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.

Freedom NHS – an Electric LINk for a Citizen Commissioner?

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

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

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

Electric LINks – a participation mash-up

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

A Citizen Commissioner – an agent of revolution

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

Government 2.0 – September Conference in US

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

Liberation root and branch style

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

Shaping the new order

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

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

Some of the other highlights of the new order include:

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

Liberation is a double edged sword

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

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

Cromwellian thoroughness and speed

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

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

A long hot summer for user and citizen engagement?

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

Not just valuable but vital

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

Eight New Laws of LINks

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

Reorganisation – flavour of the month

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

Trust the Teachers and GPs

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

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

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

MAC’s Eight New Laws of LINks – and an acknowledgement to Dr Einstein

Albert Einstein defined insanity as doing the same thing over and over again and expecting different results.  It’s a curse the new Coalition Government must avoid when it gets around to considering its plans for Healthwatch in England and what it intends doing with Local Involvement Networks (LINks).  Scotland, Wales and NI should be free within their devolved administrations to retain, improve or amend their own arrangements for user engagement, complaints and redress processes.  There is much to learn from each other about how to do engagement and participation better across public services.

MAC takes the opportunity in advance of the Health White Paper due in early July to contribute its ideas to the developmental process.  We have ideas about what LINks should do in future and about their relationship with Healthwatch and its functions.  Healthwatch funding should be entirely separate from LINk funding and the latter must not be raised or top sliced to create Healthwatch in England.

Some details are emerging about what the Government’s model for Healthwatch for England might be and what relationship it might have with Local Involvement Networks (LINks), now into the final year of their three year contract.  We have no doubt that LINks must survive and be developed to take on a more robust role across health and social care.

Now read on.

1. Integrated statutory framework.  Healthwatch England and LINks must operate within an integrated statutory framework bringing together involvement of service users, carers and the public and also embodying their rights including complaints and redress.  We are not talking about tinkering with the current fractured system in which most people don’t know how to have their views listened to or how to make a complaint about health or social care their receive.

2. Accountable to Local Authority. We wonder what  the proposed Healthwatch role about providing “leadership to LINks” might mean?   It should not be code for performance management.  Each LINk should be accountable to its sponsoring Local Authority according to a national contract and with sufficient funding to carry out its role in the local area.  Possibly it means Healthwatch taking on the function of the short-lived National Centre for Involvement?  That would be a positive move, by promoting and sharing good practice.

3. Brands  spanning health and care. Healthwatch needs renaming because it is too narrow and sounds like a regulator. “Carewatch England”, though not ideal, would be our choice, because care in its broadest sense encompasses both what the NHS does and what the social care system does. 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).  Members of the public have an equal claim to have their voice heard: patient experience is one thing; public involvement quite another and LINk can and must do more of both.

4. Statutory health and care remit.  LINks already have a statutory health and social care remit – that is right and it must be strengthened.  Above all, LINks must not be pruned back to a health-only remit or even one that focuses only on the NHS.  In a pluralistic economy, LINks must continue to be able to enter and view any and all facilities and services being used by publicly funded users – they must go where users go.  Their relationship with the inspecting bodies, particularly the CQC, also needs revisiting and smoothing out.  LINks should have synergistic relationships, not competitive or duplicative.  Enter and view should be sufficient powers for LINk – they are not meant to duplicate what the inspectorate(s) do but can already respond to concerns raised by members and from the public by making visits including unannounced ones.  There needs to be good practice enter and view models that all LINks can follow, including what happens to issues which LINks uncover and then refer to their Council’s OSC for action.  Evidence about this is lacking and Healthwatch should have a remit to uncover, assess and publicise what is happening and raise LINk standards.

5. LINks and OSCs.  LINk in many areas has a good working relationship with the local authority’s overview and scrutiny committees.  In many areas health and social care are combining into a single Adult Care and Health scrutiny body.  It should be taken as read that the LINk as a statutory body will have rights to receive all papers, attend all relevant meetings and speak at health and social care OSC meetings in addition to their existing rights to refer matters to the OSC.  But that needs to be spelled out in guidance or it may not happen in many places.

