Risk of Infection

But the uncertainty that dogs this initiative should not be allowed to infect institutions that are functioning perfectly well doing the job they were set up to do. The fear is that the Ombudsman becomes the cheerleader and the policeman for Big Soc programmes – promoting local resolution, specifying remedial actions. This is the way to the Heffalump pit of enforcement – ie making sure that what is specified is done.

‘Murky’ Success

The report has a chapter on accountability, equity, representation and management (and all this is a chapter only 3 pages long). For me the interesting idea that has applications for the areas we work is  that those concerned with Big Soc projects could work more flexibly and confidently if they take a ‘murky view’ of success – a view which is more nuanced and broadminded than ticking the one box called SUCCESS!.

The Moore Adamson Craig Partnership have always favoured a metric of success – otherwise how do people know what they have achieved? However in the world of volunteers – like people coming forward to be a patient representative in a GP surgery – there is always this mix of the personal and the communatarian.

Understanding the Needs

Participation can be prompted by personal need as well as community need and in health matters the personal is often the far stronger motivation. This only becomes a problem if the personal remains so dominant that it precludes that person developing the skills and the perspective that allows her or him to use the personal as a basis for the general agenda. Matthew Taylor’s blog is referenced by the committee where he writes about the irredeemable anecdotalism of the Big Society with the consequence that ministerial policy is vague and uninformed by any evidence. However in our view, the anecdote in matters of public engagement is often where an issue kicks off with the  evidence becoming stronger as the anecdotes accumulate.

A Matter of Political Inconvenience

However would we be too cynical to say that anecdotes that support a ministerial point of view are embraced while the ones that do not, are ignored even when a lot of time and energy has gone into organising feedback. I remember us agonising over the format and content of our local LINks Annual Report to be submitted by all to the Secretary of State for Health. There was such potential there to pull out common threads based on the patient representative experience. What happened? Can’t remember and now it is too late with LINks becoming another of those ghosts of PPI past that haunt the NHS patient participation landscape. Any evidence that might support the continued existence of these organisations has to be ignored since it is politically inconvenient. The Big Society revolution is certainly fulfilling that hoary revolutionary maxim whereby revolutions devour their own children – in this case the institutions that might have played a considerable role in achieving the NHS version of ‘murky success’.

The Moore Adamson Craig Partnership supports user and public participation,  trains lay representatives and develops responsive  health, care and education organisations.  We are ready to work with and support all those who want to make sense and a success of the new structures of patient and public engagement within the new arrangements for health and social care commissioning and providing.  Feel free to contact us to discuss the opportunities.

Lumped in with comms

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

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

Framework can’t deliver involvement

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

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

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

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

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

Much more than Healthwatch

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

No involvement, no legitimacy or support for change 

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

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

- Niccolò Machiavelli, The Prince (1532)

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

Is Surrey sure about Assura?

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

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

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

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

Probity, accountability, not to mention conflict of interest?

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

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

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

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

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

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

Meanwhile back in Surrey

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

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

The Moore Adamson Craig Partnership supports user and public participation,  trains lay representatives and develops responsive  health, care and education organisations.  We are ready to work with and support all those who want to make sense and a success of the new structures of patient and public engagement within the new arrangements for health and social care commissioning and providing.  Feel free to contact us to discuss the opportunities.

No information means no intelligent commissioning

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

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

Six domains to satisfy – watch out for Number 2

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

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

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

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

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

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

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

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

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

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

 GPs don’t seem keen anyway 

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

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

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

Not a good place to be in

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

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

The Moore Adamson Craig Partnership supports user and public participation,  trains lay representatives and develops responsive  health, care and education organisations.  We are ready to work with and support all those who want to make sense and a success of the new structures of patient and public engagement within the new arrangements for health and social care commissioning and providing.  Feel free to contact us to discuss the opportunities.

Test drive the new diagnostic commissioning tool for “EwPC”

Amid all the excitement, the Department of Health sneaked out a “diagnostic tool for commissioners”  on 4^th August in the form of a bright and shiny Excel shreadsheet.  It is well-intentioned, but alas, far too complicated for GPs who probably won’t ever see it anyway though it is aimed at their Clinical Commissioning Groups.   I took it for a test spin, but found it wouldn’t fit on my screen unless reduced to 90% and it still felt very crowded to use.

