Feeling giddy at the Health Select Committee: and it’s not just the wallpaper

The Health Select Committee, whose activities we have been following with interest on this blog,  is sitting this week to look in more detail at the arrangements for commissioning set out in the new  Health Bill.  This morning’s session, which you can listen to online, focused on public accountability and we were delighted to be given a chance to give oral evidence.

One important feature of the MAC partnership is that all four partners are actively involved as lay people themselves – not just talking the talk but walking the walk too.  And not just in health but in schools, transport, parks and even a residents’ right to manage body.

So it was with this combination of theory and practice in mind that I joined the table in Committee Room 17 today.   What can those of us with years of hands-on experience of trying to make public engagement work add to the debate at this stage in the Bill?

New structures – a triumph of form over function?

Inevitably the conversation focussed on the structures and hierarchies of accountability as set out in the Bill.  Who is answerable to whom and for what?  How we will know if it is working?  Chairman Stephen Dorrell said he felt giddy on behalf of the GP consortia who stand to be pulled in numerous different directions by the national Commisioning Board, the local Health and Wellbeing Board, possible Overview and Scrutiny and (lest we forget) the patients and the public.  And certainly the Bill does nothing to clarify these arrangements.   I doubt it is just the GPs who are feeling confused and bewildered.

Are the people up to it?

The discussion also entered classic patient involvement territory as the committee grappled with whether patients were really able to discuss issues more complex than the patterns on the wallpaper.  Does the wallpaper matter?  Yes, it does matter to patients if they have to spend a long time in your waiting room.  Can patients rise to the challenge of higher level debate and involvement?  Yes of course they can if it matters to them, if they are given the information they need, if they are asked the right questions and above all if they can see that they are making a difference.  But those are big ifs.  If these things don’t happen, they will walk away and probably tell their friends and neighbours that it was a waste of time.

So what is still missing from the Bill?

You can judge for yourself how well I put over our arguments but this is what I wanted to get over:

• We need a clearer distinction between patients’ involvement in their own care and patient and public involvement in decision-making.  They are separate in many ways but they are closely inter-related.  The learning from patient involvement in practices should be aggregated up to consortia level where it should be seen as important part of the intelligence on which strategic decisions will be based, not least commissioning decisions.

• We need to start thinking not just “No decision about me without me”, but also “No commissioning for me without me”.

• We need structures because they provide clarity but structures alone won’t make for involvement.  Form must follow function.  We need leadership, a change in culture, a change in behaviours and an understanding of patients as customers and the public as the moral owners of the health service.

• We need to ensure penalty-free participation and place a real value on what people bring to them in whatever from they bring it.

• We need good, well-trained lay people at all levels but the model should be “bottom-up” involvement.  Start where the people are – in practices, in community groups, in the voluntary sector and go to them.  Don’t wait for them to come to you.  Patient participation groups may be useful but there are plenty of more imaginative ways of involving people.  The purpose of involvement is to involve people and different people will get involved in different ways.

• We need to acknowledge that none of this will happen unless the capacity issues are addressed.  Involvement of patients and the public in commissioning should be central to the business model in consortia not an add-on.   The people who are getting involved (patients, public, lay people) need recognition, training, support and, above all, to be able to see that their input is making a difference.

• We need to find new ways to recruit new people including people who can help us understand how to overcome health inequalities.

• We need leadership: clinical leadership, managerial leadership but also lay leadership which we will find out there among the existing lay world (a world we urgently need to map), in the voluntary sector and in places we have not even dared to look yet.

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.

“Engagement” isn’t enough – only “Involvement” can influence commissioning

Have you noticed that PPI is being eased aside by many NHS bodies in favour of PPE?  The “patient and public” (PP) part is unchanged, but in the new rubric  “E is for engagement” and “I for involvement” is falling off the page.  We should be concerned if the “I-word” has been waylaid in the corridors of Whitehall in favour of “engaging people and communities” .   Engagement and Involvement aren’t interchangeable.

However it might be dressed up in the latest policy couture, “engagement” implies a process of enquiry initiated by the NHS when and how it chooses.  “Involvement”, in contrast, implies a sustained, continuous and co-created process.   Picture a gaggle of patients and members of the public hanging around until the NHS decides to engage with some of them for something specific in order to harvest their views for its own uses.  That is a relationship based on dependency, status and power and it won’t do for a user-led NHS.  It doesn’t encourage either health literacy or enthusiasm for doing it again.  You may ask what’s in a word: in the case of ”engagement” vs “involvement” the answer is rather a lot.  If PPE is now DH-approved will we see a rebranding for the NHS Centre for Involvement and the National Library of Health’s PPI specialist section and a host of other respected and established sources using the “I-word”?  I sincerely hope not.

It isn’t that engagement is wrong, just that it is insufficient on its own for the purpose of influencing commissioning decisions. Sustained involvement is the key to this. PCTs needs to develop processes to ensure they listen to patients and the public as they shape ideas for new service delivery models.  Can they be assured that service users, carers and the public are with them on the journey of service re-design as they develop service specifications, consider tenders, and monitor contracts?  If not, they are at risk and cannot demonstrate their accountability to the moral owners of the NHS – that’s you and me.

Here is an excerpt from a PCT policy that does understand the linkeage between involvement, engagement and communications:

Throughout this document we refer to involvement, engagement and communications for patient and public empowerment.  “Involvement for empowerment” is the overall objective; engagement is an aspect for specific purposes, including consultation on specific proposals; and communications is the range of techniques and tools used to interact with people, listen to their views, understand their feelings, communicate them appropriately and feed back to them what they said and what we are able to do with this intelligence.  The result of this is helping people feel that they are continually involved in our business.

Whatever you call it, If “involvement” doesn’t positively influence commissioning then it is a sham.  So why make it harder for ourselves by pretending that “engagement” will do it all?  Achieving sustained involvement is difficult, skilled and resource-intensive work, but it is an investment we cannot do without.   I am reminded of the comment attributed to ”Red” Adair the legendary oilfield firefighter: “If you think hiring an expert is expensive, just wait till you find out how expensive hiring an amateur is.”