More radical leadership and thinking required

The NAO report said thinking and leadership around neurological services were not radical enough.  We concur.  We also think handing over to clinical commissioning groups will be troublesome, because there is no consensus about “what goes where” for neurological commissioning.  GPs historically do not have a strong affinity – which means most don’t know or care much – about neurological conditions.  The temptation will be to let this complex issue drop off the local commissioning table while they get on with diabetes and heart disease.

Power is at local level

What proactive line will the neurological 3rd sector community take to overcome this?  They need to up their game and switch on the local influencing power of their members (users and carers) and allies.   As we say in our memorandum to the PAC:

“Nothing about me without me” must be owned by people with LTNC in order to switch on the power of the patient and carer voice.

As the half-way evaluation of the Long Term Neurological Conditions NSF showed recently, and the NAO report underscored, wherever users of neurological services are, they are certainly not “at the heart of neurology commissioning” as they ought to be.

A scandal that must end

Until they are at the heart of everything that concerns them, people with long term neurological conditions and carers will still suffer the chaotic situation articulated by the recent NAO report.  It is a scandal that must end.

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.

Future Forum 2

Promoting individual better health and wellbeing

Note this is not “public health”, but THE public’s health, which is quite a different thing as it focuses on what individual health practitioners, particularly the GPs, nurses and therapists working in primary and community care outside of hospitals, could and should do with individual patients and clients to promote individual health and wellbeing.

This happens already in many places, of course, but not widely enough.  In the stone-age days when I qualified in health promotion, “health education officers” tried to do this and the clinical people left us to it as they got on with treating big toes, ulcers or cancer, relatively oblivious to the complex lives the conditions were attached to.  Now health promotion is (or should be) everyone’s business.

Whether the public will see it like that and take kindly to being questioned about lifestyle  - smoking, diet, exercise, alcohol consumption, even sexual activity perhaps?  - when they see the doc (or the midwife or health visitor) for something else remains to be seen.  But it’s a start to “making every contact count”, provided the workforce has the right attitudes and skills, which many probably don’t.  They will need help seeing it as part of their core role, not a time-consuming add-on.

Integration demands full implementation

“If implemented in full these proposals will make a real difference for patients and service-users. Among other things they will help tackle the curse of fragmented care and lift the NHS out of the information dark ages.”

So said sage Jeremy Taylor, CEO of National Voices and a FF stalwart.  That’s the catch – “if implemented in full”.  Warm words and good intentions won’t cut it.   Chris Ham, Kings Fund CEO, nailed this:

“Our concern is these are warm words and good intentions but in practice they won’t be as much as we would like. There are not enough specific actions the government is committing to, which would give more confidence this was a real watershed.”

There is no compulsion to deliver integrated services in the dog’s breakfast that is the current Bill.  Unless government fixes that urgently and obviously by instituting the measures  to promote integration we have already championed, I cannot see the FF’s vision for integrated services becoming reality.

No information no integration

National Voices did a submission to the FF on what patients, service users and carers want from integrated care.   Read it. It stressed that integrated care could not work unless information flows worked -  and by general consensus we are in the “dark ages” as far as information is concerned in the NHS.

One of the problems stems from relinquishing data control to IT geeks.  In Jeremy Taylor’s colourful phrase – he chaired the information workstream on FF2 – the information agenda has been “ceded to IT people, who had disappeared up their own technological complexities”.   We concur  and have argued many times for people to own their own data and for “data intermediaries” – specialist nurses working with people who have long term conditions for instance  - to partner with patients and carers for that purpose.

A snag for the moment is that mentioning IT and NHS in the same breath has ministers reaching for garlic, a cross and a stake. The idea of another NHS IT project monster  is anathema, but there is much that could be done through EMIS is everyone in primary care used it to its full potential and shared data with patients.

