Vouchers offered for NHS opinions
http://news.bbc.co.uk/1/hi/england/london/7658352.stm

Residents in east London are being offered vouchers by the NHS as incentive to get involved in improving their health service.

NHS Waltham Forest said it would give vouchers worth £25 to the first 500 people who turn up to the public event to discuss local healthcare.

Residents who attend the event at Walthamstow Town Hall can redeem the vouchers at local shops.

The NHS insisted spending £12,500 as an incentive was “good value for money”.

The importance of branding and reputation building are also wound into the report and it is good to see those fundmental points acknowledged.  Too many in the NHS still squirm when brand and reputation language are used.  They need to grow up and acknowledge that service users understand this already.  It is much more than the PCT changing its note paper to be “Anywhere NHS” and then having hurt feelings when it is pilloried in the local press for “wasting our money” instead of doing more hips and knees.

But for my money the phrase to blow up, print out, frame and stick up on the wall of every NHS office, practice, clinic and canteen across the land is this one: “staff need to put themselves in patients’ shoes. Just the physical act of lying down physically disempowers a patient”. If only this happened, it would change everything.  Language mirrors reality” I seem to recall from a bygone philosophy lecture.  So let’s stop talking about “patients” as a first step to empowering all of us and especially the service users and carers who should really be partners in planning and delivering their own care.  Collectively we are the ones who have paid and are paying for it after all.  I for one don’t want to take it lying down.  And I want to be sure they understand that in the Boardroom.

“Gung-ho CLG seems so enthused by LINks that it seems keen to expand the concept beyond health and social care and is inviting Councils to submit proposals. Where this leads is anybody’s guess but the idea of networks of interested stakeholders is a powerful concept.”

Is this an idea linked (no pun intended) with CLG minister Hazel Blears - she of the recent community empowerment white paper and participatory budgeting experiments - to extend LINks straight across everything a Council does?   Sounds like the kind of thing that the ”government in waiting” might be keen on too.  And it is just the sort of development that some Councils might want for the wrong reasons.  A single tick box solution to involvement and consultation based on “we talked to LINk” is appealing but it is reductionist and simplistic.  We should be wary of this expansionist offer at least until we have some solid achievements with LINks in health and social care to point to and much more experience with the methodology of contacting, listening, understanding and transmitting views of local citizens.  But as the CI newsletter rightly says, the idea is powerful and something to think about for the future.

In the meantime here is a just published CLG report on barriers which people feel keep them from being able to influence local decision making.  Quite relevant for LINk and our understanding of participation generally I think. The biggest factor (barrier) is how much people trust their local council – perhaps an obvious conclusion but one that must be addressed where the answer is “not much”.

Readers could also dip into the CLG report on the New Deal for Communities pilots.  It is mercifully short and summarises lots of what we know already – so it provides a good and recent benchmark – about barriers and incentives to participation.  It talks about the “1% solution” we have previously discussed on this blog.   There is an allied report on what works well in communicationswith specific groups in the community.

This is all good stuff for us to know for LINks and Hosts should have these reports on their electronic reading lists.

(jump to our strap-line competition here)

So we have done a bit of brainstorming and come up with twenty suggestions on how we might define what we offer to clients and encapsulate that in a pithy and memorable way. The new phrase will go as part of a new look on our website.

We need an outside eye and would like to invite you to help us choose which one describes us best. Our current account of ourselves and what we do can be seen at www.mooreadamsoncraig.co.uk and the associated blog site here (www.publicinvolvement.org.uk) site.

This is, as many readers will at once realise, is an example of the approach know as ‘crowdsourcing’. The phrase first appeared in an article in Wired in 2006 and the author Jeff Howe defined it as

“the act of taking a job traditionally performed by a designated agent (usually an employee) and outsourcing it to an undefined, generally large group of people in the form of an open call.“

Let’s Go Crowdsourcing

The current calls for user engagement and involvement can perhaps be seen as being part of that phenomenon with organisations formerly closed to the user interest and totally ‘captured’ by provider interests, open themselves up and unblock their ears to the external voice.