6. Bring coherence to complaints across health and care.   Since April 2009 there has been an integrated and (at least in theory) simplified complaints system operating across English health and social care.  But this is one of the best kept secrets we know of. Many NHS bodies are complacent about complaints handling and consistently miss targets for providing responses and resolving issues. The complaints and redress system must be made more coherent. But this does not mean that LINks should become involved with complaints handling or advocacy services, though of course they can and should signpost people to where they can get such help.  Complaints handling can easily turn into confrontation.  Healthwatch England’s proposed role to “investigate and support complaints” needs very careful elaboration. We do not want the old intermediate tier of complaint handling undertaken by the old Healthcare Commission revived.   Users got a poor service and the handlers drowned in the paperwork and procedures.

The role of the Ombudsman on the one hand and local resolution on the other should not be weakened. But we believe much could be done to publicise the system and to facilitate people to find their way through it.  Healthwatch could be the independent body which commissions and manages complaints advocacy services (ICAS) for consumers.  The local or regional presence for Healthwatch has not yet been specified; perhaps the White Paper in July will throw light on this.  We note that Mr Lansley himself, unlike Earl Howe, didn‘t mention complaints in connection with Healthwatch in his Bromley by Bow presentation, but the issue cannot be ducked.  The current complaints processes are disjointed, difficult to access and not meeting the needs of service users or anyone else.

7. LINks should be host free.  LINk host bodies are coming to the end of their three year contracts.  This model should not be renewed.  The new model for LINk should be “host-free” because introducing intermediary bodies simply obfuscates governance and accountability.  LINks are statutory bodies and 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 LINk 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. It also means that LINks will need premises, something that should be negotiated with the sponsoring local authority.

8. Relationships between LINks and Healthwatch. The boundary between LINk and the local presence of Healthwatch will need careful thought so that unintended consequences do not result. The relationship should be additive and synergistic, not competitive. Otherwise consumers and inspectors will be confused.  LINk as a membership body is primarily about involvement, engagement, listening and communicating views as well as being eyes and ears about quality of services and user experiences.  Their relationship to the OSC is an essential one to develop.  This is quite different from what Healthwatch might do as a non-membership body, though clearly there is scope for collaboration.   Equally there is scope for developing relationships between LINk and Foundation Trust Members and Governors and between Healthwatch and Monitor’s expanded role as well as the CQC as the principal inspectorate for health and care.  A matrix of consumer focused activity would be a positive outcome.

Doing these things will avoid Einstein’s curse.  We will get different – and better – results from doing things differently.  LINks and Healthwatch have the potential to develop into a synergistic relationship but not one where one controls the other. For LINks, the accountability buck should stop with the sponsoring local authority.   We hope the Coalition Government has the vision to enable that to happen.

Some background for policy wonks

During the 3rd June debate on the Queen’s Speech in the Lords, the Government spokesman Lord Howe said: “We are going to give the public a strong and independent voice through Health Watch, which will be a statutory body with the power to investigate and support complaints.”

No more details were given, but we can extend Earl Howe’s statement by looking at a reply Hull LINk received to its query on what relationship there would be between Healthwatch and LINks in England.   Here is what they were told:

“ There have been three different mechanisms for patients and members of the public to engage and involve themselves in the development of NHS services in less than four years.  We believe that mechanisms for engaging patients in their health services need to endure so that confidence and brand awareness increase over time, and the experience of those who operate these mechanisms is retained.  We have therefore committed to avoid unnecessary organisational upheaval and retain LINks as the foundation of our policies for patient and public involvement in health at a local level.

However, we are concerned that LINks in their current setup are too weak and will have too few powers to command the confidence of patients and the public.  We will therefore give LINks additional powers of inspection, and the ability to act as advocates for patients who complain about NHS services.

