BMA to GPs – PPI integral to consortia commissioning decisions

The first statement from the BMA’s General Practitioners Committee about consortia commissioning responsibilities appeared last week.  We recommend you read it.

MAC’s verdict

Undoubtedly it’s a good start, but it will have to do better as it goes along especially as some £80bn of taxpayers money is wrapped up in this.  Still, we value the PPI decision making and accountability statement and lay representatives should bang this drum with their local GP commissioners and PCTs as loudly as possible.  And decide what local accountability really means.

The guidance is admirably brief and to the point, especially about patient and public involvement and accountability.

Other aspects could be improved.  Below are some excerpts (italics) we think are particularly important with our views and recommendations as well.

Good for PPI

Public and patient involvement should be integral to the work of consortia. Challenging decisions concerning treatment priorities may need to be taken based on a mutual understanding of the constraints of limited resources, and the obligation to use such finite resources wisely. The consortium must be accountable to patients and the public who will need to participate in such decisions.

This is possibly the most important statement in the whole document, but we need to ask “how will accountability to patients and the public be exercised in practice?”  And a big unanswered question – will lay people want to help GPs take the tough decisions (decommissioning, rationing, etc)?  That is what commissioning must be about, especially in a time of serious financial restraint.

Inequalities

Consortia should be required to consider the implications of their decisions on their local population, patients within other GP consortia and the wider NHS health systems, and wherever possible, consortia should ensure that NHS providers are the providers of choice. Consortia must be committed to reducing healthcare inequality wherever possible.

There is a problem here.  Inequalities in health (eg disparities in mortality and morbidity between people living in different geographical areas) are not the same as inequalities in the spread of healthcare facilities and services.  Health does not equal healthcare.

The NHS itself can do little without partnership working to address health inequalities since these have their origins – and hence their remedies – in education, housing, environmental and other non-healthcare spheres.  That’s the point that needs to be made here.  Simply having more healthcare services in deprived areas might do little to improve things and would certainly consume scarce resources.  A hospital on every street corner would make things worse and ensure bankruptcy.  Consortia should not spend their time spreading out the NHS healthcare resources evenly – local differences are justified – desirable even –  when they are underpinned by robust public health and local engagement. That will take courage and intelligence.

It is also a shame to see the tired old “NHS as provider of choice” mantra trotted out in the GPC’s guidance (and it is probably illegal in EU competition law anyway).  For some things, the NHS is not going to be the best provider and we should face that. Quality, outcomes, safety, patient experience and of course value for money (not just price) are the criteria we must use to make this call in a pluralist “any willing provider” market.  That’s what intelligent commissioning must do, and it is what the best of the PCTs were doing more of to judge from the most recent world class commissioning results .  GP commissioners must learn from that and improve upon it, not take a backwards step.

Underplays local authority role in public health

GPs will take on a wider public health role. This will bring with it responsibilities to engage constructively with other organisations, doctors and NHS staff, including colleagues in secondary care, public health bodies, local authorities, community care organisations, wider healthcare teams and others.

When we think about public health it is local authorities and community organisations that should come first on this list, not be buried beneath health professions and bodies.  We anticipate the coalition’s public health white paper in the autumn will be stern about this.  Is is to local Councils that we must look for the lead in health and wellbeing under the coalition’s proposals.

Ignores the non-NHS sector for managerial expertise

GP consortia must be professionally run organisations; they will rely on the help and expertise of the best NHS managers.

This also makes little sense. Why tell GPs to look inside the NHS for help and advice when it is in many cases – to hear the keen GPs tell it – those very same PCT managers who have allegedly been holding them on too short a leash in the first place?  What are they afraid of?  GPs are businesses too  and should be able to employ whomever they see fit. The best are excellent, but public sector managers hold no monopoly on expertise or enthusiasm.

Liberating Primary Care

If you are not White Papered out already, we’d like to offer up our thoughts about patient and public engagement in primary care.  Our views on Local Democratic Legitimacy in Health, LINks and HealthWatch are here and here.  The focus now switches to GP consortia and primary care practices, the grass roots of any effective user engagement process.  The statements quoted below in italics come mainly from Commissioning for Patients part of the suite of policy proposals that make up Liberating the NHS.

Strategy we support

The strategy underpinning the White Paper stresses that  it is

“rooted in the Government’s intention to put patients first.”

It defines a patient-led  NHS as

“one that involves all patients in the development of services that meet their needs and takes account of their lifestyles, backgrounds and characteristics.”

And it is frank that addressing inequalities and insensitivities

“will require an understanding of, and genuine dialogue with, patients so that their needs are properly understood and addressed.”

MAC can certainly sign up to that.  The hard part is going to be putting it into practice against a prevailing NHS culture which does not value sharing power or decision making processes with patients.  That’s why liberation has to start with – and score its earliest and biggest successes – in that part of the NHS that most of us make use of more than any other – primary care.

Liberation must happen at the grass roots in the thousands of GP practices in England.  These are (almost without exception) the privately owned, small businesses which actually provide the services most people think of as “the NHS”. That’s where the culture has to change.  But it is also where patients are closest to the action and can potentially have the most influence.  The chances of sharing decision-making with patients will in our experience happen to the extent that the other party – PCT, GP, consultant – actually feels confident in their own powers of decision making. The more they feel in charge the easier it is to share. It is the decision making equivalent of fighting over the scraps that makes patients losers excluded from the foodchain. Empowerment is for everyone.

Let’s be clear. Experience suggests it is going to be a real challenge – getting GPs to agree on anything is hard enough and coordinating their behaviour is akin to herding cats, in the well-worn phrase.  But there is some significant leverage in the White Paper that everyone should know how to use.  It is about understanding how the chain of accountability for the duty of patient and public involvement could work.

PPI ducks in a row: NHS Commissioning Board  - commissioning consortia – constituent practices

The role of the independent NHS Commissioning Board in all of this is crucial.  It will hold purse-strings for primary care and provide leadership on commissioning for quality as well as promoting and extending public and patient involvement and choice.  Having set up the commissioning consortia, it will hold consortia to account and commission some services itself.