New Bill needed

Taking the recommendations in FF1 and FF2 together, we have all that needs saying about what sort of NHS England needs.  So why, then, is the Government – having accepted with alacrity all the FF’s recommendation – clinging stubbornly to the wreckage?  Their behemoth of a Bill is currently mired in the parliamentary process.  It is a sow’s ear of legalese that no amount of tweaking is going to turn into a silk purse of convincing narrative for change.

Throw the wreckage overboard and rewrite the legislation around implementing the FF1 and FF2 recommendations. If Mr Lansley is really listening to the FF “listening exercise” and has the foresight and courage to do what is needed, then he would have a credible reform platform, and a narrative to support it, on which we would all be pleased to stand with him.

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.

“Improving outcomes by working together”

That’s one reason why the joint Kings Fund/Nuffield Trust recommendations to the Future Forum and the DH on integrated commissioning are worth your attention.  Have they found the answer? Is this the map to the Holy Grail?  Much as we would like to be believers, we remain doubters. There is much more to “improving outcomes” than simply “working together”.   Here’s why.

Only a few pages into the report it is quickly apparent that merger and even institutional integration between health and social care is not on the agenda – not this one anyway. What they are talking about is integration of services around the needs of individuals (elderly people, children) with complex needs and many others with long term needs, including end of life care. That is all to the good but not new.  It should have happened a long time ago of course.  There is already a guide to this, the National Voices Principles of Integrated Care which the latest report endorses – and rightly so.

Social care elephant in the room 

There is a big policy elephant in the room: the vexed social care resourcing issue.  The report merely identifies this as a “barrier” to integration.  That it certainly is and the explosion it is going to cause  this spring when we finally have to bite the bullet on how to fund social care will rock the political foundations.  But  by far the biggest barrier to integration is the acute-focused clinical culture of most of the NHS and the local authority protectiveness of much of social care. These are like oil and water and, frankly, they need nuking.  Our view is that without organisational integration, common pots of money and buckets of inspirational and innovative leadership in the professions and councils, the “pace and scale” of change which the report says is vital is unlikely to happen. There are too many vested interests conspiring against it.

Patient and carer power?

Could patients and carers not rise up, charge the barricades and demand integrated services?  We’d like to see it happen.  Individual budgets may be one way to tunnel underneath the obstructions.  But it is not sufficient to talk, as the report does warmly, about personal health budgets. That is only part of the picture: we need integrated health AND care budgets for individuals – at realistic levels – as anyone with a long term condition will tell you who uses services across the sectors.

Patients and carers could leverage more power in the system in their role as budget holders.  But they need brokers and guides to act as agents and facilitators with service providers if they are to maximise their purchasing power and not to get ripped off.  Here is a big opportunity for 3rd sector bodies and for specialist clinicians like neurological nurses  - will they rise to it? We’d like to see that, especially now that there are strong signs that the NHS pension scheme will be extended to non-NHS providers.

More radical thinking needed 

The report is a prompt to address the cultural and institutional blockages stopping integration.  It is not just about resources. It is about more subtle things, including professional leadership and personal fulfilment. Peter Carter made this plain before the Health Committee last month: the impulse of good practice like integrated services has to be “encrypted into the culture”. Florence Nightingale might have said it differently, but not any better.

Until we develop more capacity in primary and community health care to deal with demand outside of hospitals, too many elderly, frail people and others with complex and long term conditions of all ages are going to end up there by default as the NAO report on neurological services shows.  This is bad for them and bad for the institutions that have to receive them.

The reality of NHS provision – and it does not have to be bricks and mortar, there can be “virtual wards” in the community – has not matched the political rhetoric about this goal. All governments share the blame here and a few glib targets will not turn the situation around quickly. Just look at who is occupying a high proportion of acute beds to see what the problem is when people cannot be cared for at home or in intermediate settings which are better and safer for them. Better yet, we need to prevent a much higher proportion of unplanned admissions in the first place.