We will also establish a national consumer voice for patients: HealthWatch.  HealthWatch will provide support to patients at a national level and leadership to LINks at a local level.  It will also incorporate the functions of the Independent Complaints Advisory Body.  Health watch will have a clear statutory right to be consulted over guidelines issues nationally concerning the care NHS patient should receive, and over decisions which affect how NHS care is provided in an area. “

A third take on this comes from the question and answer session Mr Lansley made following his first speech as secretary of state at Bromley By Bow Health Centre, East London, on 8th June.   Mr Lansley thanked LINks for all their work thus far and said he was not going to reject people who have been involved in LINks as part of his intention to shift power down through the system and put patients in the driving seat.  He said Healthwatch England would channel more power to local bodies so that there could be more independence, more power and greater opportunities to influence the NHS and social care.  He said the Healthwatch model would be made stronger as the policy details around Healthwatch were sorted out.

Culture shift or engagement dressage?

In his first speech as Secretary of State for Health this week, Andrew Lansley backed a “nothing about us, without us” approach to patient engagement.  Sounds good. But here’s the big unknown: is this a genuine culture shift or just clever patient engagement dressage?  That’s what trained horses do of course and we think it’s a good metaphor for formalistic process that is all for show. Caroline’s blog on how things are being done with schools policy shows that any commitment to consultation can so easily be trampled under the hooves of a new government’s cavalry charge  for early achievement.

At an East London event jointly organised by National Voices,  Patients Association and Department of Health,  Lansley fleshed out some of the principles in the new Coalition Government’s plans for healthcare. This included how LINks and Healthwatch would be related – a subject MAC has a great interest in and to which we will return with our views in an upcoming post.

In making the NHS a safe, effective, successful service, his key priority will be “First, that patients must be at the heart of everything we do, not just as beneficiaries of care, but as participants, in shared decision-making. As patients, there should be no decision about us, without us.”

The corollary would be “disempowering the hierarchy:  the bureaucracy, the Primary Care Trusts and the Strategic Health Authorities. I don’t want the whole of the NHS to wait to hear from me. I want it to listen to patients, and to take responsibility for action.”

Caveat – hierarchies don’t usually relinquish power easily and a struggle is usually involved – maybe even with bureaucratic blood on the carpet.  It will take more than speeches to achieve the objective – so watch this space for the promised White Paper on Health in early July and an autumn Health Bill  as foretold in the Queen’s Speech last week.

In the meantime, we intend to take Mr Lansley at his word and judge him and the NHS by their actions.  We also remember the adage “culture eats strategy for breakfast.”  In that spirit we invite readers to consider his speech and give us their comments, warts and all.

To kick this off,  this is what Jeremy Taylor, CEO of National Voices had to say about Mr Lansley’s Bromley by Bow vision:

‘Culture shift is the key challenge for the NHS.   Despite significant improvements in recent years, there has been too much management by fear, too much inertia from professional vested interests, and too little opportunity for patients and families to be heard.  National Voices calls for an open, human, responsive and collaborative culture that puts people first.   Incentives play an important part in this but we need to understand the whole mix of carrots and sticks, and we look forward to seeing more detail from the government.’

We also wonder what this all means for commissioning as a change process driven by public health intelligence and for the role of Third Sector bodies who are trying to influence it locally.   MAC has a particular interest in upping the commissioning game for neurological long term conditions and the profile of organisations that work with the millions of people who have neurological LTCs.  It is hard enough in organisational development terms for Third Sector bodies to focus on 150 English PCTs as commissioners, especially for the less common conditions. It would be ludicrous to expect them to try to engage with the 500-600 GP commissioning consortia which Mr Lansley is describing as part of his vision.

It would be a serious – and we hope unintended – consequence to weaken the potential influence of Third Sector patient-led organisations as players around the health and social care reform table just at the time we need their voices and intelligence the most.  We urge Mr Lansley to think about the consequences of pushing commissioning crudely down to GP level and leaving the PCTs, if they even survive as viable organisations, to pick up the scraps that the GP commissioners can’t be bothered with.  That would be a recipe for fractured services far worse than anything experienced now and would quickly lead to even more yawning health inequalities.  And it is a subject we shall also be returning to in the near future.

Stronger and more accountable Foundation Trusts needed to avoid “Staffordshire 2”

At least 400 died needlessly

“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.”

The enquiry was published this week on deaths at the Stafford Hospital part of the Mid Staffordshire NHS Foundation Trust between 2005 and 2009.   It should be required reading – all 455 pages of it -  for commissioners and Trust board members everywhere. What happened in Staffordshire could happen elsewhere unless governance and clinical behaviour are drastically improved.

