One speaker at a Consultation Institute meeting on LINks held 23 June on LINks silenced the room with the passion and authenticiy of what she had to say. Val Moore was there for the Partnership and she writes:
‘Julie Bailey of Cure the NHS Stafford is the daughter of one of the 100 or more elderly people who died in Stafford Hospital. Her personal account of the horrors experienced by her mother and other patients and the complete refusal to acknowledge and respond to her concerns by all parties was most moving. To this day serious questions remain unanswered and even ignored and disbelieved including how a Hospital could gain Foundation Trust Status in spite of the appalling conditions and nursing and clinical care which was being provided in many of its wards. Powerful stuff and if anyone needed proof that the real user experience is crucial then this would have convinced them. The stunned silence of the listening audience was clear proof that no-one thought this is irrelevant anecdotal stuff.
Julie was followed by Peter Walsh of AvMA who was first class and set Julie’s experience in the wider context of the importance of accountability, monitoring, following through on complaints and learning from them to improve on patient safety.
A LINk can only call itself successful if it can bring together the many single stories into a coherent body of evidence that will truly make a difference. Would a LINk have made a difference at Stafford Hospital? It is an indication of how much LINks still have to do that this is a question that no one can answer with any certainty.
“Text cloud” for this post below, created by www.wordle.net
Ruminant Rumblings
It has been a bumper month for the public engagement debate across a wide range of participatory and management issues. We have sought inspiration for better management practice from an annual ritual in the Swiss Alps where cows battle out issues of hierarchy and succession in what we might call a ritualised ruminant rumble (to borrow the rather ancient gang fight vocab of West Side Story) complete with combat footage video. This piece brought out the worst in partner-originated puns.
Participation by Invitation Only - a discredited approach
Management issues were at the heart of Caroline’s accusation that parent power was nothing more than a piece of populist spin. The model of ‘trouble-shooting’ management embodied in an Interim Executive Board does not seek to engage parents. Instead they seem to favour the traditional ‘expert’ management style - taking the hard decisions quickly unencumbered by the burdensome baggage of external consultation. This executive pays little heed to the necessity of communicating what it is doing to parents and even as it moves to appoint a new governing body, the Board deploys the discredited practice of participation by invitation only whereby a small number chosen from the ranks of teachers and parents and a member from that most nebulous of concepts - the local community - are invited to take their place at top table. And invitations as we know can be withdrawn.
NHS Market Stimulation - new competencies needed
Andrew Craig has a different emphasis in his piece on market making in healthcare. This is a new competency for the NHS and unsurprisingly they are not yet very good at using their purchasing position within the economic framework of the NHS to get better value for patients. All are having to learn very quickly on the job as they look to managing their budgets in anticipation of them becoming subject to the new constraints on public expenditure. The debate on the positive contribution that markets may make is a theme of the current Reith lectures where Sandel tells us that there are instrinsic values in human activity where a purely economic approach does not work. The NHS will perhaps always be a battlefield between these two ideas in a context of political management.
Morality and Economics - a Reithian debate
I have touched in a previous newsletter about the deficiences in the consumerist model in those contexts where the citizen interest has to be invoked to make provision work for all sectors of societies. I wonder if this Reithian debate will form any part of Richard Thomas’s agenda as he becomes the Deputy Chairman of the Council of Management of Consumers’ Association. We marked Richard’s departure from the post of Information Commissioner and summarised the interesting debates we heard at a farewell conference in May 2009 - Jack Straw was moved to deny that the Government was using Orwell’s 1984 as a manual of statecraft. The mixture of the economic and the moral is particularly volatile in the arena of public privacy and data protection where a technology is evolving at light speed while the debate on public morality and efficiency and of course now national security and personal safety moves at its traditional pace as lots of people try and make up their minds about difficult topics.
Sarah’s Story and decency, fear and distress
An example of the controversy that can arise from sincerely held differences of opinion in the public arena came with an Advertising Standards Authority decision about five complaints received about the short film ‘Sarah’s Story’ made by the Motor Neurone Disease Association on the grounds that its violent images as Sarah is possessed by MND on the grounds that it offended against the Code clauses relating to decency, fear and distress. The ASA decided that the content was justified given the nature of the disease.
Please comment if any of the above resonates with you. We look forward in particular to hearing from Swiss dairy farmers.
And their parents?