Health and care are a continuum. We must break down the funding and cultural barriers between the health and care sectors and the rivalries and turf wars between professions. To achieve integrated services, professionals must do this in in partnership with patient leaders.

At bottom the Kings Fund/Nuffield report is well intentioned but simply does not go far enough with radical thinking.   The owners of the services – that means the public who pay for it and the people who use it – should demand nothing less.

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.

Cats and frogs

It’s been said that getting GPs to cooperate is akin to herding cats – or as my Dutch friends would have it “keeping frogs in a wheelbarrow”.  That aside, if GP Healthcare Federations were done well, they could create win-win situations for patients, public and clinicians (including the frogs amongst them).

Perhaps the way to get the frogs’ attention and persuade them is to consider the downside: if individual practices don’t take this opportunity seriously to work together with their communities, they may wake up to face an offer they can’t refuse coming from vertically integrating Foundation Trusts on their doorstep. Buying up primary care is a logical step for the consolidating acute sector to take.  I think that would definitely be lose-lose for both GPs and patients: loss of freedom for the clinician; loss of choice for the customer.

Federations more than a group of practices

The alternative to today’s vulnerable GP micro-businesses is community based provider Federations which go beyond just collecting practices together.  It is more than getting the covered wagons into a circle.   Federations have the potential to take primary care into an enterprising future if they took a logical step to become  Community Interest Companies (CICs).  They could also be commissioned to provide integrated health and social care and in which patients, carers, communities and clinicians all had a real stake and a say in the governance of a new type of social business.  This is something for GPs who don’t spend their waking hours sweating over the commissioning to think seriously about.

Some far-sighted GP Federations are already thinking along these lines. CCGs and Local Authorities may have this vision too.

Get the engagement right from the outset

I think that moving to the CIC governance form would be a great way to strengthen a Federation’s “commissionability” and competitive edge, especially if it wanted to diversify into doing business with the local Council about social care and create “thought leadership” with likely commissioners.  But it should not be done lightly, as it has serious implications for engagement as a core CIC activity.

As a CIC, the Federation would be required annually to demonstrate to the external regulator through its governance structures and the CIC’s activities that it was engaging with stakeholders within the community it served and, further, that this makes a difference to how the Federation does business.  The CIC definition of “stakeholder” includes not only patients registered with the practices but everyone living within the area served by the CIC in their capacities as both citizens and patients.

This mean it would need to find a range of different ways of engaging with stakeholders for different purposes at different times. Facebook, Twitter, virtual groups, electronic surveys etc all come in here.

 Start with practice participation

This duty will not simply be about patients having a say in their own individual care, but also about local people who may not currently be patients having a real stake in the running of the organisation.  That means seeing patients as customers, and as members and owners of the enterprise along with the GPs and their staff.

As a starting point, people registered as patients with the Federation’s practices can be regarded as a useful proxy for the wider population as a whole and the social capital and user-led intelligence harvested from them should be maximised.  Any work which is done to improve the quality and effectiveness of engagement within constituent practices will make a considerable contribution to ensuring that the governance requirement to engage with local people is met and will provide a basis for future work in developing stakeholder input into the CIC.

How it is presented to the CIC Regulator each year also needs careful thought; she will be more hard-nosed about what evidence to accept than the NHS is.  If all of the practices did the Patient Participation DES, as they should, it would be a lot easier of course.

Getting from here to there 

The view of Clare Gerada, chair of the RCGP is pretty clear about how she sees the problem:

 We need help, a sensible commissioning size and to concentrate on provider reform. What GPs do best is to get together as groups of practices, pull in the third sector and start sorting the big issues – end-of-life care, out-of-hours care.

Precisely.  The logic that springs from that is simple. The best provider reform GPs could embrace is with their colleagues in primary care (not all doctors by an means), their customers (patients and carers) and their communities (the public) in a Healthcare Federation and set it up as a thriving social business.  If they want a future that can withstand the tribulations of commissioning and fend off foraging Foundation Trusts, this looks like it.

