Ownership Matters in Foundation Trusts

Creating “the largest and most vibrant social enterprise sector in the world” particularly by giving more freedom to Foundation Trusts is a key objective of the policy blitz known as Liberating the NHS (in England).   Mr Lansley has also said FTs would have ‘characteristics’ of social enterprise, implying for some that they might not be the genuine article after all.

The Social Enterprise Coalition is concerned by this. Peter Holbrook SEC’s CEO said “There needs to be greater understanding of the differences between these two organisational forms and the different roles they can play as part of the landscape for healthcare in England.”

How right he is.

A worrying shift of emphasis

Mr Lansley’s vision seems to be moving more towards an employee-ownership model. The White Paper says as much.

“As all NHS trusts become foundation trusts, staff will have an opportunity to transform their organisations into employee-led social enterprises that they themselves control, freeing them to use their frontline experience to structure services around what works best for patients.”  . . .   “We will consult on future requirements: we envisage that some foundation trusts will be led only by employees; others will have wider memberships. The benefits of this approach will be seen in high productivity, greater  innovation, better care and greater job satisfaction. Foundation trusts will not be privatised.”  (Liberating the NHS, para 4.21)

There’s the rub.  It comes down to an ownership question: who are the owners of a Foundation Trust?  We always thought it was the citizens, patients and staff members who sign up (register) as Members and acquire voting rights to elect Governors who represent their interests to the Board and management.  Guidance setting up FTs was very clear: “The members of an NHS Foundation Trust will, collectively, be its legal owners. This is a real and not a paper exercise in social ownership. As such the rights of membership will therefore confer some limited but real legal responsibilities.”

Mutuality models vary on the ownership question.  A GP co-op as a employee-owned mutual is one thing; a Foundation Trust controlled solely by the people whose livelihoods depend on it is several magnitudes different and not in the public interest.  Mr Lansley is failing to distinguish between types of mutal ownership and that has big implications.

Building new Mutuals

Currently FTs are “public benefit corporations”  – an elusive and self-defining status that suits the fluid reform environment into which they were launched.   In theory there is nothing to stop them becoming CICs (community interest companies) – though that would give them two regulators  in the shape of Monitor and the CIC Regulator which is probably not desirable.  They could of course turn themselves into big mutuals (they are halfway there now but with an indirect election model).

Exploring this is the subject of the NHS Alliance’s latest policy paper Building New Mutuals from Foundation Trusts. The Alliance rings an alarm bell: “A potential move to employee-led organisations was never the intention of the Health and Social Care (Community Health and Standards Act) 2003 that created foundation trusts.” Other well-placed commentators such as Paul Corrigan have also spotted that doing this would be a significant shift in the FT  governance model.

Much could be improved in FT governance

There are a number of things that could be improved in Foundation Trust governance without handing the whole enterprise over to the staff and cutting off control by the community who use the service.   These include:

1. The idea that the same person chairs the Board and the Governors should go for starters as Governors must be able to elect their own leader from amongst their number.

2. There should be much more direct contact between Members and Governors.  The Alliance would go further still in democratic control: “why not have public elections for NEDs on foundation trust boards, not just for the governors? Many large co-operatives – comparable in employment numbers and financial turnover with foundation trusts – do just that.” That sounds sensible since we are not now to have direct elections to soon to be phased out PCT Boards and so far there is little enthusiasm for putting lay people on new commissioning consortia which may not even have “boards”  in any formal sense.  We will return to that subject in a later post.

3. Governance can reflect constituencies for voting, eg staff members should be able to vote directly for their own NED on the Board

4. NEDs should elect their own Board chair

5. Board accountability should be to Governors on behalf of Members for continuing involvement and engagement with strategic planning and other internal governance requirements and also to Monitor for efficient running of the business.

Members in the lurch

We share the fear that the White Paper’s vision for FTs would leave community and patient members as owners in the lurch as well as introducing governance muddle.  Our concern is that the logical conclusion of employee-ownership and control of Foundation Trusts –  despite Mr Lansley’s assertion that they will not be privatised – could actually lead to FTs leaving behind any public control at all – in essence privatisation with a social enterprise face on it.   This is the contradiction at the heart of the “John Lewisisation” of public services – who owns them? It has nothing to do with getting better outcomes, increasing staff engagement and incentivisation or customer friendliness -  all very desirable.  It is about keeping public control and accountability of publicly-owned assets.

