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.

More than talking to patients

Decommissioning is about a lot more than just understanding the needs of patients – and that’s a lot harder than it sounds anyway. GPs pride themselves on talking to patients, and so they should.  But having an intelligent commissioning approach to meeting a community’s health needs is much more than this.  Conversely, the reality of stopping an existing service and restructuring things is about a lot more than telling the existing provider their contract won’t be renewed.  It is likely to mean facing the anger of those with a stake in the status quo – which can be almost everyone.

Accept the anger

Mo Girach of the Kings Fund, author of the Pulse decommissioning module, pulls no punches about this: “Accept the anger of users, providers and the wider community and indeed some individual GPs…. listen and accept, don’t be defensive.” 

True, but very hard to do  even with the best seasoned management skills and certainly not what most commissioning GPs grouped in emerging CCGs think they have signed up to. The potential for conflict when trying to make local changes – much less national ones – may prove to be one of the biggest stumbling blocks to CCGs being effective.  It parallels the rising chorus of GP concerns about “conflict of interest” in making decisions about priorities for communities and groups of patients as well as individuals.  But isn’t that what intelligent commissioning is all about,  with the emphasis on the “intelligent” bit?  Things are going to be different in different places.  The tensions are becoming palpable, in the GP tabloid press at any rate.

Change, yes; confusion and conflict, no

It doesn’t  have to be like this.  As the HSJ’s leader says this week: “change is inevitable, but more confusion and conflict is not”.  Think “bottom up” and “evolutionary” changes.   Is this just wishful thinking?  We hope for the best, of course, but fear something worse if recent experiences in reconfigurations around the country and in specialist services are any guide.

To their credit, GP leaders say they understand the need for evidence-led, consensus changes and stress the need for real engagement and strong relationships.  At the recent annual conference of the National Association of General Practice (now a love-in coalition with the NHS Alliance)  Dr Johnny Marshall, the NAPC Chairman’s opening address stressed:

 “It will be the quality of partnership working between practices that will create the most successful CCGs as they seek to better align fiscal and clinical responsibility at practice level and lead a fundamental shift to greater clinical and public engagement in the planning, building and delivery of new and innovative local services.” 

We concur entirely with his sentiments, but wonder how things will play out in the very imperfect world of health service politics and the fight for scarce(r) resources.

Perils of decommissioning

It could be an ominous sign of things to come that powerful providers  are successfully resisting commissioning changes and reconfigurations based on consultation outcomes. A national paediatric cardiac service is the most recent example.

Reconfiguration – which usually can’t be done without decommissioning and reinvestment –  certainly is not going to get any easier.  Or any cheaper.  In the case of the Royal Brompton and Harefield NHS Foundation Trust versus the Joint Committee of Primary Care Trusts, one part of the NHS (a high profile provider under threat of decommissioning) took another part of the NHS (specialised commissioners) to the lawcourts.

That’s something that doesn’t happen.  But it did and they won.  Anger there was too, aplenty.  As Roy Lilley so colourfully expressed it

“You mess with a service like that at your peril.  When the middle classes unleash their wrath may your god help you!  They wage war with word-processors, do battle with spread sheets and call in alumni reinforcements you wouldn’t dream of.”

We are likely to see more of this. Will GP commissioners be up to it or will the Big Beast and the NCB have to step up to the plate for them?   We look forward to seeing the modules on decommissioning a national specialist paediatric service that includes the following essential content:

• What to do when another part of the NHS takes you to court
• Dealing robustly with people whose baby’s life has been saved by said service and will protect it til their dying day
• What hair style to select for that all-important appearance on Newsnight

Evidence of impact

The Pulse decommissioning module offers 1 CPD credit for reading and answering questions and doubles that reward to 2 CPD credits for offering “evidence of  impact”.  Given the contentiousness of decommissioning, one cannot help but wryly wonder if “impact” includes getting pelted with rotten tomatoes – metaphorical or otherwise – by those on the receiving end of the decommissioning decision?  A direct hit on the lead decommissioner should surely count for more CPD points?