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.

Lumped in with comms

The 2012-13 Operating Framework lumps communications and stakeholder engagement (which doesn’t seem to  include patients and the public) as a support function for developing the CCG: “Communications and PPE - Communicating and engaging with all stakeholders, managing the reputation of the NHS, media/press and FOI handling, briefing, campaigns and consultations.” 

Do these words matter?  In the case of ”engagement” vs “involvement” the answer is “yes”, rather a lot. “Engagement” implies a process of enquiry initiated by the NHS when and how it chooses.  “Involvement”, in contrast, implies a sustained, continuous and co-created process. Without involvement we can’t have any meaningful accountability.  It isn’t that engagement is wrong, just that it is insufficient on its own for the purpose of influencing decisions.   Sustained involvement is the key to this.

Framework can’t deliver involvement

The Operating Framework won’t deliver involvement, quite the opposite in fact. The “model” contained in Appendix B “Developing a communications and engagement commissioning support service” sets out a hard line centralist approach with “do once” messages devised centrally and then delivered locally.

This boils down to a bromide:  1) Tell your audience what you’re going to tell them.  2) Tell them.  3) Then tell them what you told them.  4) Job done.  5) Engagement box ticked.  That’s what PPI in the new order will come down to, it appears, and clinical commissioning groups won’t even start doing that until mid 2012. What happens in the interim one wonders?

There is nothing here about bottom up involvement or community development or leadership from patients, carers and members of the public.   And there are phrases about what the service will cost  -“best price possible” etc, –  which raises the real possibility that CCGs as “customers” are going to have to pay for this “support”.

If I was a GP with a stake in local commissioning I’d be pretty hacked off about being handcuffed like this.  They need to communicate and involve now if they are going to make the kind of changes that QIPP savings demand, not a year from now.

This OF is supposed to get us well into 2013 when CCGs take over; I wonder if we will make it that far? As Harold Macmillan was wont to say “events, dear boy, events” are always the greatest challenge.  And you can be certain that during 2012 that NHS will have its share of “events”.

Much more than Healthwatch

“Engagement” in the OF really comes down to what Healthwatch will do – assuming the pathfinders for Local Healthwatch survive and flourish. But even if so, that is far from enough. The OF skates over the 2nd domain in the authorisation pathway that is all about patients, carers and communities (and is quite robust on the evidence needed for involvement). Strange that.  Persuading people of the need for change involving known and loved local services is hard enough when done well.  Central policy locally delivered will not be up to the job.

No involvement, no legitimacy or support for change 

Where will the local knowledge and sensitivities about interacting with diverse local communities come from? Not from this Operating Framework, that’s for sure.  Co-production? Community development?  Shared decision making?  You may well ask.  And there is a warning about what happens when “a new order of things” is introduced in the wrong way.  It should be Mr Lansley’s bed time reading:

“And one should bear in mind that there is nothing more difficult to execute, nor more dubious of success, nor more dangerous to administer than to introduce a new order of things; for he who introduces it has all those who profit from the old order as his enemies, and he has only lukewarm allies in all those who might profit from the new.”

- Niccolò Machiavelli, The Prince (1532)

The Moore Adamson Craig Partnership supports user and public participation,  trains lay representatives and develops responsive  health, care and education organisations.

We don’t have the NCB in place yet – and it won’t be fully operational until 2013 – but we need it right now.  Too many cart-before-horse changes can happen locally in the interim that are not in the interests of users or the public.  If the NCB’s new chair isn’t clear about its role and relationships, we should be worrying.

Confused or just wrong – it amounts to the same thing. 

He ignored involvement, but Prof Grant did say something quite astonishing about governance and management.   He asserted to Stephen Dorrell and the members: “ It is absolutely critical to be clear about the difference between governance and management. David Nicholson will have responsibility for managing the Board. The Board will have responsibility for governing.” 

