A head teacher is all about being a lone warrior, fighting for righteousness, fighting the good fight, as powerful as any chief executive.  I am not that bothered about distributed leadership; I would never use it; I don’t think Clint would either.  We need head teachers with ego.

Did he say Clint??

On their high horses with their ears to the ground

Before he had hung up his hat, let along put down his gun, he announced that he wanted to see a network of “Local School Commissioners” whose job will be to keep an eye on schools in their area and flag up problems.  All the Sheriff’s Men.  I think he and Michael Gove have just realised it is going to be quite tricky to oversee 24,000 quasi autonomous schools directly from Whitehall.  Watch him think on his feet:

It is no good just relying on Ofsted to give the judgment. By that time it is too late.  We need some sort of intermediary bodies which can detect when things aren’t going well, look at the data and have their ear very close to the ground to determine when there is a certain issue.   These people would be non-political, in other words they would not be like LEAs responsible to a council… they would be people who would report directly to the secretary of state.

Apart from offering a rather unexpected view of the merits and effectiveness the inspection regime, what does this tell us about how he sees these new commissioners?  It is easy to say they will be “non-political” but much harder to work out what (or who) this means in practice.  Commissioners will not be responsible to the Council but will be appointed by, and report directly to, the Secretary of State. How exactly will that ensure independence and a lack of political bias?  Interestingly these guys seem to be quite a different animal from the  proposed Police and Crime Commissioners who will at least be locally elected before they get their hands on terrifying amounts of money and the power.

The election of Police and Crime Commissioners is at the heart of the Governments’s plan to cut crime.  They will reconnect the public and police, and allow us to replace bureaucratic accountability to Whitehall with democratic accountability to local communities.

Founding Principles of Public Accountability?

Maybe it is just me but I am getting increasingly confused about what this government means when it talks about public accountability in public services.  If elected local government is to have a role in the delivery of health and social care services (well the rhetoric is there even if the reality is sinking fast in the deadly morass that goes by the name of public accountability in the Health and Social Care Bill) and if police commissioners are at least going to be elected before being given unprecendented powers, why is education being dragged in the opposite direction?   School governors (including elected parents) and local authority education departments answerable to elected councils have been doing this stuff for years.  Sure, they could undoubtedly have done it better and it would certainly have helped if they or anyone else had ever managed to work out how to make school governance work properly.  But taking all the power and influence out of their hands and putting it into the hands of a Magnificent Few surely takes us further away from proper accountability, not closer.

Heroes don’t need to talk – or listen

Independent think-tank IPPR thinks it understands what school commissioners should be doing. They are appear to be worried about local accountability in schools and their description of the role of commissioners seems to suggest that they will help to make schools more accountable to the communities they serve:

Schools commissioners would not be involved in managing schools, but instead act as local champions for standards, monitoring the performance of all schools in their areas, whether academies, free schools or local authority schools, and intervening where schools were failing or coasting. In this way, they would be more visible champions of standards for local parents.

So when The Two Mikes and their gang ride into town and they want to know what’s been going on, who will they call around the table to make sure they really are acting as “local champions”?  How will they make sure their ears are very close to the ground?  Who will they talk to?  Governors? Parents? Students? Apparently not.  Look carefully at the wording above: “visible champions of standards for local parents”.  This does not mean listening to parents.  It does not mean championing the views of parents.  This means localised champions of the centralised standards agenda.  They are doing what needs to be done, “for local parents” not with them, or in response to them.   This means a man’s gotta do what a man’s gotta do and the townsfolk better be darn grateful.  Sir Michael knows how it should be done:

The job of the commissioner would be to meet the managing directors, the chief executives of those clusters, report to him or her on the performance of the group. And the commissioner would then make a judgment on whether a school needs to be improved, report to the secretary of state and then bring in other agencies to improve those schools or not.

There sure ain’t much room for public involvement there.  Not even the Head Teachers get a look in.

Get off your horse and drink you milk

There is nothing here nor in any of the statements from the Department, the Founding Principal or IPPR that even vaguely begins to explain HOW an unelected local schools commissioner would have a clue about parental views or experiences.    In fact given Sir Michael’s lone ranger stance it is not surprising he shows no interest in what anyone else thinks.  All the education system in England and Wales needs is a few hundred good men and true, cloned from the combined DNA of Gove and Wilshaw who know What Works.   No worries about messy distributed leadership here.