Only time will tell if the new commissioners are up to the job, but time is decidedly not on their side. They may face opponents less high profile that the friends of the Royal Brompton and Harefield, but what this experience shows is that even NHS family members can turn decidedly unfriendly when threatened with reconfiguration.  So lesson two for decommissioning by GPs should be: make sure you have your flak jacket and tin hats on when you go into the trenches.

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

Our friends at National Voices have made it clear in their “Nine Big Shouts” what the main theme for the Future Forum must be: integration, integration, integration.  We certainly concur with that.   As they say:

Services must become much more seamless, organised around the service user. They must support us to understand and manage our health and participate in all key decisions. The reforms and the Bill should be reviewed and amended to make sure everything lines up behind that goal.

But what of the architect of all this, Mr Lansley?  His Bill shredded. The NHS a bloody battleground. Professional tribes revolting. The public anxious about reform.  Avoidable, yes, but 20/20 hindsight won’t extricate us from the mire. Voices are raised for Lansley to go despite Number 10’s “nonsense” denials.  Will a likely lambasting from Future Forum’s report tempt Cameron to drop the pilot over the side?

Probably not. Cameron is no Kaiser and Lansley is no Bismarck.  Off the front bench nursing a spurned prophet’s wounds, Lansley is much too dangerous.  The pilot will remain in his place as the rumour mills grind on

Lansley the policy wonk at heart admitted the obvious at the weekend: ‘I’ve stopped being a politician – I just want to get the NHS to a place where it will deliver results. ‘I don’t want to do any other Cabinet job. I’m someone who cares about the NHS who happens to be a politician, not the other way around.’

OK, so here is our “five point memo to the pilot”:

Number 1. Explain and persuade better.  There is a case for reform, so make it clearly and consistently. Take a leaf from Norman Warner’s new book: without reform we face an “overspending tsunami”.  That’s gripping. QIPP isn’t to most people.

Number 2: Please take Steve Field’s report seriously. Resist the special interests’ siren songs but celebrate good managers.  We will achieve nothing without them.

Number 3: Remit parts of the bill back to Parliament, but nail the myths about privatisation, competition and regulation in public services. We have it already, it must be used in constructive ways and the NHS won’t survive if we pretend otherwise.

Number 4: Remember that Monitor has a big job still to do in controlling Foundation Trusts, those ever more powerful elephants in the room.  There are going to be mergers and failures in the acute sector in particular.  A strong Monitor must be able to handle that whatever other role it might have in competition and cooperation.

Number 5: Above all, put the user and carer at the centre of things from top to bottom.

That’s what you said this was all about in the first place, Mr Lansley.  It still is.

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.

We disagree.  No one group has a monopoly on knowledge or wisdom about healthcare for individuals or communities: it must be about shared decision making from the consultation room up to the board room.  Have they all forgotten the rubric which has been parroted all through these reforms: “Nothing about me without me”?

Here’s the question we fired off to the Guardian website in response to Field’s simplistic view.

If Steve Field or anyone else thinks that patient and public involvement can or even should all be done by Health Watch and its local off-shoots, it shows they have no real understanding or practical experience of what involvement, engagement and consultation with service users and the public are about. Don’t leave it all to Health Watch. That is NOT what “Nothing about me without me” means.

Local Health Watch is intended to be much more than LINks rebranded. As a statutory body, LHW will probably have a seat on the top level governance group – whether or not it is called a “board” – of the GP commissioning consortium and be able to make reports to the wider community following each meeting. It will also sit on the Council’s Health and Well Being Board.That is welcome. But there is a high risk transition phase to be navigated first, in which funding is not secure and much can happen to thwart objectives. Local authorities are abandoning their legal duty to involve as well.

It is essential that people working in the NHS and social care don’t by default see Local Health Watch as a synonym for patient and public involvement and therefore someone else’s job.