Quite so. Clarity on this is essential.  But clarity isn’t what he gave us.  “Responsibility for governing what?” and “Governing in whose interests?” are the big unanswered questions. If Prof Grant really thinks the role of the Commissioning Board’s CEO is “managing the board”, then he might as well give “Big Beast” David Nicholson the boardroom keys now and be done with it, because the non-executive board members won’t get back in the driving seat once Nicholson and his executive team are up to speed.

If this is just a terminological confusion and what Prof Grant really meant to say was that Sir David would be “managing the work of the Board” that’s a different matter. But we were left none the wiser about his intended meaning at the end of his appearance in front of the committee. And that is worrying in one about to take on such a key role.

Moral owners

If a CEO – any CEO –  ends up “managing the Board”, then why have a chair and non-executive directors and their associated costs in the first place? Boards must not be fig leaves or rubber stamps. And they are not – write this out 100 times – the top tier of management.

Prof Grant claims to want clarity about governance and management.  He should include in the list that key concept in healthcare –  “ownership” –  because that would help get things into focus.  Who are the owners of the NHS in England that the Board is acting for? Starting to think about this with Caroline Oliver’s essay on the subject would be a good idea.

The answer is that the Board of the NCB must govern in the interests of the people of England who are the moral owners of the NHS in England.  Boards are there to represent the interests of the owners.  We have posed in many ways and in many places the key question: “Whose NHS is it anyway?”  The answer is “not David Nicholson’s or Andrew Lansley’s or even Professor Grant’s”.

Mandate and deliverables 

The mandate the Board will receive from the Secretary of State every 2-3 years is about deliverables and outcomes.  This is a radical process and Prof. Grant’s views on what it means for accountability are illuminating.  As he told the Health Committee in widely reported terms:

[what] that does is effect an extraordinary transformation of responsibility within the NHS. …  It is passing over the responsibility and then allowing the Secretary of State, through the mandate, to hold the Board accountable against the objectives that have been set for it. It is then for the Board, through its relationship with the clinical commissioning groups, to hold them accountable for the objectives that are set for them. It allows us, for the first time, the possibility of tracking accountability and responsibility through a system and, what I would see as being the prize to fight for, restoring to the NHS the stability that it needs away from day-to-day political interference in its priorities. You may worry about the ultimate political accountability. It remains secure, but it requires a Secretary of State to define upfront what he or she wants the Board to be accountable for and to hold the Board accountable for it.

In other words, how the NCB carries out the mandate should be up to them and their formative relationships with the myriad CCGs, without feeling the hot breath of Ministers on their collective necks. The Board members will not manage this complex task themselves, of course, but delegate to the CEO and his executive team the necessary authority to achieve the mandate’s deliverables on their behalf (which means on our behalf of course), monitoring performance and holding Nicholson to account.

Governing on our behalf

The Lords can accept as many amendments as they wish to what Prof Grant has already termed an “unintelligible” bill, underlining the ultimate responsibility of the Secretary of State to provide a health service in England. That is about accountability to Parliament. It does not change the moral ownership relationship of the public to the NHS and the accountability of the NCB Chair and Non Executives to govern on our behalf.

The message Prof Grant has to hear is this: The Board of the NCB must act (govern) on our behalf as the moral owners.  If the NCB does not do this, the default is that centralised bureaucratic control in the shape of the Big Beast and the executive directors will end up pulling the NCB’s strings.

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.

Customer Insight for Business Foresight

We’re pleased to see the “insight” word in this NCB Director’s title.  MAC has banged on for years that without customer insight, no primary care commissioner or provider – or any other healthcare business for that matter – can have the business foresight necessary for success.

The new Director with the longest title in the NCB will have his or her work cut out. Too bad that it will take until 2013 for the NCB to be fully up and running.  We need it now before the hundreds of Clinical Commissioning Groups (CCGs) – some clearly not large enough to be viable – start dashing off madly with little central guidance and not giving community engagement much of a thought.  Remember the old proverb: “If I wanted to get to there, I wouldn’t start from here”.