The Moore Adamson Craig Partnership supports user and public participation,  trains lay representatives and develops responsive public service organisations including schools.   We can help you set up a Parent Council and advise local authorities and governing bodies on how to involve parents and carers.  Feel free to contact us to discuss any ideas you have.

For ten top tips on how to involve parents in school, take a look at A Short Guide to School-Parent Partnerships co-written by MAC partner, Caroline Millar, for the Family and Parenting Institute.  Contact us for a free copy.

More radical leadership and thinking required

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

Power is at local level

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

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

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

A scandal that must end

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

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

The Shock of The New

Crucially, whilst it can be very hard to get people to engage early on with the theoretical idea of Something New, the actuality of the New Thing, once it appears, can trigger wild enthusiasm to engage.  It is usually relatively easy to identify what people dislike about the Existing Thing but harder to put your finger on exactly what they like about it.  And it is very hard indeed to discover what they might want in the New Thing if it does not yet exist.   So the appearance of something new provides the perfect trigger for engagement and dialogue.  Complaint and concerns become the engagement entry point but as we all know (don’t we) a complainant properly handled can be converted to a fan: complaints as opportunity, not threat.

I have been involved as the chair of my local park user group in a major project funded by the Council and the Heritage Lottery Fund to restore the park and the almost derelict 18th century house within it.  £9m and two years since the contractors arrived on site, the house and the cafe within it opened at the beginning of this month.  Inevitably the new cafe was inundated with people from the minute it opened (5000 customers in the first six days) and, just as inevitably, the cafe, the Council and the User Group have been inundated with complaints and comments.

It being 2012 these take a multitude of forms and are directed at anyone who cares to listen: lengthy emails to Council officers and the user group; witty, sensible and balanced blogs full of good ideas followed by bitter and angry riposts from both named and anonymous  commentators; tweeters tweeting and retweeting into infinity and the familiar range of constructive and snide comments on the pages of Facebook.  Amidst all the noise there has in fact been a lot of positive feedback too but somehow that’s not what you notice or what sticks in your mind when you down that second glass of wine after reading Bile Man’s tenth post of the day.

High volume feedback

It feels like there is a heck of a lot of noise going on, though if you read carefully and once your ear is attuned you start to realise that in many cases it is the same people having the same conversation in a multitude of different forums (and I suspect under a number of different “identities” aka silly names).    I am glad I have had twenty years in this game, otherwise I think I might have been a bit overwhelmed by the wave of anger and vitriol that has been washing over my computer screen in the last few days.

If I were doing this as a job, rather than as a volunteer and interested amateur, I’d find it hard to know where to begin in terms of being responsive. I might well wish for the good old days of having to respond only if a complaint was submitted in writing to the right department and followed the Complaints Policy to the letter, complete with a turn-around time of twenty working days.  As yet no-one from the Council seems to have joined any of these public debates (although I feel sure they are watching).  I can see why, but they do need to be tapping into this wealth of user feedback in some way and letting people know they are listening – not just by making changes but telling people that they are making these changes in response to their comments.  The good old Feedback Loop.

Bad old days but simple complaints

In the old days people complained that they could not get into the cafe because there was no step free access, the coffee was horrible, the food was unpleasant and unhealthy, the service poor, you had to queue for up to half an hour to get served when it was busy and you had to go outside to use the dirty smelly toilet block and there was nowhere to change a nappy.

So what has the Council done?  It has put in a lift so buggies and wheelchairs can have access to the whole house, it has brought in an experienced cafe provider which sells good coffee and healthy and attractive food, it has knocked down the disgusting toilet block and put the toilets in the house with fancy hand-dryers and a separate baby-changing room and it has introduced table service so people don’t have to queue whilst trying to control their children, leaving their friends to hang on to a table while they waited.

Are the good people  of the Stoke Newington twittersphere falling over themselves to demonstrate their appreciation of the Council’s responsiveness and their gratitude to the Heritage Lottery Fund?  Of course not. They have long since forgotten what was wrong with the old cafe that closed two years ago.  What matters is what’s wrong with what they see now.