There must be integration between viable Local Health Watch and many other types of involvement and engagement at the grass roots of clinical commissioning structures and local providers. The MOST important part of this is patient participation in each practice and Foundation Trust members who really have a voice through their governors.

To be successful businesses, GP practices and commissioning consortia need many direct “listening relationships” with their own patients. If they saw patients as customers, this would be a lot clearer to them. Why are they so frightened of this concept? What does Prof Field say to this?

Andrew Craig
MAC Partnership LLP

Did we get an answer?  No, but we are prepared to wait. In the meantime, lots of hints about what the answer should be have been given by the Kings Fund in their latest briefing Ten Priorities for Commissioners .   They argue that the empowerment of patients – patients being the greatest untapped resource within the NHS  - and their active engagement in commissioning  must be a common thread in all priorities facing the new commissioning system.

Simple isn’t it? So just do 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.

This was wrongheaded on several levels:  1) it would have turned the FT into a staff owned mutual which is contrary to the FT’s authorisation; 2) it would have excluded the community from having a stake and a voice as Members and Governors in what is after all legally defined as a “community benefit corporation” and 3) perhaps more far fetched but not beyond the pale, it would have created an organisation whose valuable  assets  - transferred without cost from the public ledger – could be vulnerable to outside disposal if  “demutualisation” occurred.  In other words “privatisation”.  And Mr Lansley stressed again  in front of the Health Select Committee this week that he does not intend to privatise FTs.

This isn’t about John Lewis

It needs stressing that none of this has anything to do with the “John Lewis model” of employee-owned mutuals. They didn’t start out being handed valuable public assets to get their business going and they are not established legally for the benefit of the community. Significant differences from NHS employee-owned businesses.  Sure, we would like some of their characteristics about customer responsiveness and morale in the public services, but that does not mean aping them uncritically.

MAC champions the owners – the Members of the Foundation Trust

MAC always opposed the idea of staff-only FT membership  because it fudged the ownership question: who are the owners of a Foundation Trust? The answer  to this question is the owners are 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 is 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 varies

Mutuality models vary on the ownership question.  A GP co-op as an 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.   In making this proposal in Liberating the NHS, Mr Lansley failed to distinguish between types of mutal ownership and that would have had big implications.  But now we see that government has had second thoughts. We welcome that.

Second thoughts

In the response to White paper laying out the legislative framework and next steps, we find this  volte face:

6.17 Regulating healthcare providers discussed the prospect of enabling FTs to have employee-only memberships. Not many respondents commented on this proposal but, with some exceptions, those that did were generally not supportive. The CQC said that staff-only models without patient and public involvement could be at odds with public accountability and should be avoided, while the BMA thought they would do nothing to improve patient care. The Government has considered these concerns and concluded that staff-only membership would not be compatible with the foundation trust model.

Strengthening accountability through Governors

This common sense decision is another reason why we welcomed Wednesday’s announcements of strengthened powers for the FT Governors – the Members’ elected representatives – to hold Boards of Directors to account.

Could the change of heart also have something to do with still fresh memories of the scandals at Stafford Hospital, part of a shiny new Foundation Trust?

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.

Lansley’s ministerial statement spoke of  “a broad mix of support, suggestions for improvement and critical challenge”.  The results include abandoning the daft idea of the national Commissioning Board taking over maternity services.  That is welcome, but MAC still has concerns about the more difficult end of commissioning, whether specialised or not, particularly neurological long term conditions, which are not popular with GPs.  The shiny new commissioning tools we’ve had a hand in shaping may not to be used much and that would be a tragedy for all concerned.

Aspects of PPI duties

While we await the Bill, the legislative framework gives very strong clues to its content.  On duties of patient and public involvement, there are two dimensions.

1. First, the National Commissioning Board under will be under “a duty, in exercising its functions, to have regard to the need to promote the involvement of patients and their carers in decisions about the provision of health services to them. The NHS Commissioning Board will also be under a duty to issue guidance on commissioning to GP consortia, which could include guidance about how to fulfil their duties in relation to public and patient involvement.”