A few weeks ago Gordon Brown declared that he wanted to make schools more accountable to parents. The National Union of Teachers spat back that this was just a bit of “populist spin”. After all, they argued in their press release, “Schools already work with parents and governors to ensure that information is fully available to the local community”. As my kids would say, “Yeh, sure.”
Some sorts of information, it would appear, are rather more available to parents than others however. My daughters’ school is currently being run by one of the government’s newest beasts, the Interim Executive Board, an unelected and apparently entirely unaccountable group of “experienced educationalists” which replaced the governing body when the school went into Special Measures a year ago. It took the Parent Forum seven months to get our lovely shiny IEB to agree to “publish” its minutes. Publish in this context means sticking them on a notice board inside the school where parents seldom tread and refusing to put them on the school website. And funnily enough, despite massive changes taking place in the school every week, the minutes say little more than the date of the meeting and who was there and are posted approximately six weeks after the event.
Now they are setting up a “shadow governing body” for an unlimited timespan. At last, we thought, a chance for parents to stand to be elected as governors and have some say in what it going on. We had been promised elections a few months ago, but now we are told that the new governing body will be made up of the same old “experienced educationalists” plus three hand-picked new members: a parent, a member of staff and someone from the local community. No elected trouble-makers here please.
But this worrying lack of stakeholder accountability extends well beyond Schools Causing Concern, such as ours where some might argue you need emergency measures to deal with emergency situations. In her column last week in the Education Guardian, Fiona Millar describes how, despite massive protests from parents and other local people in the London Borough of Camden, the local authority has decided to go ahead with an Academy run by a “preferred sponsor” (preferred by the local authority that is). What worries her is that the legislation around Academies means that their governing bodies can be entirely dominated by the sponsor, whether it be a creationist accountancy firm or a used car salesman with a side interest in selling cigarettes to young women in developing countries.
She writes: “Meanwhile, the academies experiment is still being rolled out with a vengeance, and is making a nonsense of local community empowerment. The wholly controlled governing bodies put in place by the sponsors are often fronts for more shadowy charitable trusts that make the real decisions - such as appointment of the head - from headquarters that are often hundreds of miles from the schools they control.”
The Conservatives have been a bit vague so far about what sort of schools they want to have in the future but they seem to be quite taken with the idea of parents running schools themselves following what is described attractively as a Swedish model. A recent MORI poll however suggests that this is not really what most parents want. Only 11% of parents thought parents themselves were the best people to run schools preferring local authorities (39%) or teachers (32%). 7% said they would definitely get involved in setting up a school if they could. Another 36% said they might help. A reality check based on our own experience and other research reminds us that the good intentions expressed in a questionnaire are not a reliable guide to who will actually turn up on the night. But if they did build the school and the people came, how accountable would this small band be to everyone else in the local community?
Governing bodies may not be perfect, and it is going to be interesting to see what the new Education White Paper (watch this space) says about how they should operate in the future. But whoever runs the schools, they remain public services and therefore need to have governance structures in place which make them fully accountable to all the key stakeholders. This is not just about getting better at telling people what they are doing after they have decided to do it (which I suppose would be a start) but about involving them in developing the vision for their school and making the important decisions about its future. We need to take a hard look at what is happening to schools and make sure that the reality starts to match the politicians’ rhetoric.
The news of Andy Hornby ’s appointment to Boots was of course the cue for the digital cuttings file to be raided for lots of images of him being abused by Parliamentarians. How could this man so recently discredited, rise again so soon to head up one of our great British businesses? How can this happen to a man so fresh from being bombarded by rotten vegetables in the stocks of public opinion?
The appointment of managers is a process that more and more, takes place in public. As the process of ‘externalisation’ takes place in the NHS with lots of new social enterprise service organisations being established, how will they find their managers and agree stable management structures for all these new businesses? Read on for the Moore Adamson Craig & Millar solution to filling the need for a credible and effective process for choosing our future business leaders.
Managing in the Public Eye
How do we learn to manage in the public eye? How can we find the leaders we need and organise succession in a way that will provides solutions that stick? We give you the Swiss Queen Cow approach to succession management - an organic approach to organising succession and finding leaders, tried and tested every year.
Heirarchy and the Herd
Each spring the herd emerges from its long winter confinement in the village barns out onto the mountain meadows bright with Alpine flowers. A natural amphitheatre in the bowl set in the mountain side is our stage and it is here that the drama of the annual struggle for the right to lead the herd, takes place.