Choice and integration cannot both be masters

One of the paradoxes which is emerging as we dodge the potholes along the reform route is the tension arising between the emphasis on the patient’s choice of provider when they need elective procedures and the desire of commissioners – with the strong encouragement from Nicholson and soon from the NCB –  to have integrated services and common pathways for everything one can think of from urgent care to long term conditions.  The fact is you can’t have both in equal measure: a balance has to be struck that is acceptable to users and carers and makes sense in terms of clinical efficiency.  Choice and integration cannot both be masters if the English NHS is to lay any claim to affordability and coherence.

Some people contend that patients don’t want choice about where and who treats them, but want to “choose” better local services.  Of course they do: good, safe, responsive, effective AND local is the ideal. But we are far from being there and even if we were, it does not mean that choice, in the sense of the Patient Choice initiative, is misplaced.  Far from it according to the results of a English survey released last month by the Department of Health: Public Wants More Choice in NHS Care.

Where, when and by whom really matter

The new survey of 5,000 people revealed that over 80 per cent of patients want more choice over how and where they are treated in the NHS and nearly three quarters of patients wanted more choice in who provides their hospital care.  Women and older people in particular want to see more patient choice in the NHS. Nine out of 10 people over the age of 55 want to have a greater say in how and where they are treated.

More choice and control for patients must not come at the price of less integration and uniformity and hence ability to control costs for commissioners.  This is a challenge for Clinical Commissioning Groups and they will need excellent support from the NCB and, above all, positive and progressive dialogue with their local populations to negotiate it.

Integration difficult but “do-able”

Things that should be simple – talking to people about hard choices in healthcare –  often seem so difficult.  They don’t have to be. That is what effective patient and public involvement is all about.

Our colleague David Gilbert, InHealth Associates, had a leading role in the NHS Confederation’s latest offering to commissioners on what patient and  public engagement means and how to do it effectively in the new commissioning arrangements.  David describes his current work with the Southend Estuary CCG as an example.

It’s sound, short and practical: three excellent virtues in the current climate.  Now if we could only get CCGs to read, believe and do these things, life would be much easier.

Affordable, deliverable and acceptable 

MAC believes that a a good place to start applying this practical advice would be the principles of integrated services which National Voices has just published.  Designed “to put patients, service users and carers at the heart of care”,  these 12 principles

• be organised around the needs of individuals (person-centred)
• focus always on the goal of benefiting service users
• be evaluated by its outcomes, especially those which service users themselves report
• include community and voluntary sector contributions
• be fully inclusive of all communities in the locality
• be designed together with the users of services and their carers
• deliver a new deal for people with long term conditions
• respond to carers as well as the people they are caring for
• be driven forwards by the commissioners
• be encouraged through incentives
• aim to achieve public and social value, not just to save money
• last over time and be allowed to experiment

are an excellent place to start the dialogue about integrated services (pathways etc) that are affordable by commissioners, deliverable by providers and, above all, acceptable to users and carers.

It’s do-able, but only if CCGs start the process now and don’t wait to be told what to do by the NCB in 2013.

Is Surrey sure about Assura?

Why is that? The change of tune is because NHS Surrey decided on 16^th September  “that following a rigorous evaluation process Assura Medical Limited is the preferred  bidder for the services currently provided by Surrey Community Health.”  Assura will take on services in North West and South West Surrey, as well as some delivered Surrey-wide, including sexual health services and prison healthcare.

Those words could set off squawking  in the NHS human resources henhouse as well as in the wider public sector procurement world. What the Surrey population thinks about it, no one knows. Surrey LINks were said to be “fully involved throughout the process”.  We do not think that is sufficient involvement when the contract is worth at least £450m and the services are so fundamental to the well-being of the Surrey public.