One of the things consortia will be held to account for is engaging patients and the public:

Consortia will need to engage patients and the public on an ongoing basis as they undertake their commissioning responsibilities, and will have a duty of public and patient involvement. [para 2.6]

Making patient and public involvement a duty on GP commissioning consortia, in other words legally enforceable, is a real step forward.  And it’s what happens below the consortia in the constituent practices that is also crucial.

The NHS Commissioning Board will hold consortia to account for their outcomes, for stewardship of NHS resources and for duties like PPI and local authority partnership.  Here’s the kicker:

In turn, each consortium will develop its own arrangements to hold its constituent practices to account [by working]  closely with the patients and local communities they serve, including through Local Involvement Networks (which will become local HealthWatch bodies) and patient participation groups, and with community partners. [paras 2.15, 2.19]

PPI chain of accountability

Like something built out of interlocking lego blocks, this arrangement describes a chain of accountability for patient engagement which works both top down and bottom up.  It connects each constituent GP practice (and no practice will be allowed to remain outside of a commissioning consortium), to its local commissioning consortium and in turn hooks all consortia into the NHS Commissioning Board for discharging the duty of patient and public involvement.   That, in our view, will be the most important linkage PPI has ever enjoyed (once it is enshrined in legislation through the Health Bill in the autumn).

Build on what exists already

In the White Paper, it is stressed that a principal aim of GP commissioning is

to make decisions more sensitive and responsive to the needs and wishes of patients and the public. Good communication and engagement with the public will, therefore, be vital.

Having a good “listening ear” at local level will be necessary to hear and respond to the stronger voice that patients, carers and the public will want to have about what happens to their services.   Government knows that it is not starting with a blank page here.

Commissioners are told to “establish and nurture new relationships” with

• Local Health Watch (formerly LINk);
• Patient Participation Groups “that GP practices are increasingly using to help make their own services more responsive to patient wishes”;
• Local Authorities “who will have a new enhanced role in promoting public involvement in decisions about service priorities and changes to local services and in responding to any public concerns about inadequate involvement”;
• local voluntary organisations and community groups, “who often work with, and represent, the most disadvantaged and marginalised patients and carers.” [para 6.3]

Go for patient participation groups as practice investments

Of these, we think the most potential for liberating primary care lies with patient participation groups (PPGs) in individual GP practices.  A PPG is an investment by the practice in itself as a customer-facing business.  A successful PPG is well worth the effort and can produce a quality return on the practice’s investment many times over.

Having a PPG also aligns the practice with the grain of coalition government health policy which strongly favours user engagement within practices. PPGs are singled out as ways to achieve better informed patients who can share in decision making – a key government aim.

Some clinicians may voice fears that as PPGs spread they will end up “professionalising” patients.  Maybe they will, but that isn’t a bad thing.  We believe most practices would rather have patients as partners, sharing decisions about their individual care and collectively helping think about how to make the practice successful.  Give us that over the deferential, grumbling, ill-informed and “done to” any day.

Health Watch and LINks – synergy needed but confusion predicted

Local Democratic Legitimacy in Health is part of the flurry of papers comprising the policy blizzard that is Liberating the NHS, the white paper (with a very green tinge) published on 12 July setting out the so-called bottom up reorganisation of the English NHS.

Because this part of the suite of papers concerns local patient and public involvement representative structures and also brings in complaints and related issues, MAC wanted to get our thoughts in front of the public without delay.

Below are our views in italics on the main themes in Local Democratic Legitimacy in Health which we have sent to the Department of Health as part of the ongoing consultation which closes on 11 October.  We urge all readers of this blog if the English NHS changes are relevant to you, to have a say on these key issues.

MAC partners have first hand experience of local LINks, having created the proposals which won the Wandsworth contract for the 3^rd sector body Wandsworth Care Alliance and then working with them for 18 months delivering the policy development, governance and communications aspects of the Host role.

The comments below are on the main themes in Democratic Legitimacy and responses to the specific consultation questions are at the end.

Treat this as summer holiday reading.  There is no rush, we just wanted to have our say and tell you what we think.

o HealthWatch England

Healthwatch nationally and locally needs renaming because it is too narrow to reflect health and social care and its proposed name sounds like a regulator (think Ofcom) and risks confusion in the public’s mind with the Care Quality Commission.

“Carewatch England”, though not ideal, would be better because care in its broadest sense encompasses both what the NHS and what the social care system do together and that reflects the user experience.

o local HealthWatch (reformed & augmented Local Involvement Networks LINks)

What matters more than a name is this -  the body must not take a medicalised approach: people using health and care services are about much more than being patients (maternity services users for example and people with learning difficulties).

All members of the public have an equal claim to have their voice heard not just current “patients”.  Patient experience is one thing; public involvement quite another and the local body – whatever it is called – can and must do more of both.

Key Proposals for Strengthening Public & Patient Involvement

• LINks to become local HealthWatch, and be given additional functions and funding to:

Currently LINks are statutory bodies operating at local level. This must be maintained when they become Local Healthwatch (LHW). Otherwise  their current impact will be lost and their potential future impact with an expanded role will be attenuated.

If LHW become directly funded by Local Authorities, which are also statutory bodies, this will create an interesting governance relationship between two statutory bodies, one of which funds the other and holds it to account.

o Act as ‘citizen’s advice bureaus’, to sign-post users, and support greater patient choice in healthcare;

The CAB analogy is misleading.  LINks have no “shop front” or “high street” presence; most have a “host body” such as a Council for Voluntary Service or another 3^rd sector body and there are some private sector LINk “hosts”.

This use of “hosts” should disappear in the new Local Health Watch arrangements because “hosts” only provide support services but do not interface with the public to discharge LINk responsibilities.