2.To make this more explicit, the Bill will also place a duty on GP consortia and the NHS Commissioning Board to ensure that people who may receive a service are involved in its planning and development, and to promote and extend public and patient involvement and choice .

Of course, this is in effect brings existing Section 242 obligations about engagement up to date and is to be welcomed.

And as a welcome bonus, the Bill will also strengthen the power of Foundation Trust Governors to hold the FT Board of Directors to account through the Chair and Non Executives on the Board. This is something MAC strongly supports because the Governors are the elected representatives of the Members of the FT, who are the legal owners.

No prescription about lay participation in consortium “boards” and governance

Our friends at National Voices in their submission said it was “vital that there is equal lay participation in the governance of the consortia, and that their meetings are held in public”.  A point we and many others strongly support, but the Government has taken a non-prescriptive view.  It argues thus:

The Coalition Government has considered very carefully the issue of lay and patient representation within consortia. We are clear that requiring there to be a statutory management board for each consortium would be over-prescriptive; and that placing legislative requirements for there to be lay or patient participation in the governance of consortia is unlikely to work. At its heart a GP consortium is about a nexus of professional inter-relationships, the exercise of peer influence, and professionals taking on direct responsibility and public accountability for the decisions they collectively make. The Government does not see how this can be mediated through imposing upon consortia a small number of lay or patient appointees. The Government certainly does not wish to discourage consortia from developing arrangements for lay or patient involvement, which can often work well, but it must be for consortia to make their own decisions on this.

Lansley was clear before the Health Committee that he would not prescribe the internal mechanisms of consortia, provided that they had an acceptable constitution (but there would be no model) and achieved transparency.  Otherwise, prescription would simply re-create PCTs, he said.

“Glass half full”

Many will be disappointed by this, but prescription is not the way this government works.  In effect we have a “glass half full” position on patient and pubic involvement in consortium governance.  That means it is up to local user groups to understand the leverage, particularly through the powers of the Local Authority, which the new legislation will give and, if their local consortium is deficient on meaningful patient and public involvement.   They should create and then use their influence with the Town Hall and Local Health Watch to improve the commissioners’ performance.

MAC published our advice to commissioners and providers about how to meet their duty of patient and public involvement in the White Paper back in October.  We will now revise that to include these additional government legislative commitments.

Stand by for a heavyweight

Back in the summer people were speculating that the Health and Social Care Bill would be light, mainly enabling, and with all the details done in subsequent secondary legislation (SIs, Directions etc).  There will still be a flurry of those, no doubt, but on this outing – a 174 page legislative framework response from government – it seems clear that the primary Bill will be a heavyweight. Block out your calendar for January now.

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.

“These patients were not simply numbers: they were husbands, wives, sons, daughters, fathers, mothers, grandparents. They were people who entered Stafford Hospital and rightly expected to be well cared for and treated. Instead, many suffered horrific experiences that will haunt them and their loved ones for the rest of their lives.”

Those words from  the preliminary enquiry findings of the Francis Inquiry  into 400 deaths (perhaps more) at Mid Staffordshire Foundation Trust between 2005 and 2009 are as true now as when Robert Francis wrote them in February this year. So why has Mr Robert Francis QC chairing the expanded current inquiry chosen to focus on commissioning and related supervisory and regulatory processes in order to find out why problems leading to these deaths were not acted upon sooner.  Mr Francis said: “This inquiry is not the forum in which professionals responsible at the front line for such care can be brought to account.”

No one wants a witch-hunt and the Francis enquiry is not a trial – so “bringing to account” is misleading language for Mr Francis to use.  Real people were involved. We know who the patients were who got bad care – the relatives have told us –  so why not open the enquiry process to the people from the care giving side and let them tell their stories?