There should be active citizens involved in all stages of the procurement process for something of this magnitude.  On a local health centre procurement I am involved with at the moment, there is also a very able representative of the patient participation group at the practice being tendered. It makes a difference.

Up until now, Assura Medical has been mainly a health care property developing organisation, 75% owned by Virgin Group since 2010.  They design and build primary care centres and community hospitals.  That’s all fine, but are they the right kind of business to start providing community health services themselves?  This is not elective surgery after all, but long term, usually complex stuff – “messy” as one of my community nursing friends described it.  And you can’t “cherry pick” it.

Probity, accountability, not to mention conflict of interest?

It’s surprising to a lot of people I talk to that a company like Assura is interested in a major community service provider business. After all, they only disposed of their pharmacy business in June this year in order to focus on the property development side.  But if they can add value within budget and achieve quality outcomes – including user/carer satisfaction of course – perhaps we are about to be surprised?   The local social enterprise providers in Surrey might be surprised as well, but that’s another story yet to be written.

It will be interesting to see how the new Assura business model works and is able to avoid conflicts of interests with local GPs.  Assura’s usual operating model is to provide primary care services via partnerships with local doctors in “GP provider companies”, of which it currently has 25 across the country. Each provider company is half owned by the local GPs, with the remaining half owned by Assura.   And who is it that makes referrals to community health services?  Oh yes, it’s local GPs.

A lean time for mutuals in “Open Public Services”? 

The “Open Public Services” white paper approach could have a sting in the tail for social enterprises, mutuals in particular, if the Surrey decision sets a precedent.

The last word -for the moment –  should go to Peter Holbrook, Chief Executive of Social Enterprise UK, quoted in the Financial Times about the decision:

“If Central Surrey Health, the government’s flagship mutual social enterprise, which has demonstrated considerable success in transforming health services and increasing productivity can’t win, what does this say for the future of the mutuals agenda? Central Surrey Health reinvests all the profits it makes locally. It is difficult to imagine how Assura, with shareholders expecting a financial return, could do more to benefit people in Surrey.”

Meanwhile back in Surrey

While all this is going on, over in East Surrey a new “right to request” social enterprise ”First Community Health and Care” – a CIC (Community Interest Company) –  is “going live” on 1st October.  What must the former PCT community staff leading this be thinking now that Assura is moving in as the new big boy on the Surrey community health block?

Clearly our neighbour to the South is somewhere to keep an eye on for signs of what the future of community health and care businesses might look like.  Maybe a future blog post will have the title “It’s an Assura Thing – Mutuals Defeated in The Battle of Surrey 2011″.  Time will tell.

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.

No information means no intelligent commissioning

Our pathfinder CCG in Wandsworth is at least co-terminous with the borough and so covers all the practices and a user population of about 370,000.  These commissioners need to be smart organisations.  All CCGs will need lots of intelligent data generated by the constituent practices.  To that end, the Future Forum remains in business and is about to start Phase 2 of its work, including a focus on “How information can be made to improve health, care and wellbeing”.

They may find this a bit frustrating when they realise that Government has already made what the HSJ calls “the frankly outrageous decision” that GP practices can opt out of the new GP data extraction scheme.  This amounts to a huge potential disconnect between the grass roots and CCGs and public health just as momentum picks up down the pathway towards authorisation.  David Nicholson should be twisting the arms of GPs about this, not acquiescing to their special pleading. Perhaps this shows the real power of private businesses, aka GP practices, in the new “Nicholson Health Service”.

Six domains to satisfy – watch out for Number 2

In the recently issued draft process for authorisation, there are “six domains” about which aspiring CCGs have to satisfy the National Commissioning Board they are competent.  The second domain causes great concern in the light of recent events.