The new LINks organisations are intended to be important players in collecting and amplifying the voice of the crowd of users. The regulators in health and social care – at the moment plural as in the Healthcare Commission and the Commission for Social Care Inspection but soon to be singular: the Care Quality Commission – are touring the country to meet LINks people and work with them on the best way to feed into their assessment and inspection programmes. At the Cambridge event in September, it was very heartening to sit around the table with so many organisations focussing on how to make this work. The third sector who are working both as Host organisations as well as LINk member were well represented – Voluntary Norfolk was there (but not Compulsory Norfolk – no doubt no one had told them they had to come).

How we all laughed and there was remarkably little cynicism as in “we have been here before“. It would be wonderful if the regulators and indeed the Department of Health and other central government departments did work out a relationship with the local LINks that did not make the latter the poor bloody infantry of the regulatory system acting as unpaid data collectors for their assessment programmes while local issues and programmes were ignored. Instead there is room for a mutually profitable concordat between the individual and local voice of the user and those working at the national (English) level. Perhaps this time the views of the crowds outside the system really will count.

Back to our strap-line competition

Our suggested strap-lines / phrases are listed below and you are invited to pick your top 3 choices and the one you feel works best. Closing date 15th October 2008. Thank you.

The winners i.e. all those choosing what we think is the best out of our suggestions or even more excitingly coming up with one of their own which the Partners think hits the spot will be recognised as a hero/es. The choices of the Partners are open to discussion, scorn and mockery but we are very thick skinned given the amount of that sort of deplorable behaviour in our own meetings. So feel free to speak out and create.

Read the strap-lines and tell us your views here, or contribute by leaving a comment.

On Leadership & Management in Business

Shoes are on my mind because I have been reading the latest book by John Timpson of Timpson Shoe Repairs. The book talks about the reasons for the survival of Timpson Shoe Repairs when so many other larger and equally well-established companies have gone to the wall. The high street is a pretty spooky place if you think about it filled with the ghosts of retail chains - ou sont tous les magasins ‘d’antan’? as François Villon would have put it looking at the C15th retail scene. The British Shoe Corporation was once the Colossus of the high street with 26% of the shoe trade. All gone. Timpson Shoes itself has bitten the dust. You will have the ones you miss in mind - was it Timothy White’s? Mac Fisheries perhaps? John Collier? Salisburys for a nice bag? All this is very timely as corporations crash and burn.

The Timpson answer to the question is not 42 but 28 bullet points on p186. My own take on his survival is that John has kept things under his control - no external shareholders, no private finance companies to keep happy. He bought the company back under family control and runs it the way he and now (other son) James wants. Timpson Shoe Repairs can do their own thing. This is refreshing as we watch so many managers struggle with the new demands for accountability and transparency while trying to innovate. Compare the ease with which a private retailer shuts shops and 100s of them with the long drawn-out agonies of the post offices closure programme. Are there not better ways to manage public change especially with failing institutions?

There is a Department of Health Consultation out on this very topic about the best way of coping with failing NHS providers as they move, in the careful parlance of the document, from being ‘underperforming’ to ’seriously underperforming’ to - the horror! the horror! - ‘challenged’.

At least the problem is being faced up to which is always an achievement in the NHS that bulky leviathan where change and innovation mean that institutions and managers are often ‘challenged’. And what politician wants to be associated with closure of services the voters want? In this complex environment, the race goes so often to the small and fleet of foot who like Timpson Shoe Repairs know their business and their users and can make things happen.

On Leadership, Management & Innovation in Health Services

Which is why 2nd September was such a good day in Leeds for Andrew Craig and our client the Motor Neurone Disease Association. The Association has developed a new product called the Year of Care (YoC) Pathway Commissioning Tool in two years which more than meets the challenges of World Class Commissioning.