The black bull-like Herens cows stand out against the green hill and their horns while carefully tended and trimmed are kept in full working condition. These vast beasts clash - click on the clip below to see the video captured by our on the spot but rather far away cameraman.
Queen Cow fight to be Top Cow
The hours pass, the onlookers get steadily more refreshed and steadily over time, the winner emerges from the group. All can now look forward to a summer under their their Queen Cow until the autumn transhumance when crowned with flowers, top cow leads the herd back to winter quarters.
The Public Gallery
We have witnessed a management process that is fit for purpose, regularly tested and is based on the principles of wide consultation with the involvement of the key stakeholders. The process is sustained by total confidence in the result giving a period of stability to ensure maximum outputs over the critical production period.
No to Testosterone
One final point - we are just talking cows. The animals may look a lot like bulls but they are not.
Not a bull
Bulls have no part in this. No flashy parade of testosterone-fuelled fighting for the sake of it from males - au contraire, a contained process calibrated to achieve the desired outcome, agreed by all.
Put them in the field and let them fight it out, we say.
We have inserted as a comment on the original piece in February this year, news about the ASA judgement following complaints that the film ‘was offensive and distressing’.
A recent blog by the estimable health economist at the Kings Fund Dr John Appleby on PCTs and managing markets pointed out that in the recent World Class Commissioning external assessments, most PCTs scored poorly on competencies around stimulating the market and market management. That rings true for my corner of South West London. I’m long enough in the tooth to remember when what we now call commissioning was just “purchasing” replete with shopping trolley analogies. We’ve come some way since then, but still have a long way to go to get to the stage of being real market makers able to shape services (and more importantly provider behaviour) towards outcomes that do something positive about narrowing health inequalities and improving the health status of individuals.
To do that we need to move beyond commissioning in terms of how we describe what we are really seeking to achieve. As “purchasing” was overtaken by “commissioning”, so the next iteration of the art should be “health investing.” After all £450m is no mean sum to have at our disposal annually. We should be able to do something creative with it to make things better for our 300k+ people who use services in our borough.
Just buying the same old, same old from the local providers won’t change things much.
As John Appleby says: “The fundamental question for PCTs is how, having identified their population’s health care needs and decided on priorities, they use their purchasing position within the economic framework of the NHS to get value for patients. “
There has been a spate of helpful “how to do it” guides for market management from perhaps not-too-disinterested management consultancies. These are all welcome - we have to start learning somewhere - but the best way I think is to learn market making by doing it. Perhaps that makes me a radical empiricist in my approach to market stimulation. I’ve just finished being part of the procurement team for our GP Led Health Centre at Clapham Junction and am now part of a team getting to grips with potential providers keen to help us do something about our scary childhood obesity problem. Everyone involved is on a rapid and time-hungry learning curve. Without doubt, sharing this experience within the PCT and with our local authority commissioning partners is building our competency as market makers and market managers in a very practical way.
Obesity and other “lifestyle-related” services was an area identified by external consultants as ripe for market stimulation and open procurement. Now that we are doing just that, I’ve been amazed by the number of quality providers from inside and outside the NHS who say - at least on paper, the real test comes in eyeballing the short listed candidate providers - that they want to work in this new way to address the outcomes we are seeking to achieve. If we become competent health investors we can have competition for the market and also competition in the market. That should give us much increased flexibility to address the health and well being needs of our diverse population and provide expanded choice amongst services.
PCTs must be smart health investors. Like any successful business - especially one looking to survive and prosper during the economic downturn - we must have good customer insight (intelligence from user experiences, learning from user and public involvement, complaints etc). But insight is not enough. We must learn to join up this insight with investor foresight (our aspirations and expectations, market intelligence about demand, provider capabilities and potential etc). Putting these two things together is the only way we will be clear about what journey we are taking and - crucially - whether our local population is with us on the same journey. We cannot simply assume everyone is going to the same place just because we have a strategy document about it.
One way to start getting to grips with being a smart health investor is to use an excellent new tool developed by David Gilbert and colleagues at InHealth Associates for the Department of Health - the “Engagement Cycle” The first thing I would like to use the Engagement Cycle for in our PCT is to audit what we think we know about user-focused views in our commissioning strategy.
I’d like to be assured on these points: How robust is this intelligence? How are we relying on it in our current plans reflecting the NHS operating framework? How are we refreshing, extending and communicating our customer insight and translating it into future commissioning plans? Where is user-focused intelligence helping us to go as a health investor? Is everyone on the same journey?
