The Slough of Representativeness

“Representativeness” is an ugly word.  I stumble over pronouncing it. I don’t like hearing it, especially in the mouths of people in the new CCGs who are supposed to be taking patient and public involvement seriously.  It signals what I think is a “thought affliction” – something that blocks progress towards meaningful engagement.  A lot of time gets wasted looking for “real representatives” when in fact the quest is futile, as partner Caroline Millar has been saying recently.

Pathfinders straying from path

From reading the final report from Manchester University (September 2012, but just released) on how the Pathfinder CCGs are progressing, it sounds to me that many CCG leaders have a bad dose of “thought affliction  because they seem to be wallowing in the “Slough of Representativeness” to purloin a graphic image from Pilgrim’s Progress.

Frankly, they need help to climb out of this bog. And quickly.  Time is not on their side with authorisation looming in April 2013 and resource pressures mounting.  Without a helping hand, many of these erstwhile commissioning pilgrims on the path to the new NHS  – aka the “Celestial City of QIPP” – may not escape the thinking of PCT-land about how to engage with patients, carers and their communities.  That would be a pity, because it is obvious to people who know about these things, that more of the same old, same old PPI effort won’t get them there.

Few words, less insight 

In a report of 130 pages there are less than 2500 words about patient and public involvement.  And those words depress me because of the boxed-in thinking that they recount.   It seems the CCGs have awareness that they need engagement, and believe is a good thing,  but there is a brake on their ability to innovate to achieve it.

There were lots of instances the researchers found of CCGs starting to use what I would call the “tried and trusted but tired” techniques that PCTs have used to not very great success.  That’s just the problem.

We’ve often used the phrase that a lot of this effort – however well meaning – ends up “exhausting the few and excluding the many. ” It looks like many CCG efforts, on the basis of this report, might suffer from that too.

Case in point. The words “social media”  and “social marketing” don’t even occur in the report! And you will seek in vain for anything about investing in leadership outside the charmed circle of clinicians.   How can anyone seriously consider engagement with the public and its myriad subdivisions and interest communities in 2012 and not think about digital platforms in addition to anything else?

Frustration looming? 

The researchers concluded – perhaps a bit coyly –

Many groups told us that they were keen to develop more effective public/patient engagement than had been achieved by PCTs in the past, but in this pre-authorisation phase we have not yet seen any active initiatives that are significantly different than those which had gone before.


They continue to wrestle with familiar PPI issues, such as who is a ‘valid representative’, and in which aspects of the commissioning process can PPI be most effective/have legitimacy?

Making it to the Celestial City

These findings are diagnostic of the problem the CCGs have in breaking out conventional approaches to engagement.  Until they do that, the Slough of Representativeness will keep them stuck fast.

The NHS Commissioning Board sounds serious about making sure that engagement makes a difference ot commissioning at level. The NHS Mandate 2013-15  pledges “to ensure the NHS becomes dramatically better at involving patients and their carers. ”  

If that is to happen in CCG-land there is going to have to be a whirlwind of change in the thinking and acting at the top of many CCGs.  Otherwise they won’t ever see the Celestial City.

The Moore Adamson Craig Partnership supports user and public participation,  trains lay representatives and develops responsive  health, care and education organisations.  Feel free to contact us to discuss the opportunities.







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