Andrew had the pleasure of representing M-A-C at the Motor Neurone Disease Association Year of Care Pathway launch and “thank you” event at the Thackray Medical Museum in Leeds earlier this month. It was well attended by mainly Leeds PCT and Leeds Social Services people and also people with MND and carers who had helped with interviews, focus groups and general validation of the draft pathway we undertook there.  Mick Ward, Head of Strategic Partnerships and Development across the PCT and Adult Social Services, gave the main speech and was excellent. This is just the kind of joint leadership that is needed to make progress for people with long term neurological conditions across the health and social care cultures. He committed the PCT and City Council to being in the MND Year of Care early implementers group so we shall be seeing more of him in the next twelve months. He related the YOC to the World Class Commissioning competencies and stressed the leadership, service transformation and market development aspects inherent in WCC. Clearly he sees the bigger picture. Andrew said he couldn’t have written it better himself! The Association has produced the ‘Learning from Leeds’ report by M-A-C as a 4 page colour brochure with pictures which looks terrific. Lunch was good and it was sunny and warm in Leeds. What more could one want?

For a flavour of the MND Year of Care pathway see the snapshot and read the press release

We will be putting more details about this work which we are proud to have been associated with on our website in due course. For more details of this event and an earlier one at the House of Lords as part of the NHS 60th Birthday celebrations, see the MND Association website.

Baroness Finlay of Llandaff, a Professor of Palliative Medicine said at the House of Lords event that

“This is one of the most important documents for patient care I have seen. This is exactly what the new NHS needs, a practical working tool to help achieve patients individual choice and improve their quality of life.“

Well done MND Association and while it may be strange to make a comparison between this terrible condition and shoe repairs, both achievements come from doing the best you can for your customers/users when you can with the resources available to you. Of course that will always involve other people - whether partners in PCTs and local Councils or staff and managers - but someone has to take the risks and do it first.

Survival often means not following the herd.

The challenge is to find the right leader and I will leave you with the definition of leadership given by the anonymous bard or bards who have handed down the text of The Wanderer, one of the most plangent and moving Anglo Saxon poems on the theme of ‘ubi sunt?’ mourning the good times in the past and musings on the qualities that make for success.

Wita sceal geþyldig                                          A wise man must be patient,

ne sceal no to hatheort                                    He must never be too impulsive

ne to hrædwyrde,                                            nor too hasty of speech,

ne to wac wiga                                               nor too weak a warrior

ne to wanhydig,                                              nor too reckless,

ane to forht ne to fægen,                                 nor too fearful, nor too cheerful,

ne to feohgifre                                                nor too greedy for goods,

ne næfre gielpes to georn,                               nor ever too eager for boasts,

ær he geare cunne.                                        before he sees clearly.

Bonne Rentrée and if Anglo Saxon verse is too cutting edge for you, take a look at our September post on how the Health Service and others are using the new social networking technology. One for your LINk perhaps?

P.S. We have been asked how to retrieve old blogs now that we have moved to the new style of presentation. These are all still available. The answer is on the right hand side of the blog page - try this link

Some are using it to tell people more about the personal side of their lives. We are told that the Health Secretary Alan Johnson

“is taking his excellent staff out for a very liquid lunch”.

Hmm - rather inviting comments from the alcohol units police but we get the point - Government ministers are human and have humans working for them.

Andrew Duggan of the Countess of Chester Hospital Foundation Trust wants to use Facebook to engage with young people and is quoted as saying that

“an important objective for us at the moment is engaging with younger people; our staff, patients and (foundation trust) members of the future”.

He acknowledges the fact that this group is traditionally difficult to engage with.

This is the sort of challenge that local involvement networks (LINks) have to meet as well. The younger people are - as the phrase goes - ‘digital natives’ as opposed to digital immigrants i.e. anyone who has not grown up in the digital age. They are most comfortable working in the sort of e-environment that Facebook and others of that ilk e.g. My Space and Bebo provide.