To have insight, you first have to have the right data from your customers. If you aren’t sure what customer experience information (CEI) is, how to get it and what to do with it, PriceWaterhouseCoopers have provided a helpful guide to CEI in health and social care. Then its a question of rolling up your collective sleeves and getting to grips with learning the health investing business. I guarantee you will not be bored.
Richard Thomas’s Farewell Do
Two Partners went to Richard Thomas’s last appearance in public as the Information Commissioner. He is off to pastures new in the next 4 weeks. Some heavy hitters on stage like Jack Straw and some serious issues discussed. The discussion could have been even more participative and interesting had Jonathan Dimbleby not been gripped by the same conviction as he demonstrates on Any Questions - namely that his own questions are much more interesting than those composed by the stumblebums in the audience.
The Minister with an Advantage and in the Club
Jack Straw showed an impressive grip of modern life in spite of his recent acknowledgement of weakness in family accounting matters by waving around both his Boots Advantage Card and his key ring Tesco Club Card while making a point about the reputational disciplines and pressures that kept private sector database managers both careful and honest - pressures and disciplines absent in the public sector with its monopolies on areas like social security and tax gathering. A civil servant could not loose a warehouse of personal data when it really was a building with miles of shelving and paper files but could do so all too easily when the warehouse has shrunk into a memory stick or CD. He acknowledged a point made by Richard about the false comfort of mass data collection. Ministers post 9/11 have undertaken to keep us all safe in a world of threats. This is a decent bit of political narrative but one where the Information Commissioner had to set some boundaries when MInisters latched onto monster databases as comfort blankets hoping that they could deliver on the safety thing by having all the digital bits and pieces of our identities and lives in one big box. Then surely they would actually know not only who the bad guys were but what they were going to do next. But the boxes have proved difficult and expensive to build. The point was made that if you are looking for the proverbial needle in the haystack why build a bigger haystack?
Google and 1984
Actually said the man from Google, we don’t care how big your haystack is. Google can still find your needle in a nano-second but even their database engineers baulked at the technical challenge of building on the scale needed to meet the ambitions of the politicians to reduce risk. Jack Straw felt it was necessary to issue a robust denial of any suggestion that the government were looking to Orwell’s 1984 as a manual of statecraft in the digital age.
Citizen Not Much Involved?
The MAC take on this is how little people appear to be thinking about involving citizens in these debates. The great and the good, Ministers and advocacy group leaders occupy the platforms and argue the issues. The citizen does not appear to be involved and consulted much. One speaker summarised the citizen view as one where individuals were happy if their own privacy was protected and did not much care what happened to everyone else’s.
Government Best Seller
Pub Quiz Bore Fact of the day - the Data Protection Act is the best selling Act of Parliament. I don’t suppose the MP’s Guide to Claiming Allowances is actually on public sale and you may even have missed the boat if you decided to shop for a member of the House of Lords instead.
Which? Richard
This is not of course Richard’s last Hurrah - he is off to head up something grand and paralegal. More interestingly for us old consumer hands is his position as Deputy Chair of the Council of Management of Which? Ltd or is it Consumers’ Association - the governance arrangements of CA have got a lot more complex since Partner Adamson was a member of the Council back in .. I will withhold this piece of data in full confidence that it is held somewhere on a piece of paper and who on earth could be bothered to look for that?
There has been only a couple of articles on our blog since the last newsletter - one was a review of Christine Hogg’s up to the minute history of public involvement in the NHS. I have bought my copy and would urge you to do the same if you are trying to make sense of the structures and techniques you need to do public involvement better and to understand why you are finding achievement so elusive. I read it to get some thoughts going for a training course for GP practices and their staff on understanding and engaging with customers.
Citizen vs Consumer
The point that struck home for me with my background working for Which? and other consumer bodies is the one where Christine argues that health is a more complex business than the consumerist model can accommodate. The example she chooses to make her point is that of mental health services users whose rights as citizens are more important to them than their role as a consumer of health services. Their choices are few and in some cases, they have to rely on their rights as citizens to exit the system or refuse treatment. She goes on to see a situation where expert patients and others who care for themselves ‘break out’ (in Christine’s words) out of the role of patient and become providers. She sees that service that is truly user-centred is the one where the users work with equal status with professionals.