Focus both on process and on individual actions

Mr Francis may be underestimating the public’s expectation of his enquiry and the overriding importance of the public interest in finding out what actually happened at Stafford Hospital. It could happen elsewhere unless governance processes (including but not restricted to commissioning) and individual  clinical behaviour are drastically improved. We cannot understand governance failings without understanding failings in clinical practice and how their interaction in this instance created a culture in which failure could continue and people who were trying to do the right thing were thwarted.

There is an argument, of course, that long and drawn out enquiries, whatever their rules of engagement, are not contributing either to patients or families achieving satisfaction or to our knowledge of the causes of failure.  ”If they do not know by now what the causes of failure are, they never will” is a persuasive and intuitive conclusion.   But it may also be premature.  Without understanding exactly what went wrong (including when staff did things badly or tried to do them well) it is going to be very difficult for any recommendations to be made for the future which fully take account of the complexity of systems which rely on many individuals doing the right thing.   It is in the public interest for information about failure to be out in the open.

Openness is also empathic – with the relatives and (by proxy) the dead patients and the staff – the good ones and there are plenty – who want to hear the full story.   That is what the enquiry must address.  It is not about assigning guilt and meting out punishments.

The focus should be both on process and on individuals.  Why? Because process in the NHS is basically about how people work together.  And process fails when it does not support the people who are trying to apply it. People may also fail all by themselves even if they have the best processes in the world to help them.  So it is not “either/or” but a mixture of both that needs to be examined.  And that is why an intuitive conclusion at this stage is insufficient.

Does no right of response equal “gagging”?

If I were a member of staff at that hospital, I would want to tell my story. I would not want, in effect, to be gagged. Individual staff have a right to argue in mitigation if they can and wish to.   If we don’t see or hear from staff, the current Francis enquiry will be a charade and the public interest will not be served.  Worse than that, the relatives will be frustrated and humiliated by a bureaucratic process and their anger will simply drive them on to seek resolution in some other way.  Leaving any possible disciplinary action to a referral to the professional regulatory bodies after the current enquiry concludes is, simply, a denial of natural justice to everyone concerned.

Mr Francis justifies his position thus: “If I were to allow the identification of  nurses and doctors and others who stand accused of providing poor care, they would stand accused in a public forum of serious complaints under the cloak of absolute privilege from defamation proceedings and be unable effectively to make a response.  This is unfair to them, not helpful to the inquiry process and deflects from my central task. Fairness would, or might, require giving the individuals a right of response.”

That is precisely the point – giving them a right of response. So it is hard to understand why he doubts that a right of response could be given at his own the enquiry.  He’s the chairman after all so he should be able to ensure this.  To conclude that “there would be a real risk to their reputations and, where still employed by the trust, to the workings of the trust” is gagging and puts a permanent cloud of doubt over the reputations of every staff member concerned.  This cannot be fair to them.

What we all want: an open, transparent and safe NHS

The local campaigning group “Cure the NHS” whose persistent efforts largely exposed the scandal at Stafford Hospital has argued against the anonymity order because it undermines the main purpose of the enquiry – which is to find out what actually happened so that we can learn from these shocking events.  They know that truth is going to be very unpleasant, but it must be aired in an open and transparent enquiry.   Names and faces matter: we are not dealing with “persons unknown” here.

It wasn’t just commissioning that failed at Stafford Hospital because that is just part of a bigger governance process. It was people who individually and collectively failed in their professional duties to provide safe, effective care. Safe and effective medical and nursing care predates commissioning and will survive long after it is a memory.

Mr Lansley is on record as saying that an open, transparent NHS is a safer NHS.  We strongly agree. The public must be helped to understand how these events could happen so a recurrence can be prevented there and elsewhere.  Knowledge and understanding are the first steps to meaningful public engagement, moving from passive victim of the health care system to active partner.   Mr Francis and his enquiry team must allow names and faces to be put on events and then proceed in a fair and open way until the full and complex story is known.