Don’t just read the recommendations or you will miss the outrage you should feel at the recurring catalogue of systemic clinical, governance and above all individual failings (nurses but also doctors and managers) that resulted in the untimely deaths of some 400 people (maybe up to 1200 according to some accounts).  If a train crash killed 400 people, there would be an immediate public enquiry and Ministers would be front and centre.  But that’s not what happened here.

No openness: no challenge: no change

The Francis enquiry report  is not strong enough on improving Foundation Trust governance. It largely ignores the role of the Trust’s owners – the Members of the Foundation Trust and their elected Governors.   A Foundation Trust is after all defined in law as a “public benefit corporation” – a species of social enterprise -  but what that means in practice has been deliberately fudged by Ministers and Monitor since FTs were first created. Now we can see what that sort of “governance neglect” can lead to.  Francis could have made a big stride forward to rectify that, but instead it made a rather bland recommendation to empower members and governors.  Much, much more needs to be done about ensuring there are stronger public and service user Governors and – crucially – about empowering staff governors elected from the Trust’s own workforce.

Then there is the role of the Local Involvement Network (LINk).  Why was there not a functioning LINk locally?  Why were there no unannounced visits to these wards under enter and view powers and reports made to the local authority and the PCT about obvious care shortcomings?  I cannot image a Community Health Council (CHC) pre their abolition in 2003 failing to respond vocally to the first reports of failing standards.  This is a measure of what we have lost in local accountability.

Closed enquiry

In Staffordshire theenquiry led by Robert Francis QC was closed and so most members of the public and the media outside the region were not even aware of until it reported this week.   To its credit the Francis team produced a good report, concluding that patients were routinely neglected by a Trust that was preoccupied with cost cutting, targets and processes and which lost sight of its fundamental responsibility to provide safe care in a headlong pursuit for Foundation Trust status which it achieved in January 2008.

But however good its recommendations, this process isn’t the same as a robust enquiry held in the public and media eye and it falls far short of assigning responsibility for these failings to individuals.  Only individuals can be held to account for this magnitude of institutional failure.  Think casino investment banks.   The Trust as a corporate body and its culture are only the reflection of the sum of the behaviours and attitudes of the people who comprise it -  the clinical staff, managers and board members in particular.  Some of them did try to raise the alarm, but most did not.  Some were cowed into silence, but it seems that most chose to look the other way. Or maybe they just could not believe it was happening to them.

Where were the nurses?

Most worrying of all is the question “where was the voice of professional nursing as the patients’ champion?”  The Trust’s diverse nursing team are the most numerous group of employees and always will be. They are  everywhere and they see everything.  Had nurses taken a united stand and made their collective voice heard, the care failings of the Trust would have come to light much earlier. Where were the letters to MPs that the hundreds of nurses working in this hospital should have written?  Where were the local nursing clinical leaders? Where were the nursing trade unions and professional bodies?

Does the buck stop nowhere?

If people knew and did nothing, that must be culpable if not criminal.   If some senior people at the Trust are not personally held to account for this, then the message is “the buck stops nowhere” and accountability is reduced to a cipher.   Relatives are demanding responsibility at this level and so too should the public because this outrage took place at a time when the NHS has never been more regulated and this Foundation Trust was – on paper – rated a good, and safe, provider of services.   But no one challenged the failures.

Governance matters

The enquiry recommendations could have clarified that the governance of the Foundation Trust must be rooted in the membership community and its elected representatives whose role is to hold the Board to account and who must be supported to carry out that role.   This seems to be what the Secretary of State Andy Burnham is now talking about in his reported views about strengthening the Governors of FTs .  Will he translate these words into action?

This Foundation Trust’s board meetings were held in private.  That was wrong and Mr Burnham has now declared in a parliamentary answer that FT Boards must meet in public and Governors must have access to all Board papers. There is still some wiggle room in that which needs clarifying.  It is welcome, but in itself it will not solve the problem of a culture opposed to openness and challenge.