A number of FTs have healthy financial surpluses. Removing the private patient income cap will see these rise.  These could be used to buy out their assets.  If FTs had become employee-owned and controlled by that stage to the exclusion of community and user owners,  it would amount to an exit from public accountability.  We do not want to see that happen.

A mutual future

The NHS Alliance points a timely signpost towards the future of Foundation Trusts.  We support making Foundation Trusts into big mutuals so long as membership and majority ownership are strongly rooted in the community and the users they serve.  That is the best partnership arrangement staff members who also have a stake in ownership can have in ensuring that they too are fully engaged with the enterprise for the community’s as well as their own benefit.   The concept of mutuality is sufficiently dynamic to achieve both objectives.

Complaints Up – Good or Bad News?

Complaints up! Shock horror! I can imagine what tomorrow’s press will make of the NHS Information Centre report on English written complaints showing a 13.4% year on year rise, breaking through the 100,000 barrier. The accompanying comments from Tim Straughan the chief executive try to put this in context by offering some evidence of increased NHS activity in England e.g. GP consultations up by 44% between 1998 and 2008.

Does More Really Mean Worse?

That may help but I doubt it. More in the eyes of most people means worse when it comes to complaints. But this is to ignore the most important aspect of complaint statistics – especially those dealing with written complaints. The statistics reflect the process where written complaints remain a big part of the business. They also give a clue about such things as the emotional impetus of  the user decision to persist and sit down and write and of course the age of the complainant – oldies write more. The numbers tell us little about whether or not the complaint system is doing its job of improving patient satisfaction and raising the standards of service.

It’s the Process, dummy

The clue here is the 10,020 complaints under the heading of ‘communication’ cited in Table 5.  When I see the problem heading of communication being one of the biggest numbers as always, I see a failure to understand root cause – if the process does not facilitate good communication, it is a poor process.What gets labelled  as ‘poor communication’ are the difficulties in making a process work. People try and fail to resolve problems or to explain what is going on to others.

No Satisfaction Data, No Sense

Poor communication is therefore a topic that can be addressed not through asking people to write better letters or go on courses about defusing righteous anger but by focusing on the achievement of outcomes that satisfy and improve. Equally the MAC rule and recommendation is that statistics about complaint incidence must never be published without accompanying data on satisfaction and impact. We also need to have more useful ’cause’ headings than ‘All aspects of clinical treatment’ which accounted for 42,727 complaints – the highest single figure. Where do you start to improve quality? The category is so broad as to defy useful analysis.

Best outcomes – more voice, less letter – better

The best outcomes for complaint handling are more complaints better handled without the need for correspondence at all. By that we mean fewer written complaints across the board – certainly in areas like appointments delay and cancellation where timely, complete and empathic explanation on the day makes letter writing a thing of the past.

Then we can look forward to headlines like ‘Health Chiefs win satisfaction battle with more complainants satisfied than ever before. My confidence in the Health Service has been restored after they dealt with my problem so well’ says Mr MAC of London SW’ Until this happy day, stand by for the usual reaction.

Well-timed charitable appeal raises concern about use of NHS database

Got a nice letter from Tim Smart today. He is the chief exec of King’s College Hospital here in London, England. The letter introduced him and told me about the existence and the work of the King’s College Hospital Charity. An entrepreneurial reaction to budgeted cuts. I lose no sleep over people contacting me in the hope I will give them money. No  harm in that. But I did wonder about the timing. I have just had a procedure done at King’s – see earlier blog – and this letter arrived so soon after that I assumed that this was some well-organised campaign following up on a documented transaction with the institution. But my NHS treatment details are not available to the fundraisers – are they? I ask the question. Coincidence Tim? The letter finishes with a PS that reassures that King’s will not share my personal data with any third party. But within the trust?  They could of course get my details from the census segmented by post code and the timing was a happy coincidence – still it would be good to know.

Who You Going to Call? Ghostbusters!!

Their number for students of trivia was 555 2368. Remember that for the next time you need them. Add it to your list of essential numbers.