There is no indication that Government wants a presence for HealthWatch in the local community analogous to the Community Health Councils abolished in 2003 which had premises and staff and promoted public access to their services.  Things have moved on since then and using websites, leaflets and other interactive means to “signpost” to services and increase patient choice in health AND social care (the role across the HSC sectors must be stressed since that is what LINks do now as statutory bodies and it must not be lost) is a good idea.

o Act as complaints advocacy servicers, replacing the existing Independent Complaints Advocacy Service (ICAS);

This may seem superficially an attractive proposition, but it would turn out to be a fatal error to introduce complaints-related work to the LHW role. There is no doubt that the unified complaints and redress process spanning health and social care which was created in 2009 needs to be better publicised and used by the public. The current complaints processes are disjointed, difficult to access and not meeting the needs of service users or anyone else. But this does not mean that an integrating role should be given to LHW. This would in our view fatally skew its activity and doom it as an effective enabler  of local voices.

Complaints advocacy is a specialist service and is best commissioned from specialist providers.  The current ICAS service has not been properly evaluated and it should be before any changes are made so lessons can be learned.   Health Watch England could commission complaints advocacy services  (there are existing providers of the service which is currently commissioned by the DH), but it should NOT become a provider of complaints advocacy.  Many CHCs found themselves doing little else but handling complaints which exhausted the staff and often put them into confrontation with hospital providers (they had no primary care or social care remit).

If Local Health Watch had a complaints and advocacy remit and worked across health and social care in its entirety, this would sink them with workload and consume considerable resources. It was the undoing of the Healthcare Commission.  Complaints should continue to be handled through local resolution (commissioners and providers must get better at this as the Ombudsman repeatedly stresses in her reports) and the Ombudsman in England should remain the destination for escalated complaints that cannot be resolved locally.  The present arrangements, therefore, should not change.

o Visit provider services to inspect.

This must be explained because “visit” may not have the force as the present “enter and view” powers which LINks exercise as local statutory bodies.  Whatever Local Health Watch does vis a vis commissioners and providers of health and social care services, it must be no less extensive that “enter and view” is currently.

• Local authorities to be the funding bodies for local HealthWatch, as well as contracting their services. They will also be responsible for ensuring that local HealthWatch is held to account for delivering cost-effective services, and that their activities are representative of their local community.

The proposals make no mention of “host bodies” for LHW in the way that LINks currently relate to “hosts”.  Instead, local authorities are described as both funding and “hosting” LHW.  That is right. There is no need for intermediary bodies to hold the money and provide support services.  It is a confusing governance relationship and anecdotally has resulted in confused working relationships. Each LINk should be accountable to its sponsoring Local Authority according to a national model contract and with sufficient funding to carry out its role in the local area.

• Local HealthWatch will be able to report directly to HealthWatch England instances of poor health or social care. HealthWatch England will sit within, but not be a wholly owned subsidiary of, the Care Quality Commission.

The positioning of Healthwatch England within – but not as a wholly owned subsidiary of – the Care Quality Commission is an opportunity to develop a synergistic relationship between it and LHW towards the quality regulator. Additionally, Healthwatch England could take on the developmental function of the short-lived National Centre for Involvement.   That would be a positive move, by promoting and sharing good practice.

Improving Integrated Working

• Under the proposals contained in ‘Liberating the NHS’, people using services will be given more choice over provider, treatment and care.

This is right.  But information must be road tested with potential users to ensure that it is given in usable formats and actually supports making choices.  Websites such as NHS Choices and Patient Opinion (a social enterprise) should be developed further for this purpose.  In addition, HealthWatch England should post performance data relating to each GP practice which the NHS Commissioning Board contracts with in England.

• Personal Budgets will be extended in NHS and social care, facilitated via joint needs assessments and care-planning.

This is right. The major users of personal budgets are elderly people with complex conditions and younger physically or mentally disabled people  with long term conditions.  An integrated health and social care budget, reflecting assessed and changing needs (the onerous burden of requesting  reassessment must be addressed) would drive choice and also create a market for specialist bodies including third sector bodies and social enterprises to enter the “brokerage” market.   The budget must reflect the agreed personal care plan.

• Quality Standards will be developed to span care pathways, e.g. NICE dementias standard, and be supported by CQC in its role as inspectorate of essential quality standards.

This is right.  Another area for quality standards spanning pathways is long term neurological conditions.  The NHS for LTNC (2005) already contains “quality requirements” which are in effect standards applicable to all long term neurological conditions.  Year of care  commissioning pathways already exist for motor neurone disease and Parkinson’s disease and soon for multiple sclerosis. Because these reflect the NSF, they are ready made to be combined with quality standards which CQC can use in its inspecting role. More information about this is available from Neurological Commissioning Support.   www.csupport.org.uk This service was praised by the Secretary of State for commissioning innovation in his evidence to the Health Select Committee recently.

• Payment systems will be aligned to support joint working, e.g. Payment by Result (PbR), and proposals to penalise hospitals with poor readmissions rates.

The proposal to penalise hospitals for readmissions  has merit, but must be more sophisticated.  Breakdowns in community services over which the discharging acute facility has no control must be addressed through better integrated commissioning; otherwise it is simply buck passing.  Payment by Results (in effect by activity) must become Payment by Outcomes Achieved.

• Providers will be ‘freed-up’ to innovate in line with the needs of local populations, e.g. Foundation Trusts expanding into the provision of social care.

There is everything to be gained from innovation and integration that reflects the needs of local populations and is sensitive to their experiences of local services.  That is what any user-led business should do.  But integration must not lead to takeovers and cartels that in effect have the opposite effect by restricting choice and stifling innovation for institutional or professional group self interest.

The expanded role of Monitor will be key in this regard.  Foundation Trusts should become the independent social enterprises originally envisaged for them as “community benefit corporations” controlled by their members and accountable to their Governors.

• New commissioning arrangements, i.e. GP commissioning consortia, will facilitate better joint commissioning, e.g. in relation to children, or older people, with consortia being required by statute to ‘work with colleagues in the wider NHS, and in the social care’.