Health is Different
This is a radical and ambitious view that goes well beyond the conventional consumer model of market influence where user and producer interract but remain separate. Christine’s view takes into account the fact that health is different from other things that people want. Jonathan Miller has written “Of all the objects in the world, the human body has a peculiar status: it is not only possessed by the person who has it, it also possesses and constitutes him. Our body is quite different from all the other things we claim as our own. We can lose money, books and even houses and still remain recognisably ourselves, but it is hard to give any intelligible sense to the idea of a disembodied person. Although we speak of our bodies as premises that we live in, it is a special form of tenancy; our body is where we can always be contacted ( Miller J The body in question Random House 1978 quoted in The World Health Report 2000 Health Systems: Improving Performance so ably edited by our Associate Angela Haden ) So being a consumer of health is different from being a user of a PlayStation®. We do not live inside something made by Sony - not yet anyway.
Better Customer Care
The reason for this revisiting of this debate is to explore my idea that the tensions embodied in the arguments about differences between being a user of a consumer good or service and being a consumer of health impact on complaint handling. A couple of the many things we have failed to blog about recently are the latest initiatives on complaint handling from the Department of Health and the Health and Public Services Ombudsman. The Better Guide to Customer Care represents a great leap forward in its simplicity, clarity and freedom from an obsession with process. There is an explicit overlap with the work of Ombudsmen and the six principles of good complaint handling. One of the unacknowledged things that make complaint handling - never easy - more difficult in the NHS is the difference between the complaint about health-related service received and the one about your electronic gizmo. As we have written before, emotion is the driver and the emotion involved in complaining about the place ‘where we can always be contacted’ is of a different order and magnitude than a complaint about an object external to us. The only example in the world of consumer goods and services when the emotional temperature came close to rising into the health temperature range in my complaint consultancy experience, was men complaining about repeated quality failures in their Range Rovers. The letters and calls made Jeremy Clarkson look like the soul of reasonableness.
While the Treasury’s advice about financial redress is worth reading, the question of money while it can no doubt help resolution, is not the clincher - recognition of how close to home any complaint about our health and the body we live in remains the best route to resolution.
Owning and Using Data
And if our body is our own, we argue in Andrew’s blog on Real Patient and Public Power, so is the data that we give the NHS by filling in questionnaires and being available to be measured and counted is data which patients and their families should be able to understand and use in any initiative to improve health and social care services. We would like to see the definition of expert patient extended to include an expertise in how user data can be put to work and create action for improvement and change.
Data Delusions
We are reminded how open to interpretation, questions on a checklist can be in one of the final publications of the Healthcare Commission as it morphs into the CQC - Listening, Learning, Working Together? The question mark indicates uncertainty about some of the findings - what the Healthcare Commission calls ‘mixed evidence’ about the standards of patient and public engagement. 98% of healthcare organisations claimed in their annual health check returns that they met core standard 17 which is the one about taking the views of patients and others into account when designing services. The snag is that there were a lot of negative comments from patient forums, voluntary organisations as well as the relevant local government committees (OSCs) that trusts were failing to seek the views of patients and public. Mixed not to say contradictory evidence indeed. Which is the correct view?
Management - Delusions, Comfort and Safety
Christine Hogg tells us that it is a mistake to ‘believe that user involvement can be managed and voices captured’. She is worried that participation ’seems to be a management tool to be disposed of when it does not produce the goods’. Actually it is not being ‘disposed of’ that is the problem and of course the activity has to be managed - it costs money and involves resources so how else would organisations behave? No - what we have to be wary of is delusion. And the delusion amongst public and patient involvement managers is that the performance of the function - attended 10 meetings, produced 4 newsletters and ran a stand at the local fair or whatever and printed 5000 leaflets on topic X - is enough to tick the box. Delusion of this sort is after all a much more comfortable and safer place for managers to be than copping the comeback from relaying rude and disruptive comments from outside, uncensored and un-deodorised - a terrible assault on the sensitivities of one’s superiors whose lives are difficult enough without this vulgar din.
Thank you and farewell Health Commission - we knew you when you were still CHAI. How short institutional life is in the NHS, we Partners muse.
Access and Understand Data
Knowledge is power - but only if you know how to use it. MAC champions the ownership of data by the service users who generate it so they can make decisions and choices based on their and others’ experiences. This means they must not only have access but also the tools to make use of comparative data.