I browsed the commissioning tool’s content for EwPC = “engagement with patients and community”  and – for me at least – learned a new acronym. What was wrong with PPI or PPE I wonder?  But never mind, because, surprisingly, the tool is very positive on this subject. Whoever wrote the tool understands that effective commissioning can’t happen without local public understanding and user/carer support for redesign and different ways of doing things together.

Can’t quibble with that.  But here’s the point: the new tool is likely to be a futile exercise where PPI, PPE EwPC or whatever acronym for meaningful engagement is concerned.

Reasons for futility 

Why futile? Two main reasons.  First, CCGs can opt out of using the commissioning tool (and many will to avoid its rigour),  but more importantly because the death knell for local and meaningful engagement with patients and the public sounded on 28^th July in the form of the “shared operating model” for clustered PCTs.  No one can opt out of that and its centralising grip is getting stronger.

It means that CCGs aren’t going to do their own engagement work in the “shared model” as it will all be integrated with “communications” controlled from much higher up the hierarchy of command and control – extending right to the Big Beast himself as CEO of the National Commissioning Board.

We’ve had our say about this throttling of PPI at the hands of “communications” and it clearly struck a nerve with readers because more of you left comments than we have ever had on a subject before.

There’s a second reason the new commissioning tool is likely to be DOA.  The throttling of real engagement continued in early August when Mr Lansley launched the 75 Local HealthWatch pathfinders, but failed to provide any resources to get from here to there and no ringfencing for budgets when LHW go live, leaving it to the discretion of each local authority.

The launch press release had these honeyed words -

“These new learning networks will champion patients’ views and experiences, promote the integration of local services and improve choice for patients through advice and access to information. Local HealthWatch will provide a collective voice for patients and carers, and advise the new Clinical Commissioning Groups on the shape of local services to ensure they are informed by the views of the local community. “

Withering pathfinders in scorched earth resource environment

It is a great aspiration, no doubt about that.  But it will be merely wishful thinking if the Local Healthwatch pathfinders wither and die because starved of resources between now when they are still LINks and October 2012 when the Local Healthwatch bodies are supposed to go live.

Malcolm Alexander and the National Association of LINks Members (NALM) has rightly sounded the alarm loud and clear about what this means.  Councils will get money for Healthwatch, but you may see more holes filled in your road as a result.  Ensuring adequate funding of LINks and their transition to a viable Healthwatch is a different matter.  There aren’t many votes in public involvement across health and social care.

It’s systemic

Why is all this happening to choke off the possibility of public involvement at local level at a time when government’s engagement rhetoric and championing of “localism” has never had a higher profile?  To find the answer, search no further than David Gilbert’s insightful analysis for the Commission for Healthcare Improvement (CHI) back in 2004 that involvement was not in the “corporate bloodstream” of statutory services.  A prescient metaphor.

He said then: “… PPI needs to be made part of everyday practice, or ‘mainstreamed’. Unless this happens, PPI will be a passing fad, and a unique opportunity to ensure better quality care, treatment and decision making would be missed.” 

With some notable exceptions the “mainstreaming” we all hoped for hasn’t happened. PPI and co-created, user-focused intelligence aren’t centre stage in most decision making processes – certainly where commissioning is concerned –  because most “professionals” don’t want them to be.  They threaten the prevailing culture of control, especially in a cold climate with short rations.

And for that reason, we conclude, the “reformed reforms” have a poor prognosis.

When the dust settles 

When all the dust settles, assuming it ever does, our conclusion is that “liberating the NHS” has produced not logical reform but confusion characterised by organisational drift and indecision, increased cost pressures, network dislocations, unplanned staff changes and confusion and needless anxiety in service users and the public.  ”Nothing about me without me” has been throttled in that climate because, lest we forget, the “Nicholson challenge” is still to save £20bn+ by 2014 and we are still miles from achieving that. That is why the iron grip is tightening from the centre.

It is a huge disincentive to involvement. As the old saying puts it, “If you wanted to get to there, I wouldn’t start from here.”

The Moore Adamson Craig Partnership supports user and public participation,  trains lay representatives and develops responsive  health, care and education organisations.  We are ready to work with and support all those who want to make sense and a success of the new structures of patient and public engagement within the new arrangements for health and social care commissioning and providing.  Feel free to contact us to discuss the opportunities.