Of course and the sooner the better.

Health & Wellbeing Boards

• There is also a proposal to formalise joint working on health and well-being, via a statutory duty placed on local government to establish a ‘health and wellbeing’ board. An alternative proposal is to allow local partners to design their own arrangements.

It should be a statutory duty.

o If Health and Wellbeing boards are to be mandated, their functions are proposed as being:

• assessing the needs of local populations and lead statutory joint needs assessments;

Agreed.

• promoting integration and partnership across the NHS, social care, and public health;

Agreed.

• supporting joint commissioning and pooled budget arrangements (where all parties agree that this makes sense)

Agreed.

• undertaking scrutiny, especially in relation to major service design – in this capacity it would replace Overview and Scrutiny Committees (OSC).

Agreed. And the presence of independent lay people on the Board who are not elected councillors is essential.  This is because in many authorities, the majority party is in such a dominant position that effective opposition and challenge is not possible and the boards and their expanded scrutiny function would suffer because of this.  Such independent lay members of health and wellbeing boards should be publicly recruited and rewarded on the same basis as elected councillors serving on the board. They could be made accountable to the NHS Commissioning Board for discharging their function.

o It is anticipated that boards may split their functions in some areas, and that they would also replace some existing health partnerships to reduce bureaucracy.

Agreed.  Boards could and should replace Local Strategic Partnerships and such arrangements.  Their meetings must be advertised to and open to the public to attend.

o The boards would comprise of:

• Local elected representatives, including Council Leaders or Directly Elected Mayors;

Agreed.

• Representatives from Social Care;

This is ambiguous.  It should be specifically commissioners of social care, not the providers.

• NHS Commissioners – from the local GP consortia and where appropriate from the NHS Commissioning board;

Agreed.

• Local Government representatives;

Agreed.

• Patient Champions – including local HealthWatch;

See views above about the need for independent lay members, their role is distinct from  “patient champions”.

Representatives of provider organisations, although this would be discretionary.

This should be treated with caution as providers have different interests to those outlined for the health and wellbeing boards.  In a pluralistic market where the local NHS is no longer the preferred provider,  a provider presence in any event could be difficult.

o In the event of a serious concern over a proposed service redesign, a Health and Wellbeing board could refer a decision to the NHS Commissioning Board, which could further refer on to the Secretary of State in the event that the Board was still unsatisfied, under advice from the Independent Reconfiguration Panel, Monitor and the CQC.

Agreed.

Local Authority Leadership for Health Improvement

• The abolition of PCTs will see a transfer of responsibility and accompanying funding to local authorities. A key plank of this will be their greater use of Public Health functions, and the appointment of local Directors of Public Health.

This is right.

• Local Authority health improvement activities will be complemented by the creation of a National Public Health Service (PHS), which will;

This is right.

o Have powers in relation to the NHS, matched by corresponding duties for NHS resilience

This is right.

o Support the Secretary of State to ensure that the NHS is resilient and able to be mobilised during emergencies.

This is right.

o Jointly appointed local Directors of Public Health with local authorities, who will be responsible to both their local authority and to the Secretary of State (via the PHS), and will have ring-fenced budgets, allocated by the PHS.

This is right.

o Agree, with the Secretary of State, how local authorities will achieve national set health improvement outcomes at the local level.

This is right.

Taking the proposals forward.

o health improvement functions will transfer to local authorities from 2012.
o Statutory partnership functions would also be established formally from 2012.
o However, if the idea receives positive support, the Departments of Health and Communities and Local Government will support local authorities to establish shadow arrangements with the PCT, emerging GP consortia and LINks in 2011.
• The Government proposes to make the changes through its forthcoming Health Bill, planned for introduction this autumn

This is the right process.  Rapid transition is required.

Questions The consultation asks 17 specific questions:

1. Should local HealthWatch have a formal role in seeking patients’ views on whether local providers and commissioners of NHS services are taking account of the NHS Constitution?

Yes, LHW, as LINks are currently, should be a membership body (individuals and organisations), whose role is primarily about involvement, engagement, listening and communicating views as well as being eyes and ears about quality of services and user experiences. Locally, there is scope for developing relationships between LHW and Foundation Trust Members and Governors and with patient participation groups which all GP practices should be required to support as a condition of being part of a commissioning group.

The reference to the NHS Constitution is essential and LHW must ensure that local commissioners and providers of NHS services are taking it in account.

LHW relationship to the new “OSC” function of the local authority through the health and wellbeing board and also the CQC  as the HSC quality inspectorate are essential ones to develop.  This is quite different from what Healthwatch England might do as a non-membership body.  Equally, Healthwatch England should NOT be the national body representing LHWs.  That would invite a revival of the worst aspects of CHCs and ACHCEW and confuse the issue about to whom LHW was accountable (it must the commissioning local authority).

2. Should local HealthWatch take on the wider role outlined in paragraph 17, with responsibility for complaints advocacy and supporting individuals to exercise choice and control?

No for complaints advocacy; yes for helping individuals exercise choice and control.  See views above.

3. What needs to be done to enable local authorities to be the most effective commissioners of local HealthWatch?

A national template contract setting out clear deliverables and accountability lines is essential.  LHW should be “host free”.  LINk host bodies are coming to the end of their three year contracts.  This model should not be renewed because introducing intermediary bodies simply obfuscates governance,  accountability and wastes management resources.

LINks are statutory bodies and this should also be the case for LHW.  They should be established as budget holders and employers in their own right, accountable to their local authorities for their performance against national standards and compliance with a national contract.  This means each LHW should hire and manage its own officers and get the service they need to carry out their roles, something most of them are not able to do at the moment because the Host stands in the way of their independence.

LHW will need a much higher profile and access to the public.  This might, but does not have to mean premises due to the high costs and physical access issues involved.  It is something that should be negotiated with the sponsoring local authority.  LHW as a virtual but easily accessible and responsive body is the vision.

4. What more, if anything, could and should the Department do to free up the use of flexibilities to support integrated working?