Avoid Unnecessary Deaths - Pay Attention to Patients and Families
More reports appeared in recent days into the deadly debacles in Mid Staffordshire: clinical, managerial and governance failings at the local Foundation Trust Hospital; shortcomings by PCT commissioners and pretty much everyone else - except of course the patients and families using the hospital who weren’t listened to in the first place. As David Colin Thome’ makes clear in his report, “national approaches were being followed but local signs were missed”.
He concludes: “Real patient and public power, information and choice are strong drivers for improving the NHS and making it a dynamic, responsive service rather than a service that gives patients the message that they should accept what they are given. Patients should be seen as equal partners in their own care described as ‘the meeting of two experts’ when a patient meets their clinician.”
Unlock the Data Treasure House
When these “two experts” meet they must have access to the same data. To make this happen, we say prise the lock off the treasure house of data in the Information Centre’s “NHS Comparators” resource and provide public number crunching units so people can relate the comparative data to their local situation and inform their potential choices.
Christine Hogg’s Citizens, Consumers and the NHS: capturing voices (Palgrave MacMillan, November 2008; 224p; £19.99 ) provides a thorough narrative of where the Community Health Councils (CHCs) came from in 1974, what they achieved over 30 years and why they passed from the patient and public involvement (PPI) scene in England in 2003 after a rancorous final chapter following their surprise abolition almost as an afterthought in the NHS Plan of 2000.
Woven through this narrative is an analysis of citizenship and social rights versus consumerism and user choice as drivers of often competing, conflicting and even contradictory initiatives in the PPI world from the mid ‘70s until now. As Christine Hogg makes clear, the one cannot be properly appreciated without an understanding of the other, so in essence this is two books in one. You will not be disappointed if you pursue either or both strands as the history and theory are inextricable.
An overriding conclusion from the book is that 30 years of fragmented policy, political expediency and false starts in PPI have taken a fatal toll on organisational memory. That is perhaps the greatest collateral damage from the death of the CHC movement and the miserable interlude from its creation in 2003 to its extermination in 2008 of the Commission for Patient and Public involvement in Health and its ill-fated Patients Forums. After only one year in operation it is too early to tell if the Local Involvement Networks (LINks), the main element in the still-fragmented replacement system to everything that went before in England, will succeed in spite of their vague governance and accountability arrangements and a seeming lack of interest from the Department of Health. But as the author makes clear, without understanding the mistakes, missed opportunities but also notable successes of the past 30 years, we shall all have to live through - or perhaps be dragged through - them again.
Conspiracists might conclude that all governments wish to divert user knowledge, energy and the attention of user-led organisations away from the levers of power. That retrospective is sloppy and simplistic, though consumed in large quantities. The truth about why the CHCs were not reformed but abolished in England and the motivations of the major players at the time and subsequently is a tangled skein, but a vital story emerges from the unpicking in this book. Rather like democracy in Weimar Germany, CHCs did not fail on any objective criteria so much as because their potential was never seriously understood, valued, developed or - most importantly - reformed to meet evolving circumstances. By 2000 the NHS Plan’s diktat simply ordered their demise in England to everyone’s surprise (though in Wales they have evolved and prospered in what is becoming quite a different healthcare environment). Perhaps Wales therefore provides the counterfactual historical model to the English experience of CHCs: “what would it have been like if…..”.
The story of PPI over the last 30 years as Christine Hogg explains “has much to celebrate and much to mourn. Though the world has changed enormously since 1974, the issues that policy makers tried to address in setting up CHCs are still current and seem to have advanced little.” What patient - not forgetting carers - and public involvement is actually for (in other words, the ends of the policy) is still the hardest question to answer and the one most easily avoided and obscured as the debate about the means to encourage and sustain participation thunders on generating more heat than light and often exhausting the participants. It will be interesting to see if the NHS Constitution is but the most recent example of avoiding the real issue of ownership and control of our most important public service.
As one of the “usual suspects”, I am delighted to be among this book’s collective dedicatees - it is good company to be in. Would I recommend this book to others? Without reservation, particularly to Chairs of LINks and their members for whom Christine Hogg has provided a reliable anchor in history and theory for the otherwise uncharted journey they have begun. For LINks and their Host bodies, Citizens, Consumers and the NHS should help them understand the issues and efforts of the past which are with us still so they don’t waste time discovering them anew and wondering what to do next.
There are many people with first hand knowledge of the CHC experience and its closing chapter in particular. This is an open invitation for them to comment from their experience and give their views on what followed.