The challenge of course is not so much the technology. It is easy to set up what Facebook calls ‘pages’ where companies and organisations can post news and promotional messages for fans who have signed up to the page. Quantities of said fans are then supposed to post their reactions to the content. The difficulty lies in coming up with the hook that gets users signed up, interested and posting. Remember the internet phenomenon ‘the lurker’ - those who observe silently but never join in? I shall ask the MAC instant family-based research panel of digital natives - some pictured below and ranging in age from 5 to 26 - what would get them interested in a NHS site? We will report back.

It sounds interesting and fun and one for the Wandsworth LINk to take on board at once. Watch their space.

Andrew Craig delved into the EU directive on health without frontiers with a reminiscence about handling a complaint for reimbursing a patient who saved her hearing by going off to France for an operation which the NHS kept promising but never delivered. He concluded that health travel would broaden the minds of British patients and vice versa. And acute trusts here looking to keep up their balance sheets would do well to consider where the waiting lists were longest in member states as health travel will work both ways. Fleishman-Hillards’ blog “Public Affairs 2.0” picked this up and gave it pride of place in its review of blogosphere opinions about the directive.

Two blog pieces also looked at activity outside the UK with the first written from Canada on current obsessions with detached body parts and how Canada’s best selling newspaper approached reader representation. The other looks at the way one Ontario hospital does its follow-up questionnaires for in-patients 4 weeks or so after they have gone home.

Closer to home, MAC’s Caroline Millar and Rebecca Macnair went on the day of the NHS 60th birthday to the parliamentary launch of the motor neurone disease year of care pathway commissioning tool. This culmination of two years work with the MND Association was praised by Baroness Finlay, professor of palliative care at Cardiff University, as “one of the most important pieces of helpful documentation I have seen for patient care [whose] beauty is its simplicity.” Now we embark with our clients on the implementation phase, including action research with four pairs of NHS and local authority commissioners as they put the commissioning tool into practice. This should produce a rich learning stream about how statutory organisations work together, with 3rd sector bodies and most importantly with patients and carers to improve quality - Lord Darzi are you listening? Belated Happy Birthday NHS.

Colin Adamson
Partner
The Moore Adamson Craig Partnership

What impressed me the most was the quality of the covering letter which addresses questions that many managers prefer to avoid or gloss over when doing these sorts of surveys. For example, the letter confronts head on one of the main reasons why people do not respond. They are scared that if they say bad things about their stay in hospital, bad things will happen when they are back in. “Please feel free to express your opinions frankly and be assured that your future care at the hospital will not be negatively impacted.” They go on to offer more reassurance by saying that no one from the hospital will contact you about your comments - not least because they do not get any personal information from the survey company. A name and telephone number is given if people do want to talk to someone “directly regarding your care experience”.

The other nettle to be grasped is sending questionnaires out if the person has died. The way Lakeridge Health addresses the issues is first to say that they try their best not to send out questionnaires “to families of patients who have passed away”. They go on to write “If a grieving family member receives this letter, please accept our heartfelt condolences and our sincere apology”. However if people do have things they would like to get off their chest, then “If you would like to respond on behalf of your loved one, you may certainly do so, but it is not our intention to add pain to your sorrow and grief”. This is common and good practice - when we do complainant questionnaires, it is very important to avoid sending them to the families of the dead.

The fact remains that hearing from families and carers about what happened in these distressing circumstances, is actually very useful. Information can offer some very useful insights into how processes and policies in this highly sensitive area can be improved just as in any other service context. We were reminded of this when we did a group discussion amongst people who had cared for someone who had recently died where the insights offered gave us a very valuable extra dimension to the patient experiences we were collecting. However a self-completion questionnaire received out of the blue by the grieving family is a disastrous way to go about this. All of you who have had to manage a death in the family will remember how many forms had to be filled in to satisfy everyone from the Registrar of Births and Deaths to the Inland Revenue and how the heart sank with each post bringing more forms. A questionnaire enquiring amongst other things about the quality of hospital food is an unwanted extra chore.