For the statutory service, Section 75 agreements  and “virtual” trusts such as for children’s services are already a possibility and their use needs much clearer explanation.  From the user perspective, it must be made clear at every opportunity that LHW’s remit is to work across all health and social care, whether provided by NHS bodies or non-NHS ones commissioned to provide NHS services.  LHW should go where patients and clients go who are using publicly funded services regardless of the provider.

5. What further freedoms and flexibilities would support and incentivise integrated working?

A solution will have to be found to the perceived barrier presented by the pension arrangements of public sector workers. This is the biggest block to incentivising the creation of mutuals and other employee ownership approaches to delivering services.

6. Should the responsibility for local authorities to support joint working on health and wellbeing be underpinned by statutory powers?

Yes.

7. Do you agree with the proposal to create a statutory health and wellbeing board or should it be left to local authorities to decide how to take forward joint working arrangements?

It must be a statutory duty.

8. Do you agree that the proposed health and wellbeing board should have the main functions described in paragraph 30?

Yes.

9. Is there a need for further support to the proposed health and wellbeing boards in carrying out aspects of these functions, for example information on best practice in undertaking joint strategic needs assessments?

Yes, the board will need to be well supported.  Their interface with Local Strategic Partnerships must be clarified.  No reason why the Boards could not absorb the LSP functions in order to reduce duplication and management costs. They should have no less than the level of local authority analytical and administrative support available to Health and Adult Social Care OSCs currently.

10. If a health and wellbeing board was created, how do you see the proposals fitting with the current duty to cooperate through children’s trusts?

Yes, they are complementary.

11. How should local health and wellbeing boards operate where there are arrangements in place to work across local authority areas, for example building on the work done in Greater Manchester or in London with the link to the Mayor?

These issues should be for local discussion and agreement, eg in London the boroughs and the Mayor must work out a way forward.

12. Do you agree with our proposals for membership requirements set out in paragraph 38 – 41?

Yes, with the inclusion of independent lay members are discussed above.

13. What support might commissioners and local authorities need to empower them to resolve disputes locally, when they arise?

The NHS Commissioning Board must address this but it must not become the automatic destination for local disagreement; local resolution must be enabled to work.

14. Do you agree that the scrutiny and referral function of the current health OSC should be subsumed within the health and wellbeing board (if boards are created)?

Yes.

15. How best can we ensure that arrangements for scrutiny and referral maximise local resolution of disputes and minimise escalation to the national level?

The NHS Commissioning Board must address this but it must not become the automatic destination for local disagreement; local resolution must be enabled to work.

16. What arrangements should the local authority put in place to ensure that there is effective scrutiny of the health and wellbeing board’s functions? To what extent should this be prescribed?

This will need to be consistent across England and must therefore be included in Directions consequent on the passage of the Health Bill.

17. What action needs to be taken to ensure that no-one is disadvantaged by the proposals, and how do you think they can promote equality of opportunity and outcome for all patients, the public and, where appropriate, staff?

We do not have the wisdom of Solomon to answer this.  It is not possible to say that no one will be disadvantaged by these proposals, eg some may lose their jobs.

18. Do you have any other comments on this document?

This document has much “greener edges” than others in the White Paper series; there is much to address in the definitive proposals that will underpin the Health Bill in the autumn.

That’s the way to do it?

A debate is ramping up in the GP press – Pulse online is required viewing – about how (or even if) GP commissioners can make savings by doing things better vis a vis secondary care (aka hospitals) than PCTs generally manage to achieve.  Everyone knows that acute trusts are past masters at maximising income.  And the games some play would put a chess grand master to shame.

That’s how they’ll do it

I was taken by this contribution on the subject from Dr Michelle Drage, joint CEO of Londonwide LMCs .  As GP professional bodies, they know a thing or three about the system and its perversities.  This is how she said GPs would do it, meaning reduce expenditure on secondary care and improve primary care:

The first thing GPs will do is put a stop the tricks that NHS trusts play to generate more income from the same episode. And the coding games.

Then they’ll stop unnecessary admissions through A&E and other revolving doors.

Then they’ll work with clinicians to help them get the admin support they need to prevent patients coming back to GPs with no information so they get referred back unnecessarily.

And they’ll help consultants who use 85% of the budget manage their systems and workload in context with that of GPs who see 90% of patients with only 15% of the funding.

And services will be commissioned based on primary care need, not hospital income generation or colleagues’ favourite types of procedures.

And then they’ll make better use of the funds released so that patients in general practice get the best holistic general practice possible, not a service which only allows 10 minutes per patient, and that in turn will mean more appropriate referrals to hospital, greater patient satisfaction, and less unnecessary work for hospitals.

That’s how they’ll do it.

Hospital charivari

At this point an observing Mr Punch would squawk “That’s the way to do it!”  And it sounds good I admit.  But hang on.  The more switched on GPs in practice based commissioning clusters have been trying these things already with strong PCT encouragement.  Have referrals to A&E and demand for secondary care generally gone down?  It doesn ‘t look like it from national data and our own local experience in London.

The Nuffield Trust’s recent analysis of the rising trend in emergency admissions highlights how costly and largely preventable many admissions are especially for older people.  Big variations exist between areas and there is no clear link with deprivation.  That suggests the phenomenon has something to do with variations in the clinical knowledge, skills, attitudes and behaviour of the referrers -  in other words this trend is linked to what GPs do (or more accurately what many don’t do to prevent these admissions).

The perils of success

Dr Drage and her progressive colleagues have their work cut out turning that around.    And here’s the sting that may scupper success.  If all of this prescription worked (and we sincerely hope it does because we have waited far too long for it), then the inevitable, inescapable, inevitable and incontrovertible consequence will be a drop in hospital income. Possibly a significant and sustained one.

When demand drops and stays down, secondary care providers will have to respond with reduced capacity and prices (fewer wards, people, procedures and lower costs).   That could put the rising stars of GP commissioning on a collision course with local defenders of well-loved but threatened institutions.  They both can’t succeed.  We back the GPs.