Strange. Somehow this got published even though it was never officially launched and was still being worked on when I was last involved with it in April this year. Was I asleep? I think LINk put it out anyway. There is a feature on it on the LINk site dated last week.

Anyway, a more useful version is here and a version with rather different categories went to the (Wandsworth) health and social care OSC at its meeting earlier this month.

And I have been having correspondence (with nobody you will know dear reader) about why this was NOT published yet and what could be done to break the logjam. It really is Alice in Wonderland I think.

….Put together these two versions give us an interesting picture – from the standpoint of what interests the user and potential patient – about access, advance appointments and other key issues about “what good looks like” across the 46 practices.

There are two surgeries with a 97% satisfaction score – one is our old friends at the Balham Park Surgery where Partners Craig and Moore helped Natalie Goldsmid-White the Practice Manager set up their Patient Liaison Group many moons ago now.

Are we seeing the first hesitant and rather disorganised steps to getting people aware of and interested in using good data to unlock the information key to better healthcare for themselves? Is the real revolution in the health service happening while pseudo-battles range about structures and processes which citizens, patients, carers are learning how to by-pass? Today’s paper ( 7th July 2011) tells us that more clinical information on death rates for specialist surgeons and also prescribing rates for GPs are to be published for the first time from December. The usual ‘doc orgs’ are worried about ‘simplistic league tables’. Wandsworth are to be congratulated for being one of less than 10 PCTs to give this information now. And the word is that the Department of Health plans to stop funding audits which do not allow the public to make comparisons

I was given a context for this triumph for the march of openness even if it was achieved by unknown and back to front means by looking at a couple of TED chats on how the web is moving on from text to data. None other than the great guru T B-L himself called for “Raw Data Now”. Data is relationships and understanding the power of the links took me to another TED talk where Dave Debronkart talked about the patient as the great underused resource. He found a cure for his cancer thanks not to doctors but expert patient groups who knew where the data was and could use it and point him to it. He harked back to hippy history and the medical editor of The Whole Earth Catalog (whose got my copy?) who is still going strong – shorter hair, bigger gut – and who recently compiled the profile of the e-patient in the spirit of the subtitle of the Catalog – access to tools.

The E-patient is:

• Equipped
• Engaged
• Empowered
• Enabled

and the key to all this is access to data which will be accessible to us across all platforms. Just as T B-L used the language of html to make documents accessible, we are now seeing the invention of a similar platform to link data. The crucial distinction is between the data and information. Information is edited and tailored by the author or editor to make their point: data is raw, unfiltered and unrefined and the new epatient can use it how they like.

Will the citizens of Wandsworth use the GP data? How will the new commissioners publish their data – will they show the data to foster participation in their decisions or will they just give us the information that supports their decisions?

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.

Triangulation

Try triangulation between

1. the applicant consortium
2. the approvals process of the NCB and most importantly
3. an independent reference group or panel comprised of knowledgeable local lay people, including councillors

This we think can be implemented in an effective way which at the same time strengthens a Council’s Overview and Scrutiny function.

Independent lay reference group

The independent lay reference group should be hosted within the relevant Council’s health and social care scrutiny function.  It should comprise a group made up equally of serving councillors who are experienced in or currently involved in scrutiny (preferably but not exclusively from health and social care), together with an equal number of independent lay people (called “assessors”) who are recruited from the local population on the basis of their ability to make a substantial contribution to the scrutiny and authorisation process.

It is important to stress that these lay people are not “patient representatives”, but individuals able to play a role in the authorisation process in the public interest.  “Lay members” would be another descriptor. They may comprise any or all of the following: expert patients and carers, patient advocates, representatives of 3^rd sector user-led bodies,  experienced LINk members and other individuals selected for their expertise in health and social care issues.  Half a dozen people in each consortium area should not be difficult to identify.

These lay assessors should be rewarded for their time and level of responsibility in contributing to the consortium authorisation process at the same level as councillors who undertake scrutiny functions.  The recruitment process should be simple, e.g.  inviting expressions of interest against a person and role spec available online on the Council website.  Selection of assessors should be a joint LINk and Council activity.

Assessors working with councillors

The purpose of the lay reference group (councillors and assessors working together) would be to scrutinise and validate evidence submitted by the consortium to the NCB and to form a consensus view based on local knowledge of the compliance of the consortium with the NCB’s authorisation criteria.