Panning for gold

Maybe it is not the “Taking Away” or the “Giving Something New” that is the problem.  Maybe it is simply a matter of change.    It is a fact of life for anyone involved in delivering change in the public realm that some people won’t like it.  And it is another fact of life that you won’t get everything right first time: them damn punters just won’t use the building the way they are supposed to.  But our new cafe is not finished, the building has opened but what happens inside it is a work in progress and here we have a great opportunity to get a dialogue going with users.  We have existed for twenty year struggling to get more than twenty people into the room for our bi-monthly meetings to talk about all the boring stuff.  Suddenly everyone, everywhere seems to want to be heard and there is gold in them there users (once you can filter it out).   How we handle this is the next challenge facing User Group and the Council.

I can understand why the people who are working flat out to deliver new and better things to an apparently ungrateful public might be tempted to start seeing these people as a tiresome minority who will never be satisfied and metaphorically dump them in the files marked variously moaner, whinger, nutter, axe-grinder, single-issue-obsessive. And from personal experience this week I can assure you that it can be very difficult to respond positively in the face of the unfounded, misinformed personal attacks that often accompany the nastier blogs and tweets.  I get this stuff at some of our meetings too so it is nothing new.  Some are insulting – some plain baffling. (The man who turned down my offer to meet him in person to talk about his concerns suggested “knitted yogurt” may “float my boat”. Huh?)

Listening is a two way street

It is hard to stay in listening mode with people who seem determined to think the worst of everyone who is engaged in trying to make things better whether they be public servants, politicians or local volunteers and who insist on attributing the worst possible motives to your involvement: I obviously must be receiving back-handers from the Council; the cafe offering to provide free tea and coffee for the user group’s first meeting is a sign not of support for local involvement but of “ingratiation”; because I described the bread as “fresh” when the word is not actually used on the menu, I am thought to have some sort of insider knowledge which probably results from the fact that I hold shares in the cafe.  And not content with having a go at people like me who are sort of asking for it, they even have a go at other ordinary people who have the audacity to say they quite like the changes.  If this is what Big Society feels like I am not surprised it is not get many takers.

Instant gratification – instant turn-off

Every time your respond you simply breed yet more comments and sometimes you wish they would just shut up and leave you alone.   You want to turn off the computer but you know if you do they will still be at it, angrily bashing at their keyboards forming new alliances with other people with equally silly made-up names, finding new people to despise and practising their one-up-man-ship skills. Just waiting for you to come back as you surely will and must.  Worst of all are those websites where every single reply invites another reply, and that reply another reply and so on for ever and ever and suddenly you have not a single snake of comment and counter-comment but a multi-headed hydra with all the heads screaming at each other and at you.

You can’t even satisfy them by asking them to read info you have prepared earlier.  ”I’ve waited two days for a direct reply to Emma’s question….” said a post at 9.58am on Sunday haranguing me for not answering a question about the user group’s constitution posted at lunchtime on Friday even though I had immediately posted a link to the website where there is loads of detailed information about how we work.  The more you try to respond the more the process saps your time, your energy and your goodwill.  And like I say, I am just a volunteer. If I worked for the Council (WHICH I DON’T BTW) I’m not sure I’d be wanting your hard-earned Council tax to be spent paying me to do this.

We need an engagement answer that works

So what is the answer to this modern conundrum?  How do service providers and small unfunded voluntary community groups like the Clissold Park User Group engage constructively and cost-effectively with users in this new world where so many people are keen to share their view, opinion or bad experiences (plus the odd inaccurate or misleading “fact”  and a couple of unpleasant insinuations) not just with the service provider but with other users?  How can providers and user representatives  manage and make sense of a wealth of unfiltered, uncontrolled feedback?  How do you get the facts out to people amidst all the clamour?  How do you get the dialogue right when each individual can choose the time, place and medium through which they express themselves rather than following the rules of engagement set down by others.  How do we all make sense of a world where it feels as if, to quote Tim Minchin in the musical Matilda,  ”What you know matters less than the volume with which what you don’t know’s expressed”?