It is an indictment that without the persistence of “Cure the NHS” -  a local group of patients and relatives who knew that things were going wrong within the hospital, who raised complaints and whose members kept shouting despite efforts to silence them –  the magnitude of this scandal would never have come to light.  Their contribution is praiseworthy, but they should not have had to make it alone.  The Foundation Trust is after all “owned” by its Members who elect a Council of Governors to hold the directors of the business (the Board) to account for delivering safe, effective services and fulfilling their strategic plan.

Stronger Governors needed now

Should FT Governors therefore have a role in the complaints process?  That is one option raised by Francis, along with the possibility of the Governors electing their own chair instead of sharing a Chair with the Board as currently.  Both suggestions have merit and need serious consideration. Governors could be effective scrutineers of the complaints process (which could do with improving its performance in many Trusts), but should not as individuals get directly involved in complaints handling.  And Governors deserve their own, independent chair.  Having the same person chair the Board and the Governors invites conflicts of interest as was obviously the case in Staffordshire.

FTs at a crossroads

The Mid Staffordshire scandal shows Foundation Trusts at a crossroads. We must learn from this and quickly because all other NHS Trusts are headed for Foundation status or else franchising from an existing FT.   These “community benefit corporations” must be made to behave for the benefit of the community and be accountable to its representatives.  They  must be directed by Government down the road of greater local accountable to their Membership communities through stronger, more effective Governors – public and staff.  If this does not happen, then it is just a question of waiting for “Staffordshire 2” to happen.

England needs a Welsh lesson

The Conservatives created them in England and Wales without appreciating their full potential.  Labour neglected, belittled, callously fragmented their functions and then destroyed them in England as an afterthought in the NHS Plan, despite widespread agreement that they could and should have been reformed and refocused. But in Wales , Community Health Councils (CHCs) survived.  

It’s time England learned a lesson about this. As Carol Jones, Director of the Board of CHCs in Wales wrote recently in the Cardiff Western Mail, CHCs have never been more vital as that country embarks on a new approach to its heath services .  

A Welsh lesson would be timely with a new Government on the horizon.  MAC believes now is the time to recover our inheritance, dust off the organisational memory and move on.  In effect reinvent CHCs for England. This isn’t a homage for just doing things as before.  First and foremost, we must keep the expanded health and social care remit of LINks, which is the one good thing to come out of Labour’s chaotic “reforms” of patient and public involvement.  

England needs unified geographical authorites to integrate local commissioning of health and social care.  We also need local statutory consumer bodies mirroring the health and social care commissioning spectrum.  Their job would be to co-produce, enable, articulate and advocate based on the views of the public, users, clients and carers.  To start fleshing out this role, we’ve identified the following chacteristics of “CHCs Mark 2″: 

• comprehensive strategic and collaborative remit with NHS and local authorities balanced with attention to quality and detail of service delivery which matters to patients, clients and carers
• professional staff to continuously engage with their communities, co-produce intelligence for action and support their members
• sufficient real budgets including recognition and reward for lay people’e time carrying out public duties
• access to all premises and services where publicly-funded patients and clients go
• one stop complaints and redress advice across health and social care
• visibility on the high street as well as the web
• national operational standards and an independent regulator and auditor to ensure probity and compliance
• independence in governance and funding from the services scrutinised
• democratic control and accountability to local people for their policies and actions
• access and rights of referral to overview and scrutiny bodies and ministers when issues cannot be resolved locally.

Rights and influence are the trade off for responsible and accountable behaviour.  We want new-style CHCs in England to be the informed and critical friends of the statutory services.  Too often in some places in the past they were allowed to become the neighbours from hell in confrontational relationships with local services.  A governance approach reflecting the suggestions above would go a long way to ensure that did not happen again.

MAC would like to see people elected to new-style English CHCs as independent members without party affiliation for the individual contribution they could make because of their knowledge, skills, local networking and other attributes. Public money should fund election hustings and “town meeting” type events where candidates would be voted on to CHCs and where on a regular basis reports would be made back to the public about the body’s activities.  It is good that the NHS in England now has a statutory duty  to listen and engage, but without a stronger voice the listening ear is just an appendage.  Let’s try some real localism for a change, because centralism doesn’t work when it comes to getting things down “down our way”.

