Care plans or A&E – your choice

A&E and ambulanceI had a revealing encounter with Sir David Nicholson this week in the grand surroundings of the Royal Society in SW1. National Voices hosted a smashing conference there on “patients as leaders: how people power will shape the new health and social care system”.  (@publicinvolve  reported it live on Twitter).

Nicholson gave an opening address and took questions afterwards. A quick whip-round of views at my table confirmed that we should ask him about individual care plans for people with long term conditions (LTC).  And I got to do the honours with the roving mike.

“Give patients more power”

Sir David’s remarks stressed the “need to give patients more power” through the Commissioning Board’s imminent information revolution. That meant in particular access to their own records in primary and secondary care because “giving patients more clout is absolutely central to how the CB needs to go forward”.

For Long Term Conditions, he said, “patient control of care” was essential for the future delivery of quality and cost effective services.  I certainly agree with all of that.

What about LTC care plans? 

After that statement of his position, we thought it was reasonable to ask him the following question: “How will everyone at local level with a long term condition really be in control when it seems that most people do not yet have an agreed (meaning “co-produced”) care plan? How long will it take for this to happen and for resources to be put together with agreed care plans so people can control their own resources and their own lives?”

And this is what he replied

It’s going to be a trade off …

He stressed the position the CB laid out in its recent “Everyone Counts” commissioning guidance for 2013-14 for the detail of how this and other issues would be tackled.   He added that the key criteria for measuring success would be how well they have dealt with the issues like the one we raised.  So far, so good.

And then he said the hard part: to make a reality of giving people with LTC control through personalised care plans and budgets, two things needed to happen which required achieving a “massive ambition” by the CB.

1) the “right levers in the system to make things happen about how care and resources are planned and delivered” had to change.   He gave an example from North West London where introducing co-created care plans meant reducing investment in secondary care and closing 4 A&Es with the loss of 700 beds

2) and, as if that wasn’t hard enough, the second thing that needed to happen was “changing general practice and how we pay and resource GPs and their teams”.  The CB will commission primary care of course, so in theory the lever is in their hands for this.

You could hardly pick two things more resistant to change in the NHS than reconfigurations of emergency services and acute sector bed reductions, and changing how primary care works.

…. but is it fair? 

This trade off is going to be a hard sell.  Culture and organisational change issues aside – huge as they are  – some people are going to see this as “a trade off too far”, particularly if it means losing local hospital emergency services and hearing their beloved GPs squeal.  If the media distorts the whole thing into a “robbing Peter to pay Paul” scenario where the interests of people with long term conditions (care plans, control of services, personal budgets etc) are seen to be pitted against the fight to keep resourcing for much loved local NHS services, then it will be grossly unfair on everyone.

Don’t fight the users

Decommissioning in order to reinvest and reconfigure is absolutely needed, no question about that. There are some glaring examples in London that have to be addressed.  But it must not be adversarial.  The local community has to understand and support the changes if they are to be lasting.  Even better- they have to be part of devising the proposed changes! Giving people all the evidence (which does not mean blinding them with science and statistics) and then enabling everyone to be part of the decision making process at the grass roots should be at the heart of meaningful engagement. Usually it isn’t.

There is evidence and good advice about how to be smart about building public support for change.  But it takes time and has to be done from the bottom up.  Quick fixes and “engagement sticking plasters” to disguise pre-decided solutions are worse than doing nothing.

The Lewisham fiasco has made the reconfiguration engagement process even harder than it was going to be anyway.  Will anyone else – people in North West London for example –  now go meekly into major acute sector reductions after this?  I don’t think so.  Trusting relationships are the essential ingredient for delivering co-created changes. Trust is in very short supply in the public services.  What is left could evaporate very quickly.

Step forward our newest patient leader

Now that Sir David Nicholson has declared that he too has a long term condition – type 2 diabetes apparently – I wonder if his professed commitment to long term care plans and budgets for all will take on a new dimension?   Does he have his yet?

He told us from the podium at the National Voices conference that his aspiration was be a patient leader.  I don’t know whether to be delighted or terrified by that prospect.

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.  Follow MAC on Twitter @publicinvolve


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