In carrying out this role, Councillors and lay assessors would be of equal status.  The chair of the OSC would chair the panel and, in the unlikely case that voting was necessary, have a second and casting vote.

The process would be for the reference panel to consider the consortium authorisation application documentation and to hear a presentation from the consortium leadership about the evidence the consortium was putting forward to support its case for compliance with the NCB criteria for authorisation.

Panel’s engagement with the public

The panel’s meeting to consider authorisation would be publicised and it would meet in public.  The consortium application and the NCB criteria would be available on the Council’s website for wide viewing in advance of the meeting.  Interested members of the public would be invited to submit questions to the reference panel in writing in advance via the website.  These would be considered at the meeting and a list of questions and consortium responses would be published.

Questions for lay assessors to ask

The lay assessors on the panel would in particular ask questions about:-

• the consortium’s strategy and operational practices for patient and public engagement at whole consortium, subdivision (eg “locality”) and individual practice level and the evidence that existed of successful functioning.  Example: Will this ensure responsiveness to patient experience and public feedback about current services and service improvement priorities?
• the process for gathering user-led intelligence and applying it to commissioning decisions and evidence that this was viable  Example: Will this ensure a strong voice for patients and the public in the planning, delivery and review of clinical services?
• evidence that using evidence from patients, carers and the public will lead to service changes (reconfigurations, redesign, decommissioning, new developments and alterations etc) that are beneficial to patients.  Example: Can you point to specific instances that demonstrate how patient led intelligence will be or has been used to create or change services?
• the consortium’s ability to influence their providers to be responsive to user views and to emphasise improving the patient experience as part of their contractual obligations. Example: What specific policies and practices in providers demonstrate that and can you point to specific instances of it happening?
• the consortium’s capacity as a commissioning body to handle and resolve complaints and concerns through local resolution.  Example: What is the record on complaints handling (performance against targets etc) and examples of local resolution and learning from complaints?

Decision options for the panel

Following the scrutiny, the reference panel would then form a view on the adequacy of the consortium’s readiness for authorisation and give advice on that basis to the NCB. The panel would be able to choose between these options for its decision:

• the consortium is ready for authorisation without qualification;
• the consortium is provisionally ready for authorisation, subject to further evidence being received by the panel on identifiable areas [named] in a set time frame. If this option is chosen, the panel process would be repeated to consider the additional evidence when it was submitted.
• the consortium is not ready for authorisation until more evidence is supplied about specific areas [named].   If this option is chosen, the panel process would be repeated to consider the additional evidence when it was submitted.
• the consortium cannot be authorised because it does not meet one or more of the criteria for authorisation [detail to be given] and an action plan is required for improvement for submission to the Council by [date].  If this option is chosen, the consortium’s action plan would be monitored by the Council and regular reports on progress towards authorisation would be received by the Overview and Scrutiny Committee meeting in public until it was deemed to be ready for authorisation by the NCB.

Handling complaints and concerns about the consortium after authorisation

Once authorised, a consortium’s performance will be monitored by the NCB [details of how this would be done to be determined]. Post authorisation, local people may have reason to raise issues of concern with the NCB about  the consortium’s performance.  This should be possible through the Council’s overview and scrutiny process in the form of a public petition detailing the concerns [criteria to be agreed].

Once formally lodged with the Council, this petition alleging poor consortium performance would have to be heard in a meeting of the OSC which was publicised and open to the public and at which the petitioners had the right to present their case and ask questions of the consortium representatives.  The OSC councillors would then decide whether a case had been made on which to base a formal complaint to the NCB about the consortium’s performance.  This process would be entirely separate from any rights pertaining to LINks or, in time, Local Health Watch.

What happens next?

We have submitted these views to members of the NHS Future Forum – their report should appear in early June – and will blog about them on the Forum’s website.  They have also gone to those at the Department of Health charged with working out the authorisation process for the NCB.  They are now in the public domain.  If readers would like to pick them up and incorporate them into similar submissions, you are welcome to do so.

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 were ably led by Wandsworth LINk chair Jenny Weinstein.  One of the things she identified in discussion as essential when consulting was something that often gets left out when giving people feedback on what happens to the views they offer. When the answer is “no, we can’t do that”, it’s necessary to go further and to say why and what else would  or could be done instead. If this doesn’t happen, the “no” giver comes across rather like the character in the illustration and it may be the end of any further dialogue.