As Carol Jones rightly observed, “If we want to avoid another Mid Staffordshire catastrophe, learning from the Welsh experience and building on it for the English NHS and social care system seems an obvious way to go.”  Let’s not quibble over names; it is roles that matter. Whether it is called “Healthwatch”   or something else, a new-look English CHC rose by any other name would smell as sweet, so long as it was up to the job.

Citizens, Consumers and the NHS

Christine Hogg’s Citizens, Consumers and the NHS: capturing voices (Palgrave MacMillan, November 2008; 224p; £19.99  ) provides a thorough narrative of where the Community Health Councils (CHCs) came from  in 1974, what they achieved over 30 years and why they passed from the patient and public involvement (PPI) scene in England in 2003 after a rancorous final chapter following their surprise abolition almost as an afterthought in the NHS Plan of 2000.

Woven through this narrative  is an analysis of citizenship and social rights versus consumerism and user choice as drivers of often competing, conflicting and even contradictory initiatives in the PPI world from the mid ‘70s until now.  As Christine Hogg makes clear, the one cannot be properly appreciated without an understanding of the other, so in essence this is two books in one.  You will not be disappointed if you pursue either or both strands as the history and theory are inextricable.

An overriding conclusion from the book is that 30 years of  fragmented policy, political expediency and false starts in PPI have taken a fatal toll on organisational memory. That is perhaps the greatest collateral damage from the death of the CHC movement and the miserable interlude from its creation in 2003 to its extermination in 2008 of the Commission  for Patient and Public involvement in Health and its ill-fated Patients Forums.  After only one year in operation it is too early to tell if the Local Involvement Networks (LINks), the main element in the still-fragmented replacement system to everything that went before in England,  will succeed in spite of their vague governance and accountability arrangements and a seeming lack of interest from the Department of Health.  But as the author makes clear, without understanding the mistakes, missed opportunities but also notable successes of the past 30 years, we shall all have to live through –  or perhaps be dragged through –  them again. 

Conspiracists might conclude that all governments wish to divert user knowledge, energy and the attention of user-led organisations away from the levers of power. That retrospective is sloppy and simplistic, though consumed in large quantities.  The truth  about why the CHCs were not reformed but abolished in England and the motivations of the major players at the time and subsequently is a tangled skein, but a vital story emerges from the unpicking in this book.  Rather like democracy in Weimar Germany, CHCs  did not fail on any objective criteria so much as because their potential was never seriously understood, valued, developed or – most importantly – reformed to meet evolving circumstances.  By 2000 the NHS Plan’s diktat simply ordered their demise in England to everyone’s surprise (though in Wales they have evolved and prospered in what is becoming quite a different healthcare environment).  Perhaps Wales therefore provides the counterfactual historical model to the  English experience of CHCs:  “what would it have been like if…..”. 

The story of PPI over the last 30 years as Christine Hogg explains “has much to celebrate and much to mourn.  Though the world has changed enormously since 1974,  the issues that policy makers tried to address in setting up CHCs are still current and seem to have advanced little.”  What patient – not forgetting carers -  and public involvement is actually for (in other words, the ends of the policy) is still the hardest question to answer and the one most easily avoided and obscured as the debate about the means to encourage and sustain participation thunders on generating more heat than light and often exhausting the participants. It will be interesting to see if the NHS Constitution is but the most recent example of avoiding the real issue of ownership and control of our most important public service.

As one of the “usual suspects”, I am delighted to be among this book’s collective dedicatees – it is good company to be in.  Would I recommend this book to others?  Without reservation, particularly to Chairs of LINks and their members for whom Christine Hogg has provided a reliable anchor in history and theory for the otherwise uncharted journey they have begun.  For LINks and their Host bodies,  Citizens, Consumers and the NHS should help them understand the issues and efforts of the past which are with us still so they don’t waste time discovering them anew and wondering what to do next.

There are many people with first hand knowledge of the CHC experience and its closing chapter in particular.  This is an open invitation for them to comment from their experience and give their views on what followed.

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