Is that the way to do it?  Our  crystal ball is a bit blurry about that.  But whatever happens, a ringside seat is advised.

MAC neurological clients praised for commissioning innovation

It’s great when the Secretary of State for Health singles out a MAC client for praise.  It happened this week in front of the Health Select Committee, no less, when Mr Lansley was giving evidence about his proposals in Liberating the NHS for instituting radical bottom-up changes to commissioning in the NHS in England.

NCS singled out for praise

MAC has a particular interest in things neurological, stemming from the years I spent doing health promotion in the epilepsy world during the ‘70s and ‘80s.  And of course more recently MAC helped the Motor Neurone Disease Association create the year of care commissioning tool for MND and then went on to work with Neurological Commissioning Support (NCS) service  (a joint initiative of MND Association, Parkinson’s UK and the MS Society)  and Beetlebrow web designers to move neurological year of care commissioning tools on to an interactive web platform.

And there was Mr Lansley  this week saying that the NCS was an example of commissioning innovation and expertise coming from the Third Sector which was “just the kind of initiative we should look to see happening”.  (ref 11:48:08 in the podcast).   We could not agree more and hearing him say it made all the hard work worth it.

Get neurological about long term conditions commissioning

Now the challenge, of course, is to make sure that the new commissioners in GP-led consortia get this message. We talked about neurological opportunities recently in terms of the revised Operating Framework for the NHS in England. And more recently the proposed Outcomes Framework has appeared.   This has no neurological content other than stroke treatment and rehabilitation (important though that is).  So there is a job to do to identify what it does say about the quality of life for people with long term conditions with long term neurological ones so people realise this is about more than diabetes, angina and COPD.

Another source of help which we were involved in to make commissioners ‘neurological about long term conditions’  is the new Guide to Shaping Services published under the auspices of the Neurological Alliance’s Regional Development Project . Its focus is on supporting both staff and volunteers in that network to engage with commissioners – at whatever level – in productive and practical ways.

Switching on commissioners does not have to be an uphill battle, even though “neurological” doesn’t appear anywhere in the 72 pages of the latest Outcomes Framework.   Commissioners should be reminded that there are already very good metrics for long term neurological conditions devised at the time the National Service Framework for LTNC was created in 2005 and updated since then .

Better neurological metrics and the Outcomes Framework

As we are at the mid-way point in the ten year NSF plan for Long Term Neurological Conditions, what better time than now to dust off the LTNC “better metrics” indicators and link them to the domains of the new Outcomes Framework supporting Liberating the NHS?  They provide clinically relevant measures of performance to support the development of measurable local targets and indicators for local quality improvement projects for people with LTNCs.

That’s what Mr Lansley says he is looking for.  MAC will ensure we make that point in our response to the consultation. We hope others will do likewise.

Freedom NHS – an Electric LINk for a Citizen Commissioner?

If you can get past the alliterative battering of the title of their newsletter, the Delib Digital Democracy Digest (well you were warned), there is some interesting stuff about the Your Freedom site calling for citizens’ ideas – their reactions, uses etc. What it set off for me was whether the NHS needed a dedicated Freedom site of its own since Health was not included in the Topic Tags. It comes up as part of the ideas posted e.g. Abolish NHS Direct and scrap the national NHS IT programme. I though it would be bound to have something on that top of the list health topic – paying for parking at hospitals – but nothing came up.

We already have a limited idea of what a NHS Freedom site would contain from current sites like Patient Opinion and others which offer a space for patients to sound off and suggest change on the basis of their individual experience.   Contributors to those sites are not asked for their views on the NHS big picture.

The Partners all have worries about the patient/ user/ citizen voice being heard in the current rush to change – see Caroline’s piece on changes in schools and closer to the Health agenda, Andrew has written about the relationship between the new Healthwatch and the existing LINks.We are also worried about GP-led commissioning given the lamentable record of many GPs in patient participation and engagement - Balham Park Surgery honorably excepted. (Read our report on how they manage patient participation and if you want to know more speak to Natalie Goldsmid-Whyte our latest Associate – the Managing Partner for that practice).

Electric LINks – a participation mash-up

E-communication channels are changing the face of consultation. Our recent training of lay representatives had an entire session devoted to using the web and email to do that job. The old stereotype of oldies crumbling in terror at the thought of opening a computer is fading fast. I am sure that soon we will be communicating much more on health matters using the web. Can we look forward to the Electric LINk. All LINk sites could be linked to it and all minutes and published material from individual LINks would be visible and useable. The material would be available to all under a Creative Commons-like licence and be used as a mash-up to bring together the user and citizen opinions.

A Citizen Commissioner – an agent of revolution

Pulling together this material and using to formulate and test the arguments and bring them to the attention of national decision makers would be a new type of person/role whom we will call the Citizen Commissioner. A whiff of the incorruptible seagreen of Carlyle’s French Revolution (see Robespierre’s end left) – but turning our back on history, this would be  a useful job which will sit at the centre of the web of user information, experience and ideas to pull together and give due weight to the citizen voice. It will stand for independence and a degree of detachment from the NHS and Whitehall machine and be there for the citizen in a way much closer to the original Swedish Ombudsman than the complaint handler that the UK versions now are. Could such a Citizen Commissioner be a post in the new Commissioning Board?

Government 2.0 – September Conference in US

Perhaps we should set up an event like the second Gov 2.0 Summit being held in Washington DC on 7-8th September where the role of IT in changing the way we interact with our government is at the centre of the agenda. No one on the list of speakers I saw on the site is from the UK government or any other UK organisation which is a shame. Last year’s was a sold out event. We will have to hope that someone from Delib will go and tell us all about it. If they can’t make it, I’m free if anyone fancies paying the air fare. Thank goodness it does not clash with Vinea the big wine fair in Sierre in the Helvetian canton of Valais. There are some things that never will be done on the web and wine tasting is one of them.