I called the police the other day. My bedroom window had two small holes in the outer pane of the double-glazed unit. Stones? Airgun pellets? Should I call the police? It was a bit late in the day to be calling 999? I realised that I had no idea what other number to call. As it happens a few days before a leaflet had come through the door giving me a number for my Police Neighbourhood Safety Unit. It was still near the top of the pile of unsorted mail and sounded suitably non-emergency so I rang that and got an answering machine – it was after all the weekend. I got a call back and on Monday two friendly members of the Unit called, had a look and said I had called the wrong number and gave me a card with a non-emergency number to call to get through to the police persons I needed. The trail had gone very cold and in the event no ‘real’ police came round but I did get after a couple more calls, what every citizen needs – the reference number for the insurance. And there the matter rests with the only other communication the standard victim support offer letter.

The non-urgent police number is 0300 123 1212 or at least mine is.

These musings have been prompted by the news that 111 is to be rolled out as the non-emergency number for the NHS and will we are told replace the NHS Direct number in due course – 0845 46 47 48- probably just about the time when most of us might have managed to remember it. There are hopes that it will be UK-wide. Admirably simple but of course not as simple as the single gateway to all services that 999 represents embedded as it is in the national consciousness. Can we expect a single gateway to the non-urgent? What has for example happened to 101 – the number being trialled by the Home Office?

If your list of important numbers is anything like mine, it is already long enough – doctor + out of hours, hospital – appointment numbers/ switchboard; utilities; NHS advice – two; police – three if you count 999; local authority – refuse collection. Others would be add schools and work contacts. I hold less and less of them in my head and rely increasingly on the electronic prosthetics represented by the speed dial or handset directories. Of course the number is inevitably on the other phone.

The internet is fine but there are times when a call is better. Adding yet more numbers to a list that is already long enough is not user-friendly. We remember either the number that is called every day or the one that has been around for ever. Innovation is unsettling and might well lead to increasing misuse of the one we all remember – 999. Soon enough they will no doubt be piloting the robots and their voice recognition software sophisticated enough to deal with the unsure, uncertain, loud-mouthed, drunk, scared, half-asleep and all the conditions of UK humanity in all their differing circumstances.

Until that day good luck to the Co Durham and Darlington NHS Trust – the rest of us will have to wait till 2013.

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.

On my face; in my face

Operations on your face are very much in your face. It is an oddly intimate atmosphere where strangers are very close  to you, murmuring in your ear advising you to close your eyes. The knife makes no noise – nothing like the whine of the dentist with their noisy drills and sucking tubes. Background music has no place in the austere day surgery room, although in one of these bizarre and impromptu occurrences that humanises the NHS,  the receptionist’s daughter turned up to give us a turn on her cello.

New Discourse Needed

This atmosphere is a total contrast to the formalities and generalities of the usual dialogue with the patient. The abstractions and generalities of a rights-based approach – duties, principles, respect – are linked in the time before the operation to the risk-based vocabulary constructed to serve the institutional interest and provide evidence of due process. These are essentially formal and impersonal communications. Clinical staff administer them and patients sign them.

The conversation takes a wholly different turn in the theatre. A whole new discourse is needed – one that acknowledges that the patient is awake and listening. Imagine if instead of the set-piece announcements you get from the pilot you heard the entire cockpit conversation for the whole flight.

Suggestions Please -new script needed

My first suggestions for that much needed guidance for authentic yet reassuring dialogue are below – suggestions welcome to create that warm, reassuring and calming ambiance that optimises clinical outcomes.

• I liked hearing the consultant sharing learning with the registrar – what would they do? what were the options?Where are we now? what are the risks? (could be dodgy but not when done as part of an established professional dialogue). It is essential that the registrar plays his/her part reinforcing the professional context by knowing most of the answers or least sounding eager to learn.

• Keep it up – by this I mean that if clinicians start by  involving the patient in the conversation then they must keep it going. There is a strong temptation as the op goes on, to get absorbed by the procedure – a tricky slice here, a dab there. Silence apart from heavy breathing and random tugging can be disconcerting. Operations on the face bring strangers close enough for kissing.

• Discussions about rotas, lunchbreaks and last night’s or indeed tomorrow’s piss-up are to be discouraged. They break the mood

• Any surprises – bloody hell we have a bleeder here – or discussion about the non-availability of some piece of kit should be kept to a minimum. While they can act as a reminder that we are all human, they do again break the mood

• Jokes must include the patient and not sound as though the patient is the joke.