Is there a way to prevent people feeling that if they get a response they are just being fobbed off and and if they don’t, no-one cares or is listening? And how do we address the inherent imbalance and lack of openness in the fact that complainants can lurk behind masks of anonymity whilst make personal attacks on named individuals who are either doing their job as officers, acting as democratic representatives or volunteering their time.   In a small and demographically compact community, how do we encourage people  to show their faces and join the debate openly- should those who won’t  be given the same status in the conversation as those who do?  After all this is not a school or a GP’s practice we are talking about where there may be real issues of confidentiality or personal anxiety about power relationships: this is just a local park with a cafe in it.

Listening to the waving – and the drowning  - but not the shouting

And while we are talking about public engagement in services like health, education and social care, it’s worth thinking about how the challenges of modern public and user involvement affect these much more important and more sensitive areas. With all this racket going on, what can people in positions of responsibility and influence do to make sure they are hearing the people who are not shouting but quietly waving or maybe even drowning?

The Moore Adamson Craig Partnership supports user and public participation,  trains lay representatives and develops responsive  health, care and education organisations. We work with complaint handlers to achieve user satisfaction and recommendation.

What Gets Ed Going?

5 things got Ed’s goat:

• Bank charges NB overdrafts – this was something a Financial Conduct Authority had to address pdq and not be a Lapdog but a Watchdog!! (Which? campaigning message)
• Control of the costs of train travel – making the inflation +1% cap a reality across all fares and all routes and why not car parking charges as well
• Energy markets – where a six supplier stranglehold made a nonsense of claims that this was a properly functioning competitive market place and where the older digitally disadvantaged consumer is barred from the most advantageous online tariffs.
• Low Cost Airlines – no more surprises to be allowed when suddenly late in the booking process, large new elements are added to the original tiny fare
• Pension Administration Charges – where dignity in retirement is protected by not allowing excessive admin charges swallowing up too large a slice of pensions.

There you have it. As an early questioner – your man from MAC – made the point that these were all private sector examples. Could Mr Miliband perhaps tell us how he wanted to strengthen the user voice in the public sector e.g the NHS? Ed acknowledged that this was something that past efforts had not got right and we need to look at it some more.

Union difficulties

In the spirit of the age, we took questions from a Twitter stream – one of which asked bluntly how he felt about the London Tube drivers holding Londoners to ransom with strikes. The answer hovered for a moment on the edge of falling into the Ed Loop trap  – the only thing my twenty- something children brought up when asked for their ideas on questions for Ed. There were other interventions on the limits of choice and action on behalf of the vulnerable and other plugs for Which? current campaigns. I guess the entire Policy and Campaigning team at Which? were under a three line whip to get up early and be there.

Resurrection: A Minister for Consumers

Perhaps the most interesting question that gave some hint of the future was the one from the Which? editor who asked Ed directly whether he intended to appoint a Consumer Minister to co-ordinate the consumer interest across all departments. Ed said he would think about it.   What goes around comes around. The last time Which? worked so closely with governments in the ’70s- both Labour and Tory – was what we see now was the highwater mark of the consumer movement’s influence – a Department of Prices and Consumer Protection with a Secretary of State rooting for the consumer cause, an Office of Fair Trading founded (one for the Tories) and grants for Advice Centres plus new legislation.  (This government support included –  I can tell you now  - a secret rescue plan for Consumers Association and Which? were it to go bust at a time of skyscraper inflation when costs were outstripping the organisation’s capacity to raise subscriptions.) Ed said he would think about it. (Which? these days is doing fine financially.)

Get Your Soundbites Here

Did this all sound exciting and convincing? The five issues listed were all good, easy and populist targets on the list but a bit scattered and disparate  while staying well away from the public sector. It does not yet add up to a strategy – merely plums plucked from the Which? campaigning hit list. We ended on the note of Ed deploring the Fast Buck Culture – ground that Ed claimed he had occupied well before Cameron – and the squeeze on living standards.

The man needs a bit more than this to light his fire and indeed ours as voters. Can he start by doing some classic engagement and participation work with people in his own Party? Develop his own empathy and connection skills that will convince first his friends and then his enemies and capture the trust of the uncommitted that when he says he is on the side of whoever – whether it be squeezed middle or squashed bottom – they believe it. Then there will be some feeling and meaning behind the easy epithets and the self-consciously twee soundbite – dogs, laps, watch etc. Meantime, Which? will continue to do their thing with their usual energy and impetus – offering their shopping list of issues to all callers of whatever political hue. Ed should stay in touch.