How right she is.  It is necessary to go further than just saying “no”, however politely it is dressed up.  Suggestions made in good faith must be treated with respect even if they cannot be acted upon.  Is it to do with money? Are there legal issues? Environmental barriers? What are the reasons? Participants have a right to know.  Otherwise consultation fatigue and alienation from engagement set in very rapidly.

Listening to the discussion on this point prompted me to dig out  a list of the patient and public involvement commitments that I wrote into the consultation document in 2001 which set up Wandsworth PCT.  I was then vice chair of Balham, Tooting and Wandsworth Primary Care Group.

Back in 2001, we said we were committed to giving patients’ views greater prominence in shaping NHS services and we identified five “tests” about this.

1. In practical terms, this means that the views of users and their representatives must be sought about priorities for investment and options and implications for service development.

2. We will therefore involve users and representatives and consult with them as part of planning service provision. They will be consulted in the development and consideration of proposals for changes in the way those services are provided, and on decisions to be made by the Primary Care Trust, affecting the funding and operation of those services.

3.  As part of its patient, carer and public involvement, the Trust will show that it has sought and taken account of such views, in return for the time and effort, which users and representatives have given them.

4.  We will be open about our decision-making and will acknowledge when public involvement has been responsible for change.

5.  Equally, when resources or other restrictions mean that well-informed views for alternative approaches cannot be implemented, the Trust will explain to those who have given their views why it is not possible to agree with them. It will also make clear the rationale and implications for whatever investment, service developments or other changes have been agreed instead.”

It is number five that really addresses the point that Jenny Weinstein made about “not just saying no”.  The new commissioning consortium  must do more than  just aspire to that, and we hope they will be able to avoid the pitfalls we encountered in PCT land.

However good the commitment, I think an objective observer would conclude that we failed the delivery tests on many occasions.  The reasons will be only too familiar: we were overtaken by events; “must dos” and targets rained down from above with ridiculous timescales and meaningless performance management; we endured reconfigurations; there were always personnel changes; and financial crises of course; you name it.

Dusting off the 2001 wording, its clear to me that “responsiveness” is the concept which emerges as the best test of “what good looks and feels like” in user and public involvement.  It’s a lesson we must hang on to in the current difficult times.  I think this sums it up:

“By involving local communities; the patients, service users, carers and residents of Wandsworth, we can gain a better understanding of how local services need to be changed and developed. By creating greater local ownership of health services we can improve the quality and responsiveness of those services and reduce health inequalities.”

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.

That’s because Health Watch organisations should give a big push to how primary care businesses interact with and respond to their customers.  We hope that the changes which are said to be coming from the Future Forum report at the end of May for the HSC Bill, will set Health Watch – and patient and public involvement in the wider sense – on a firm and leading course in the reforms.

Two new players on the board

There will be two more three-letter acronyms to learn:

Health Watch England (HWE) – providing leadership, advice and support to Local HealthWatch; advice to the NHS Commissioning Board, Monitor and the Secretary of State and able to propose a Care Quality Commission (CQC) investigation of poor services.

The positioning of HWE within – but not as a wholly owned subsidiary of – the Care Quality Commission is an opportunity to develop a synergistic relationship between LHW and CQC on everything to do with regulating quality.

Local Health Watch (LHW) – developing the role of existing LINks by ensuring that the views and feedback from people who use services, carers and members of the public are integral to local commissioning; providing advocacy and support to people about complaints and helping them make choices about services; and providing intelligence for HealthWatch England about the quality of providers including primary care bodies.

As thinking currently stands, LHW will probably be able to recruit and employ its own staff – a significant change from LINks. Are CHCs being reinvented by default? Many would like that, but the answer is probably “no”.  There is no indication that Government wants a presence for Local Health Watch in the community analogous to the Community Health Councils which had premises and staff and promoted public access to their services. In reality, things have moved on since shopfronts equalled access. The intention is that LHW will maximise use of websites and other interactive media to “signpost” to services to increase patient choice in health and social care.

Transition to LHW could be delayed

Local authorities received a “transition plan” at the end of March for helping LINks turn into LHW. Local “pathfinders” are being encouraged – reflecting the accelerated development process going on in the commissioning consortia and the health and well being boards .