Turning government on its head – we hope so

To coincide with the publication of Liberating the NHS, the Department of Health has published its departmental priorities in the form of a Structural Reform Plan.  SRPs are required by the Coalition Government from all government departments.

Head stands

SRPs are designed, in the word’s of the DH one,  to turn government on its head, taking power away from Whitehall and putting it into the hands of people and communities. Once these reforms are in place, people themselves will have the power to improve our country and our public services, through the mechanisms of local democratic accountability, competition, choice, and social action.

This will be a neat trick in more than one sense of the word if it can be achieved.  We hope it can, because the first priority in particular strikes a strong chord with us about user participation and control of public services.

New priorities

1. A patient-led NHS –  Strengthen the patient’s ability to exercise extended choice, to manage their care and to have their voice heard within the NHS

2. Shift resources to promote better healthcare outcomes – Shift focus and resources towards better healthcare outcomes, including national healthcare outcome measures, patient-reported outcomes and patient experience measures

3. Revolutionise NHS accountability – Create a long-term sustainable framework of institutions with greater autonomy for doctors and nurses, and greater accountability to patients and the public, focused on outcomes

4. Promote better public health – Promote better public health for the nation by centring the Department’s focus on public health, developing a clear strategy and partnering with the voluntary and private sectors

5. Reform social care – Enable people needing care to be treated with dignity and respect; reform the system of social care to provide much more control to individuals and their carers, easing the cost burden that they and their families face

Two observations

First, why have we had to wait so long for something like this? These are the obvious things for a government department responsible for health, well being (public health) and social care to be doing in the first place! Let us hope there are enough talented and committed people left when the department is slimmed down to achieve them.

And an elephant warning

Second,  priority 5 about reforming (adult) social care will turn out to be the hardest to achieve. It is the elephant in just about every room you care to enter.  There is no consensus on form or funding.  That was amply demonstrated by the pre-election squabbles about funding processes and affordability.

The Coalition Government has promised a commission on social care to look at all the options. We know what these are likely to be of course.

There should be a government “vision for social care” by the end of this year, with a white paper in 2011.  The Social Care Commission, when established, will report within 12 months on social care funding options.  The White Paper states: The Commission will consider a range of ideas, including both a voluntary insurance scheme and a partnership scheme. As a key component of a lasting settlement for the social care system, we will reform and consolidate the law underpinning adult social care, working with the Law Commission.

We wish this well.  But if you thought GP commissioning was going to be a punch-up, just wait until we really get into social care funding and provision for a burgeoning older population and the many more people with disabilities who are living for much l0nger.

That will really be the main event.  Tickets available from the usual outlets very soon.  Book early for a ringside seat.

Liberation root and branch style

Liberating the NHS the new Health White Paper on “equity and excellence” could turn out to be, in Chris Ham’s prophetic words today, the “biggest organisational upheaval in the health service, probably, since its inception”.  This is about England only of course: the contrast with the other three countries in these islands will now be even starker.

Shaping the new order

Speaking in the Commons this afternoon as the document was published, Secretary of State for Health Andrew Lansley said his objectives were putting patients right at the heart of their care, putting clinicians at the heart of decisions about services and achieving health outcomes comparable of our neighbours.

We are to have an outcomes framework identifying what the health service should achieve and it will be up to the professionals (in collaboration with the public and patients if Lansley is serious about “no decision about me without me”) to say how it should be achieved in each part of the country.

Some of the other highlights of the new order include:

• A payments system that acts as a driver for quality, safety and integrated care not just a reward for activity (very welcome)
• Decision making as close to patients a possible, including patients with long term conditions having budgets (we hope for health AND social care combined) to make real choices about their care.
• Real, local accountability: Local Authorities will agree local strategies to integrate NHS, public health and social care together.  (fine, assuming councillors rise to the challenge and there isn’t likely to be extra money for cash-strapped authorities)
• Consortia will commission NHS services in line with the local health plan agreed with the local Council; this is how GPs will lead bottom up redesign of services:“GPs are senior professionals in public service and paid well for that.” No opting out.
• Patient choice over treatment options, including the consultant-led team that treats them, based on a torrent of information to guide informed choices
• Choice of GP practice and  power to control our own patient records. (no practice boundaries)
• Patient voices will be heard and acted upon by Healthwatch as a national body working through local healthwatch incorporating the current LINks (across health and social care which is essential)
• An English NHS “liberated from command and control”, including all NHS Trusts to be Foundation Trusts with power in the hands of their employees and users: “Our ambition is to create the largest and most vibrant social enterprise sector in the world.” (could help with getting assets off the government’s balance sheet and sort the pensions issue too)
• Any willing provider in the health care marketplace, provided they deliver to NHS standards and prices
• A more powerful Monitor as economic regulator and CQC as the guardian of safety and quality standards
• The NHS Commissioning Board holding the national GP contract, managing performance, allocating resources to commissioning consortia and leading specialised commissioning (big job all of that, any applicants on the horizon?)

Liberation is a double edged sword

MAC’s initial reaction to all of this – our deeper thoughts are for later –  is that what Mr Lansley is proposing  - and the devil will be in the detail of the coming consultations and the autumn Health Bill – could certainly be “liberating” both in an innovative but also in a chaotic sense (think Pandora’s box)  - and probably at the same time.  The phrase “constructive discomfort” comes to mind.

But there’s a catch. The NHS in England must save recurrently some £20bn by 2014 - “every penny saved will be a penny reinvested for the benefit of patient care” Mr Lansley said. That takes many steady eyes and hands on the job and some well placed voices are wondering if now is the right time to pursue wholesale root and branch change which will be very distracting in our largest and most expensive public service? Managers fashioning lifeboats for themselves may have concerns other than achieving efficiency savings.