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

But how much will patients be involved? The BMA seemed to be back-tracking on their earlier commitment within the space of a month. Patient representation is in danger of being relegated to a ‘nice to do’ thing whereas the White Paper treated it as central. Andrew thought there might be a danger of the BMA digging in to play its trade union role at the expense of the wider more inclusive approach that took in the whole spectrum of patient needs. Andrew wrote “The BMA, a trade union after all, asserts in its most recent commissioning guidance that “effective commissioning is effective general practice”.   This is so wrong on so many counts: primary care is about so much more than general medical practice no matter how good it is and effective commissioning must stretch beyond health into addressing the wellbeing of a whole community.”

The frustrating thing for us is how little value many GPs appear to put on the rich resource that is the views and contributions of  involved patients. Andrew’s blog on his evening with patient representatives in Wandsworth is a breath of fresh air. The closeness of the focus and the specificity of the issues is in contrast with all the hot air and pontification of much of the public debate about ‘Liberating’ the NHS. It is worth reproducing a large chunk of that blog:

Two themes stand out

Two themes during the discussion really stood out for me.

First, the overriding importance of real patient and public involvement in new arrangements – “No decision about me without me” is a hostage to fortune and the Government will be mercilessly pilloried if they abandon it or, worse, let the special interests water this down to mere lip service or box ticking.

Second, the central role of local authorities in leading on the things that matter to local people about health and well-being.

The question came up unprompted several times about why commissioning was to be divided between GP consortia and Councils.  Would it not be more effective, people asked, to deal with Wandsworth as a single place with a single population and a common pot of resources and expert people working in a single agency to do the work across health and care?

The Go Go Gove Gov style

However the user involvement story is not one that is confined to health as Caroline’s blog on the energetic Mr Gove. The GO GO GOVE GOV style has little time for the views of others – no doubt in part for fear of delay and complication. The Secretary of State for Education gets a 0 out of 7 mark when rated by reference to the Consultation Code.  Consulting or Commanding? asks Caroline, drawing on her own experience as a parent and school governor – recently elected to be Vice Chair of the Governors – she makes the point ‘nothing is guaranteed to create greater consternation at times of high anxiety than a perfunctory letter from the school and a “public meeting” called reluctantly at short notice where the powers that be fall into default passive aggressive mode and make it clear without quite saying so that they are simply waiting for the meeting to end so that you will get out of their hair and they can get on with what they or their bosses have already decided they are going to do.”  Honesty is much the best policy – parents and children deserve better.

The Partnership Process – uniting the personal with the policy

The theme of ownership last treated in a blog on 1st September returns as a theme in Andrew’s last piece in September. It is he writes a theme that should not and will not go away. The issues becomes the clearer the smaller and the more local the State sector becomes. What will engagement look like in this new down-sized and delegated environment?

There will of course be casualties along the way and we regret that the AJTC should be top of the list of quangos to be culled. It is a small specialised body and its hit listed pre-eminence is purely alphabetical. Yet with Richard Thomas in charge with his vision of a truly user-oriented justice system, there was the potential for a transformative national project that would make sense of the jungle of institutions and processes that make up the legal system and seem at times to stand between the citizen and the resolution of his/her problems rather than facilitate them. Certainly Colin Adamson’s experience of one branch of the Tribunals service shows that there be dragons lurking in wait for the unrepresented first time user.

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

Future gazing at shifting horizons

There are some positive statements about the benefits of citizen engagement in the recent 2020 Public Services Trust report ( chaired by Andrew Foster) that could be used to support specific arguments in Whose NHS Is It Anyway? and other public services.  The “2020″ work and other signposts to the “small(er) state” new order such as Magna Carta for Localism from London Council leaders in Wandsworth, Westminster and Hammersmith&Fulham  are strongly influencing the Coalition’s direction for public services reform across the board.

You can see this in Deputy PM Nick Clegg’s recent speech to the Institute of Government on “horizon shift” by which he meant a radical redistribution of power away from the centre.

A shift to localism must bring local ownership with it – and that does not mean local bureaucrats in control it means local communities in control. To prepare for this, we need to be thinking more widely than just health as all public services are interconnected and users would like to interact and influence them without barriers.