The problem is, this may all take rather longer than anticipated in the Health and Social Care Bill. David Nicholson’s latest “managing the transition letter” of 13 April said that Health Watch England will be delayed from April 2012 to “not earlier than July 2012”.

Slippage down the line from the creation of HWE could mean that Local Health Watch bodies won’t appear in each local authority area until the end of 2012 or even later. A transition that prolonged and coupled with uncertain funding through cash-strapped local authorities makes for high risks.

LHW impact on primary care beyond patient involvement

Many LINks are already interested in promoting patient participation in primary care. Our Wandsworth LINk has made this a priority for 2011-12, with a project aiming “to ensure patient involvement exists in all Wandsworth GP surgeries and in GP commissioning from the outset.” That’s significant in itself, but there are two more potential impacts on primary care beyond the obvious one of patient involvement.

“Enter and view”

The “enter and view” power of LINks will transfer to LHW, meaning that visits can be made (including unannounced ones where there is sufficient justification) to any place that care is being given to an NHS-funded patient. Once on site, authorised representatives can talk to patients and others and observe what is going on.

Typically, “enter and view” reports about primary care include things like patients wanting more access, including by telephone, being able to book more appointments in advance and being able to see a clinician of choice. None of this will be news to primary care professionals of course. LINks have powers to refer concerns higher to the Local Authority; Local HealthWatch will have the power to recommend to HealthWatch England to undertake investigation into particular services if there are local concerns about it.

This is quite separate from inspection powers of the CQC and other regulators, though close collaboration between LINks/LHW and regulators is an obvious implication. “Enter and view” rights by LINk authorised representatives (who are trained, CRB checked, etc) include the independent sector and of course all family health services contractors (GPs, dentists, pharmacists, optical services). How would you and your practice colleagues feel about having LHW representatives visit your practice, talk to patients and then publish a report of what they had seen and heard? It is something you should be thinking about now as we move to a more consumer focused primary care system.

Complaints and advocacy

Government has a vision of LHW as an all-round consumer voice working similarly to a Citizens Advice Bureau. Current official thinking is that LHW will also become the focus for health and social care complaints and advocacy. This would be the most significant change in the transition from LINks. This proposition is attractive to some, but it could cut two ways and have unintended consequences.

I asked our patient participation group at Balham Park Surgery for their views on this recently. My question was , “should Local HealthWatch take on new functions around health complaints advocacy and patient choices?” They clearly said this should not happen because health complaints and complaints advocacy are specialised areas which the local authorities should lead on. But, they said, LHW should be involved with providing information and helping people to make good health and care choices.

Debate over complaints vs independence

There are some in the LINks world who would like to see LHW become providers of complaints handling and advocacy services, replacing the existing Independent Complaints Advocacy Service (ICAS). Superficially this may seem an attractive proposition, but it could turn out to be a fatal error. We recently told the Health Select Committee that LHW should not take on a direct responsibility for complaints handling or complaints advocacy because such functions would skew LHW’s main purpose.

Among the reasons our LINk in Wandsworth have for opposing LHW taking on these functions is that it would place Local HealthWatch in a position of negotiation with health and care agencies as to what is a ‘reasonable’ health and care service response. As they point out, this is a different role to the wider representative role of LHW and could compromise its independent position. That is a view from grass roots activists that should be heeded.

There is no doubt that the unified complaints and redress process spanning health and social care introduced in 2009 needs to be better publicised and accessed by the public. Current complaints processes are disjointed and difficult to utilise. They do not meet the needs of service users or service providers in primary care who need to learn from them to make improvements. But this does not mean that the role should be given to LHW.

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. Memories of CHC days suggest focusing complaints work on LHW would fatally skew its activity in many areas, introduce conflicts of interest and confrontation with local commissioners and providers and could doom LHW as an effective enabler of local voices.

Drowning under the weight of complaints handling was one of the main contributors to 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.

But don’t leave it all to Health Watch

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.

Despite this high-profile role, it is essential that people working in primary care don’t by default see LHW as a synonym for patient and public involvement. It cannot all be left to Health Watch. 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. To be successful businesses, GP practices and commissioning consortia need many direct “listening relationships” with their own patients.

The new Patient Involvement Directed Enhanced Service (DES) agreement between GPs and NHS Employers which began on 1st April is the key to building up involvement from the grass roots in the local practices.  Without that, LHW may find it is legless.

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.