the CCG Board’s Integrated Governance Committee and the Lay Members with governance and PPI oversight on the Board itself.
Feedback must also be given to the “111URG” participants about what we did with the information they provided. This feedback can be texted to them on a regular basis. It should also go on the CCG’s website under a “you said and we did” section. That makes a virtuous circle from the engagement process. And of course, this should all be plugged into the work of the new Wandsworth Healthwatch.
Will it work?
It can work, but only if we want it to and if the CCG invests in it. The risk of bad word of mouth spreading about NHS 111 locally, just to name the obvious, is clear if we do nothing. But it is also just as serious if we do something that is seen to be ineffective. I hope we do the right thing right. I will report on this blog about what happens to this proposal.
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.