• A note for us as patients is in order – do not guess at who these people are. I mistook a registrar for a houseman. Fortunately they took it well since they were doing an intensive bit of needle work on my nose at the time

• We need some sort of concordat on what I would call ‘minimising’ vocab – as in ‘a wee bit of bruising’, ‘a little discomfort’ (as in ‘excuse me while I stick a needle in your face’)

Tell us what you would like to hear – we need this now and more and more in the future with the growth of day surgery.

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.

The Wrappings on Local Health Watch

Thanks to Jeremy Taylor for raising in a comment on the LINks and Healthwatch post the thorny issue of Local Health Watch (LHW) and the proposed relationship to local authority funders.  He said: HealthWatch should be funded through local authorities but not accountable to them. How can you be accountable to the body that – in part – you are holding to account yourself? Why not make them accountable to local communities as community interest companies?

Look beneath the wrapping

This is a very pertinent question and about much more than just what wrapping eventually gets put around LHW. It’s what in the box underneath the pretty paper that matters. Community Interest Companies (CICs) and other forms of social enterprise might be a viable form for LHW to take if other things were also true about their status.

Jeremy is right that the conflict with the LA as funder and the LA as a key body to be held to account by LHW could pose big issues. The phrase “lap dog not watch dog” (a twist on the old ACHCEW slogan) comes to mind. To make it more tricky, the LHW would be on the Health and Wellbeing Board run by the LA as well.  So if that’s the problem, maybe a social enterprise form – and CICs are attractive if they have a wide community membership base – is a way for LHW to get out of a potential governance tangle with their funders.

Having mulled this over, here’s what we think about a way forward.

Best of both worlds

Re the governance status and accountability relationship of LHW, we don’t  see a conflict with being a CIC social enterprise, with all the community ownership/accountability that should go with that, and having a statutory foundation, legal powers and public funding stream.  We certainly would not support anything that said LHWs were not to be statutory bodies.  They should be no less established in law than LINks are now and with powers of enter and view  at least as strong as those that currently exist.

If LHW were simply voluntary bodies, whether not they were SEs doesn’t matter so much, their potential would be lost and there would be a status issue with CQC and everyone else they need to influence. No one would have to listen to them.

LINks accountability unclear now

On the point of accountability, it is a moot point to whom LINks are accountable at the moment.  Certainly not to DH or the SOS in any formal way.  The previous government, when they said anything at all about LINks governance, just repeated the mantra that they are accountable to their members/communities, but gave no idea of how that process was meant to operate. Locally our LINk sees itself as accountable to its 350+ members in some way, but this is never put to the test and it is unclear how it would be.

CIC would clarify accountability to community

If LHW were CICs for governance purposes, however, that would at least clarify a big part of the accountability point.  As there is a CIC Regulator, she would hold them to account for fulfilling their governance and engagement obligations to the community through their membership.

Their funding local authorities, through a model contract, would then be able to hold them to account for doing their job and keeping within budget.  Messy though it might be, part of that job would be scrutinising/entering and viewing/possibly blowing the whistle on local authority social care services that were not up to scratch.  That’s part of the LHW job and it can’t be ducked.

We think that dual arrangement would meet the point that Jeremy as raising in his comment that accountability only to the funding LA would be asking for trouble when scrutinising their services/talking to their users.

Analogy with Foundation Trusts

LHW as CICs could have the best of both the statutory body and social enterprise worlds. The analogy with Foundation Trusts as “community benefit corporations” comes to mind. FTs are technically owned by and accountable to their members through their elected governors. This theory has never been elaborated very much, but we think there are signs of more progress towards a clearer SE model for FTs after the Health Bill. After all the coalition say they want to create the biggest social enterprise sector in the world.  Pushing FTs and LHW down that road would certain achieve it.

What of Health Watch England?

And if we get LHW sorted out,  then there is HealthWatch England (HWE) to consider.  Is that to be a new Arms Length Body?  - probably not when some have just been given their death warrants.

And what does HWE nesting in CQC actually mean? Just facilities, pay and rations for staff? Or maybe something stronger.  Who is HWE going to be accountable to?

Trouble is, everything is connected to everything else. We should always keep an eye out for unintended consequences of  what might otherwise appear to be tidy solutions.

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.

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