 1. A strong clinical and professional focus which brings real added value

2. Meaningful engagement with patients, carers and their communities;

3. Clear and credible plans which continue to deliver the QIPP (quality, innovation, productivity and prevention) challenge within financial resources, in line with national outcome standards and local joint health and wellbeing strategies;

4. Proper constitutional and governance arrangements, with the capacity and capability to deliver all their duties and responsibilities including financial control as well as effectively commission all the services for which they are responsible;

5. Collaborative arrangements for commissioning with other CCGs, local authorities and the NHS Commissioning Board as well as the appropriate external commissioning support; and

6. Great leaders who individually and collectively can make a real difference

What happened at the end of July to effectively throttle local patient and public involvement on the alter of central control of the idol known as the “shared operating model”calls into question whether any CCG can satisfy this domain.  But when one looks deeper, it becomes clear that David Nicholson doesn’t really expect them to do much.  His draft  says it is sufficient for Health and Well Being Boards and Local Healthwatch to be proxies for local people and their views.  Real local voices and views from individuals and groups will not actually be part of the authorisation process.  That is unjust.  It makes a mockery of “nothing about me without me” and simply invites disengagement and distrust from the outset.

MAC was clear at the end of May when we wrote about the what the lay role should be through the whole authorisation process, not just one slice of it, including how to complain about what a CCG did once it was up and running. But this will not happen if the authorisation follows the mechanistic and excluding process contained in the draft:

There will be a role for shadow health and wellbeing boards in the authorisation process.  Health and wellbeing boards will be crucial in bringing together all of the key local leaders  for health and wellbeing such as local councillors, commissioners of adult social care,  children’s services and public health, CCGs, and representatives of patients and public  through local HealthWatch, to develop joint health and wellbeing  strategies to inform both  CCGs and councils’ commissioning plans. Health and wellbeing partners will be key in the  360 degree review, providing views on the CCG’s willingness and ability to be involved in  partnership working and their relationship to the local population. This will influence the  final judgement made by the NHS Commissioning Board [p 15]

 GPs don’t seem keen anyway 

To say that CCGs won’t work without all GPs on board, or at least not opposing, goes without saying.  But will this happen by 2013 or even 2014?  “Towards authorisation” may not be an obvious destination if the results of a recent IPSOS MORI poll for KPMG are correct.  Top line results from a weighted sample of GPs across England interviewed during July suggest that patient and public involvement is way the down list of what they see as important. Only 15% identified it as a priority and the same percentage said they might “buy in” PPI work anyway without doing it themselves.

Financial expertise and pathway redesign were considered much more important.  These are important, but what they fail to appreciate is that tough financial decisions – think decommissioning –  and service redesign to achieve pathways, cannot succeed without patient and public involvement in shared decision making at every level of the NHS.  The Future Forum report was crystal clear about this, as was Mr Lansley in his acceptance of its report.  Someone should tell the GPs!

That aside, much more worrying for the Big Beast at the National Commissioning Board was that this snapshot found only one-quarter of GPs thought their CCG would be ready to take on full commissioning responsibility by April 2013 and maybe not even then.

Not a good place to be in

So where does that leave the prospects for authorisation?  Not in a very good place we think.  Pathfinders are rushing ahead, and in London taking over huge swathes of PCT responsibilities – virtually all of it in some areas – by this autumn.  LINks are struggling in a parched climate to turn themselves into Local Health Watch and not exhaust the volunteers who are running them, while taking on huge new responsibilities with inadequate resourcing.  PCT “clusters” are tightening their grip at the behest of the interests coming together in the NCB.  CCGs of wildly varying sizes and capabilities are starting down an authorisation pathway many cannot finish.  Lots of grass roots GPs just want the reforms to go away so they can wake up and “just be doctors again”.  Their professional bodies are gearing up for a campaign to derail the Health and Social Care Bill when it re-enters Parliament in early September.

But the bad news is it isn’t going to go away, however many placards get waved.  In a few months, we may well be looking back on this quietude of late summer 2011 with nostalgia as the cold blast of an arctic winter born of funding discontent, alienated professionals and confused and angry patients hits home. Who then would want to run a clinical commissioning group?

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.

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.