Engagement in the smaller state and bigger society

Questions to address include:

What could engagement be like in a much smaller state funded sector?

Would engagement be different in “Big Society” initiatives, if so how and why?

What competencies do lay people need to make an effective contribution?

What new levers are easiest to pull nationally and locally that make a difference?

What kind of lay representatives will be fit for purpose in this new environment (implications recruitment and selection)?

What will be their training and support requirements and who will supply this?

What does everyday participation mean when the centre is no longer in control of many things?  Must everyone become a professional lay person to have a voice that is heard?

All of us are Owners

Earl Howe, coalition health minister in the Lords,  speaking about GP commissioning at the Kings Fund on 13 September reiterated a tenet of the new government:

“Our proposals for GP commissioning will push decision making much closer to patients and local communities and ensure that commissioners are accountable to them.   …    This government believes that power is something to be given away, not hoarded.  Local services should be accountable to local people.”

Lots to consider here.  Whose NHS Is It Anyway? is just part of the answer to a much bigger ownership question. Moral ownership and a right to have a say in how they are organised and delivered and that makes all of us “owners”  of public services and that is true irrespective of our contributions as taxpayers. Our friend Caroline Oliver was eloquent on this  recently.

We believe government should be taken at its word about wanting to give away power.  It is time for the owners to start raising their voices in the conversation about the future of public services.  That way we will find the synergy between active citizens in all the sectors from health, care, environment, transport, education and beyond.

The blog pieces are a mix of the political and the personal. The pole political position was Andrew’s long analytical piece on the relationship between Healthwatch and LINks – if you need to catch up on this, look here. Good blogs prompt responses and the follow-up piece byAndrew took up a comment made by Jeremy Taylor about accountability and the proposed relationship with the local Healthwatch bodies and local authorities with the latter as the funder and also the body being held to account. Biting hands that feed etc Accountability came up again in our latest blog on Ownership and Foundation Trusts. The concern is that FTs will no longer be publicly accountable if they are wholly owned by employees. Community and patient members would be frozen out.

Innovation was praised with the Secretary of State for Health holding up the National Commissioning Support service supported by major neurological charities as an example of innovative best practice – Andrew’s piece quotes him as saying that the vision of liberating the NHS foresees innovation coming up from users. There is more to come here in the way of innovation as NCS prepares to launch its new commissioner support software in the autumn while the neurological grass roots local associations prepare themselves for productive relationships with commissioners with a new guide on Shaping Services published this summer by the Regional Neurological Alliances. We like it – we co-wrote it.

A  lot of the debate about commissioning of course is focused on whether the new lords of commissioning – the GPs – will be able to hack it. MAC advises you to read the BMA’s General Practitioners’ Committee’s view on how patient and public involvement is central to the new commissioning arrangements and how GP should address these issues. GPs are having some fun with the chance to work with acute trusts and as an article in Pulse points out. they can address the tricks trusts play to generate more income for themselves.

Policy has to be balanced against the personal and in all this heady talk about Liberation and Power to the People, we still need to honour the individual patient experience at the heart of it all. How is that going? Do more written complaints with the numbers breaking through the 100,000 a year barrier mean that things are going to the dogs? A MAC blog says it is a classic mistake to publish numbers without putting them in a satisfaction context.  Will a single number – 111 – make it easier to make that call for advice to the service that we are told will replace NHS Direct? But not everything can get done on the phone. Things get even more up close and very personal when Partner Adamson gets taught a lesson about leaving his body out in the sun too often as bits get sliced off his nose while the medics chat. The post-operative experience includes not only the satisfaction questionnaire but the charitable donation mailing. The humanising touch is not forgotten in the new NHS as the receptionist’s daughter plays the cello for us all.

So as the new(ish) Government proceeds with its programme of change and reform throwing out the bathwater of the regime formerly known as New Labour, we will always insist that the babies that remain will flourish best if nourished at the breast of public participation and engagement.