The experience merits a more personal approach and one where specialist interviewers will help make sure that the people interviewed are treated with compassion and respect.

The topic is very relevant in a UK context given the introduction of PROMS – Patient Reported Outcome Measures – into the NHS shortly as part of the post-Darzi drive for quality in everything the NHS does. The most important measures of quality are measures of the outcomes of care, and that can include a “good death” as assessed by relatives. The best assessment of outcomes will usually be provided by the patient. Florence Nightingale had these too. All her patients on leaving hospital were recorded “relieved, unrelieved, dead”. It has taken us a long time to do as well as Miss Nightingale in many things, but from April 2009 the NHS will have pilot schemes for rather more sophisticated patient outcome measures for hip and knee replacement, inguinal hernia repair and varicose veins.

Let us hope our questionnaires on pain, mobility, depression and anxiety, and the ability to undertake the normal activities of daily life after the hospital experience are at least as tactful as the letter from the hospital in Oshawa.

In Canada, by C.Adamson

There was an immediate rush of stories about the civic duty of the fellow passengers on the bus. Should they have intervened? Or was their primary duty to themselves and to get out of there? I have no doubt as to what my reaction would have been. I have not been on a Greyhound bus since the time in the 60’s when the company offered what was surely the best travel bargain ever - $99 for 99 days of unlimited travel in the USA (and perhaps Canada as well?). There were indeed some dodgy moments but I never felt in danger of imminent attack by a crazed fellow passenger and believe me there were some very crazy fellow passengers to say nothing of those who appeared to live in the downtown bus stations.

If you wanted to influence the way the media covered the story, then I can tell you now one way of doing so - apply to join the Toronto Star’s Community Editorial Board. Launched in 2000, the Board has been ” a vital part” of the newspaper’s efforts to “understand and reach the many communities in the GTA”. (Greater Toronto Area). I was interested to see them making an effort not to get the usual suspects - “we are not looking for official spokespeople for communities but for ordinary people who share a passion fo the city and its residents”. How familiar that goal sounds to those of us looking for user and public representatives - the hunt for that elusive being: the ‘ordinary’ but passionate person.

The examples of previous members offered by the paper sound anything but ordinary but does seem to hit all the bases for diversity of input - the immigrant from Somalia who runs his own consulting firm or the Ojibway student who used to run a small business. (The Ojibwa is the largest group of native North Americans-First Nations north of Mexico- Wikipedia). Other members were a Sikh woman and environmental activist and the chemist of Pakistani origin.

The group discussed coverage of terrorists, foreign disputes and minority groups in the GTA as well as being able to sit in on meetings editors held with major political figures and write guest columns on topics of their choice.

If you want to apply, you are asked to get in touch with a Mr Ian Urquhart, the editorial page director, a member I am confident in saying of what must be Canada’s dominant anglophone (after a fashion) immigrant tribe - the clue is in the name. I wonder if Canada will be seeing Alex Salmond MSP over soon to announce that he favours ‘Le Canada Libre’ (except presumably Quebec) united with the auld country. Where Charles de Gaulle led, can he be far behind?

We urge Mr Urquhart to give his group a higher profile. A search on the newspaper’s own site showed 0 results for ‘community editorial board’. It would be great if Canada’s highest circulation newspaper took reader and community involvement offered some evidence that it takes community engagement seriously.

In the meantime back at home, the Wandsworth LINk gathers momentum after the Interim Executive was formed with one meeting already held and another planned for the end of August. More on that in future postings

Colin Adamson
Your Canadian correspondent.