Future Forum 2

Promoting individual better health and wellbeing

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

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

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

Integration demands full implementation

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

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

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

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

No information no integration

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

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

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

New Bill needed

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

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

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

“Improving outcomes by working together”

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

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

Social care elephant in the room 

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

Patient and carer power?

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

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

More radical thinking needed 

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

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

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

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

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

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

The late Mr Gray’s play was Cellmates which fits the patients’ situation rather well since whatever the chaos being visited on the NHS, they – and that means all of us without private healthcare – are banged up in our cells with no choice but to serve out our term within the walls of the monopoly supplier. The patient interest seems caught up in the Goon Show episode Tales of Old Dartmoor (transmitted February 1956) as an unwilling passenger in the fantastical voyage of Dartmoor Prison. Remember? It put to sea to rendezvous with the Château D’If in search of the Treasure of the Count of Monte Cristo. The solid stone of what we thought were well-established institutions become the ghost ships of fable, haunted by lunacy and laughter.

We have erred into the other dangerous area of newsletter writing – maudlin reminiscence of the times when Britain were great or at least when Spike Milligan was alive, even if driven mad by the memories of German shellfire and the pressure of writing comedy shows. It would appear that we need a good madman or two to do justice to the past 12 months. The next 12 defy my powers of prognostication although other partners may try and deploy their Delphic powers.

Just enjoy the pleasures of revisiting some of the pieces of the last 12 months – we have been tweaking our website and you now have the opportunity to go back and visit the MAC Partners choices of the past blogs that they have particularly enjoyed.

For the dedicated policy wonk, see how Andrew Craig’s thoughts and views developed as the proposed arrangements for commissioning and other organisational changes emerged.

I always look forward to what sounds like another Goon Show episode – Tales of  the Clissold Park Users Group – and Caroline Millar’s struggles to create a local park space to be enjoyed by all – dog walkers included.

For those interested in the consumers’ and citizens’ right to privacy and how this story is being played out in the Leveson enquiry, you may look at my blog sparked by the points put to Richard Thomas the former Information Commissioner about how his attempts to strengthen the law and give more protection to citizens vis a vis an intrusive press were directly impeded by the Prime Minister of the day. Also note how creative and adventurous action within the regulatory orthodoxy of one era of consumer policy is challenged as being faint-hearted and misplaced in the years that follow – with Richard being pressed as to whether he was too lenient in the face of the journalistic establishment.

It was a reminder how valuable and necessary it is for consumers and citizens to have a strong advocate of their interests – established by statute and ready to take risks to make that often unpopular case for vulnerable consumers in the face of vested and powerful interests. We have argued in the past for a Citizen Commissioner speaking for patients in the NHS – with statutory powers to intervene like an Official Solicitor – an Ombudsman before the fact if you like with amongst other things power to support the whistleblower. Otherwise the citizen or patient voice interest is as insubstantial and as easily ignored as any fantasy dreamed up by a Goon and illustrated by Ronald Searle.

Enjoy 2012.

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

Cats and frogs

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

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

Federations more than a group of practices

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

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

Get the engagement right from the outset

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

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

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

 Start with practice participation

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

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

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

Getting from here to there 

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

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

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

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

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.

So in part his reluctance to go legal is a product of the mood of the policy of the day. But his other more managerial concerns illuminate the area where the demands of public policy cross over into the realities of office budgets and resources. How much will this cost? How likely are we to win? Will we get the political support we need? Now even in these times when regulation is preferred to the weedy and woolly self-regulatory approach, the questions will not go away. The fact that a law exists does not mean it is enforced. What will produce the better set of outcomes?

Must get back to the live feed. We are getting to the bit about calls from Jack Straw about pulling the bill and then calls about withdrawing the clause that increased the penaltiesand the moment of the summons to No 10 and discussion with Gordon and the unsuccessful search for a comprimise. Result – the clause was dropped. Hot stuff.