Cromwellian thoroughness and speed

The reforms to commissioning and accountability aim to be Cromwellian in thoroughness and speed.  Andrew Lansley seems to be taking Tony Blair’s approach further and faster than anyone thought possible, but the difference is there seems to be a map this time.  Our modern day “major generals” (aka Strategic Health Authorities)  are being marched off to the Tower awaiting termination  - or as Mr Lansley termed it “disempowerment of bureaucracies” – by 2012, to be followed by PCTs by April 2013.

As we move towards then, will the crowd be shouting “behold the heads of tyrants” as we breath the free and pure air of GP commissioning, or will we just be too distracted to care?  And will there be anyone left in PCT land by then to turn off the lights, cancel the milk and put the cat out?

Whose NHS Is It Anyway?

What does it mean to be one of the owners of the most important public service this country has?  Most people using the NHS don’t think about that question and neither do the 1m+ people who work in it.  That’s a big part of the problem and that is what has to change if the NHS is to meet the demands made on it in the 21^st century.

Whose NHS Is It Anyway? will help people start thinking like owners and about what power sharing with patients and the public should be like.  That is what is needed to make participation and involvement part of the culture of public services, not an add on as it usually is.

Launched by the NHS Alliance  on 30^th June, Whose NHS Is It Anyway? is the product of many hands, including MAC’s, on the Alliance’s patient and public involvement steering group, led by Dr Brian Fisher, GP in Lewisham and the Alliance’s spokesman on user engagement.  MAC is pleased to host this resource on its site and recommends it to all our readers.  It is brief (only 15 pages) and practical – a double blessing for any policy document.  Above all it sets out an action plan which could make things better quickly, starting with shared decision making in the consulting room.

PCTs have an uncertain future in the new government’s plans, but whatever structure is adopted for commissioning, it must be underpinned by the full participation of informed owners of the service – that’s all of us.  One of the best things PCTs could do now is to help new commissioning consortia explore Whose NHS Is It Anyway? We pose these questions for those conversations:

• What works well now locally that can be built on?
• Where are the gaps and how can they be filled?
• Do we have the right user led intelligence to inform commissioning?
• Do we understand and practise co-production in determining what quality and responsiveness mean?
• How we do we handle complaints and redress and are we learning anything from this?

The answer to all of these is “could do a lot better is most places”. Whose NHS Is It Anyway? points the way to doing things a lot better. MAC is delighted to endorse it and to urge the new Coalition government to adopt its approach to ownership and engagement in the NHS and all public services.

For policy wonks, MAC’s responses to the questions posed in the consultation leading up to Whose NHS Is It Anyway? can be read here.

A long hot summer for user and citizen engagement?

The budget sparked a debate  about postponing retirement and getting your pensions.  Elder citizens and users who are involved in public engagement must be heard in any such  debate about retirement ages and reform of the job market. They frequently form a majority  of volunteers in citizen participant groupings and all too often get precious little thanks for that. Instead they are lumped under such derogatory labels as the ‘usual suspects’ with their (majority) presence seen as proof of a lack of diversity and a narrow approach to inclusion. It may be that such unworthy thoughts may even have flashed on rare occasions through my and fellow partners’ minds.

Not just valuable but vital

Only to be dismissed at once when at a recent training we did for Wandsworth NHS we met active and interested older volunteers who were a strong reminder of the value of this resource. As people often tasked to set up user panels as well as train them,  we readily acknowledge that many a participative venture would collapse without the time, energy and ideas that the older involved and retired citizen brings to the table. Is the prospect of working beyond the current pensionable age  a threat to this resource? We say no so long as we get the flexibility in the labour market that encourages part-time working. The new volunteer in this context would have a wider set of choices between paid and unpaid work which may well enhance the chances of their participation and at the same time increase the value of that contribution because they remain connected to the wider world through their paid work.

Eight New Laws of LINks

Certainly when we look at any form of future development for LINks, no progress would be possible without good quality people being ready and able to serve on and contribute to them. The elder community will remain an important pool of recruits. Andrew was very gung ho about LINks in his piece. He wrote that LINks must not only survive but take on a more robust role. To that end, he promulgates eight news laws for LINks – essential reading for policy makers we would say.

Reorganisation – flavour of the month

Reorganisation – how fast, how far, how good – crops up in almost everyone  of our blogs. Caroline Millar writes 12 years as a parent have provided many an example of how change gets sneaked through in the summer. Leading the charge for change in education, is the new Secretary of State for Education. Glinting in the sunshine of his new powers like the granite of his native Aberdeen, Mr Gove is granite-hard in his resolve to create Academies asap. In doing so he seems very ready to dump any commitment to consultation in his rush to deliver. He is of course ready to consult later when all the important stuff has got done. Why are citizens cynical about consultation do I hear you ask?

Trust the Teachers and GPs

Having identified  bureaucracy as the enemy of local change, local authorities in education and PCTs in health are being bypassed in favour of teacher and doctor power. Parents are also being urged to get involved in schools but the knowledge that entry to ‘their’ school will probably be by lottery  so their own children may not get in, is a bit of a bummer. However as graduates of the consumer movement in a number of its manifestations, three MAC partners have a superstitious reverence for the power of Young and so cannot dismiss entirely the chances of success for y0ung Young channelling his dad’s influence from beyond the grave to create a new school in West London. (It is an article of faith for all consumerists and others in the field of social policy generally that  ‘Michael Young later Lord Young of Dartington was the greatest British social entrepreneur of the second half of the 20th century’. Discuss using one side of the paper only).

GPs working within consortia are going to be the new commissioners of health and social care services. We have two immediate concerns. The first is the very uneven record of GPs in setting up effective and credible patient participation bodies. Secondly, our work with commissioners of long term and not so long term neurological conditions makes us very wary about GPs being able to take on this complex and often neglected area of clinical and social care practice. Andrew discusses his reservations in a head to head with Lynn Young of the RCN here.

More substantively, his piece Neuro Knees Up or Knockback? raises important questions on how best the Third Sector and in particular neurological organisations can safeguard what we know is a considerable investment in making the best of the commissioning system in place now. Reform threatens to waste this effort and set back their work in improving care for people with neurological conditions.

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