Canada! by C.Adamson

The EU Directive isn’t very radical and rather watered down compared with earlier drafts, but it is welcome nonetheless to have existing rights (though most people never knew they had them) focused in one document. The sticking point about an NHS patient travelling to another EU member state has always been getting “prior authorisation”. But that is dealt with in the Directive.

About 1 in 5 Luxemburgers regularly receive state-funded care in another member state. But for us Brits, arranging this can turn out to be a “through the looking glass” experience. Some years ago I chaired a complaints panel involving a request to reimburse a patient who had had a stapedectomy (middle ear surgical procedure to improve hearing) done at a well known otology centre in Beziers, France, because the local NHS couldn’t say where or when it would be done here. All the consultants she had seen in the UK agreed the treatment was clinically indicated and the health authority repeatedly insisted that it could be done here in England. But no one was able to tell the patient - whose hearing was deteriorating - who would do it, where and when. Faced with that sort of dithering, the patient did what any sensible person would do and packed her bags for the trip to Languedoc.

When she returned after a successful result and claimed the costs back from the NHS, they refused indignantly to entertain her claim - after all the stapedectomy could have been done here and she did not have prior authorisation. Naturally she complained and that is when the fun really started. When the case finally got to me at the appeal panel stage, I am ashamed to say that I could not have imagined such bureaucratic contortions as my own health authority went through as it struggled to claim that black was white in order to avoid admitting that they had left the patient with no alternative but to travel for her operation unless she wanted to accept deafness in one ear. The panel found for the patient and recommended full cost reimbursement as compensation, which the health authority board to its credit agreed to pay on an ex gratia basis. And they had the sense to agree to a second Beziers trip for the other ear to be seen to when that too caused trouble a while later.

Did we learn anything from this? I never saw another complaint like it and I hope that this particular patient’s experience is not longer typical, but the DH’s latest hand wringing about the evils of two-way “health tourism” isn’t reassuring. The European Court of Justice has made crystal clear in a string of rulings that national health systems cannot refuse to refund costs of overseas treatment if patients have waited longer than clinicians advised, even if waiting list targets were met. The EU sees this as benefitting people with relatively rare or complex conditions and who could say no to that?

Of course, travelling for health care isn’t risk free, and there are costs above that of the treatment itself. Also, I’m not advocating (even if anyone would pay for it) crossing borders for botox, tummy tucks and such like. But I can see a number of very good reasons to encourage people to travel around in Europe for something they cannot get done speedily at home:

1. They will get a better idea of comparative standards in health services in other member states - rather like having the Euro helps compare other things we consume. That’s both good and bad perhaps, but it might put paid to the situation we have now where most people say their own NHS experiences are pretty good, but if asked how things are in the country at large they are convinced that the end if nigh for publicly funded healthcare. Travel broadens the mind in more ways than one and better health literacy back here at home might result;
2. It will encourage partnership and break down paternalism, of which there is still too much about in the NHS despite all the rhetoric to the contrary;
3. It could bring in revenue to the NHS because acute trusts’ capacity will have to be filled somehow as PCT commissioners redirect resources and services outside the hospital gates. If I were a Foundation Trust business director, I’d take this as a serious new business opportunity and get the map out to see which member states had the longest waiting lists for specialities I’d like to sell more of. But before I placed the adverts in the local papers, it would be a good idea to get the hospital’s cuisine up to higher level!

EU member states now have to translate the framework of the Directive for healthcare without frontiers into national law. Let’s hope the UK makes some sensible progress towards that goal and stops moaning about it. And it will be interesting to see if our proto-federal island kingdom can speak with a united voice on this one: what England’s NHS thinks about healthcare without frontiers, may not be the same as the views of Wales, Scotland or Northern Ireland at all. Comments from those jurisdictions would be very welcome on this point.

And a final bit of nannying - if you haven’t got your new European Health Insurance Card yet (replaces the late and un-lamented Form E111) apply for it here http://www.ehic.org.uk now!