Bigger boards but no room for patients

Good timing for the publication of the Health Select Committee’s latest  report on commissioning.

Following the government’s new-found interest in “listening” to what others have to say about health service reform, let’s hope they have set aside some time to read this report which draws together the written and verbal evidence put forward by a wide range of key players, not least the Moore Adamson Craig Partnership.  As the Committee Chair, Stephen Dorrell says, the proposals it puts forward are a lot more than just a “minor tweak” to the Bill.

In our evidence both in person and in writing, we stressed the importance of ensuring that the new commissioning structures allow for proper accountability to patients and the public and although the Committee makes some very welcome steps towards tightening up the governance arrangements we are disappointed that the voice of the public and patient voice is not given more importance within their proposed new governance arrangement

What’s in a name?

The headline of the report, and a sensible one in our view, is the suggestion that we drop the concept of “GP commissioning” in favour of a more broadly-based decision-making model of “NHS Commissioning Authorities” .  (And if you think this sounds a bit like Primary Care Trusts you can wash your mouth out with an alcohol based handwash immediately.)

Our proposals are designed to ensure that NHS Commissioning involves all stakeholders – GPs, certainly, but also nurses, hospital doctors, and representatives of social care and local communities. We believe this broadening of the base for commissioning is vital if we are to achieve the changes that are necessary to allow the NHS deliver properly coordinated healthcare”.

Wider clinical representation, but where are the people?

MAC has talked a lot about the need for robust governance arrangements that recognise patients and the public as the moral owners of the service.   So it is disappointing to see that the Committee’s proposed structure for commissioning authorities explicitly excludes both patient and public membership of their boards.

GPs would be in the majority, making up at least half the membership of the board, balanced by a professional Social Care representative; an elected member (a councillor or directly-elected Mayor), nominated by the local authority; a nursing representative; a representative of hospital medicine and a public health expert nominated by the Director of Public Health.  The reason given for the exclusion of patient and public memberships feels more than a little bit lame:

“The Committee has concluded that an attempt to introduce a broadly based patient voice into the governance structure of local commissioning bodies, while maintaining the representative balance described in the report would make the Board unmanageably large”.

While it is undoubtedly true that large boards will become cumbersome the solution cannot be simply to exclude the public and lay voice altogether.   When we said we did not think it was right to have just one lay person at the table, we did not mean that it would be better to have none.   How about having fewer GPs? If, as the report suggests, these commissioning authorities should take on not only primary care, but secondary care, community care, dentistry, pharmacy and suchlike it becomes rather less easy to see why the bias of boards should be so strongly in favour of GPs.

Don’t leave it all to HealthWatch

The Committee suggests that the best way to provide a patient voice in decision-making would be through creating a strengthened role for HealthWatch, requiring the local commissioning body to consult regularly with HealthWatch who in turn would be required to carry out its own consultations.

This is all well and good but it will not address the vital need for proper patient and public engagement at ALL levels in the commissioning process, with patient derived health intelligence being aggregated up from the individual practice, through local commissioning and to the national level.  The need to establish an effective means of doing this was central to our evidence and is not mentioned anywhere in the report.  Under the Committee’s proposals we would have real concerns that GPs and the commissioning authority boards will feel they have been let off the hook as far as meaningful public and patient involvement in commissioning is concerned.    As we said in our written response:

Local HealthWatch is important but it is essential that it is not by default seen as a synonym for effective patient and public involvement. There must be much more than simply a viable Local Health Watch. More work needs to be done as to how the new HealthWatch bodies will be integrated into GP commissioning structures.  At a local level, we would like to see a stronger and more diverse membership of HealthWatch properly engaged in commissioning decisions as of right. However we think that this needs to be complemented by GP practices and consortia having direct “listening” relationships with their own patient

The Committee concludes that its proposals would mean that there would be no need for establishment of Health and Wellbeing Boards which may make sense if the commissioning authority boards can come up with the goods (and it’s a big if).  But without a public or patient voice on the commissioning body or a locally accountable Health and Wellbeing Board it remains questionable as to whether the structures proposed here could really been seen to be properly accountable to patients and the public.

Watch this space

With the Bill “on hold” and the Select Committee Report definitely offering a very different picture of how things might unfold it is hard to see where we go from here.  There is much to be commended in the Select Committee’s recommendations, perhaps most importantly the emphasis on the need to be properly “proscriptive” about what governance should look like but MAC will continue to push for a form of governance which properly recognises the role of patients, the public and lay people in making health services fully accountable.

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.

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.

All right Guv’nor?

Having recently become a school governor again after a four year break, I have just stumbled across a report on school governance to which I contributed so long ago I can’t even remember what I said or whether it was sensible.  The Twentieth Century School: Implications and challenges for governing bodies was the result of a valiant attempt by the then Schools Minister, Jim Knight , to try to get a grip on school governance.    You can see where he was coming from.  With schools taking on greater “autonomy” to spend public money (a trend which has taken on a new impetus under the new government) there is an urgent need to strengthen governing bodies both in terms of their make-up and their skills.

They’re 21st century schools Jim, but not as you knew them

Disappointingly, Mr Knight (now Lord Jim) was reshuffled into another post before this piece of work was completed and I would like to think that if he had seen it through he would have come out with something a bit tougher.  But perhaps we should console ourselves with the fact that the newly austere Education Department has stuck a big yellow and red sticker on it on their website saying “Important” rather than one of its tantalising “This page may not reflect government policy” stickers (reserved, rather worryingly, for publications on issues such as how to prevent homophobic bullying.)

Haven’t we heard this somewhere before?

Perhaps the reason it has received the Seal of Gove is because it doesn’t really say much.  There was, to put it mildly, some difficulty in achieving a consensus in the meeting I attended so what is left is pretty much what you would expect:

Governing bodies need to be clear about their purpose and follow a defined set of principles for good governance of schools;

There needs to be more clarity concerning the strategic management role of the governing body and the day to day management role of headteachers to ensure that neither party crosses over into each other’s role;

The principle of stakeholder representation on governing bodies is essential but needs to be balanced against a requirement that all governing bodies have the necessary skills to carry out their tasks;

Improvements to the training for governing body chairs, new governors and governing body clerks needs to be made to clarify the points above.

“lack of time and other commitments, lack of publicity around the role and awareness of opportunities for involvement, lack of confidence and alienation from the education system and additionally some governing bodies were reluctant to take on potential governors who were not already known to them”.

Training, training, training?  Is it the answer?

But the report does not try to address why this might be or how it could be changed other than suggesting (yawn, yawn) that governors undergo training.  It is convenient to imagine that simply by sending people off on a couple of two-hour training sessions this will somehow address the fundamental confusions that lie at the heart of school governance.

All a training course might do is make you slightly better able to manage the inherent lack of clarity that faces you as a governor – what it cannot do is create clarity of structure where there it is lacking.  And there is little in the report to help.  Where do you draw the line between “strategic guidance” and “operational involvement”?  The report does not say. Should head teachers have voting rights as members of the governing body?  The committee could not decide.  Should staff governors have the right to vote when their boss doesn’t?  It’s a bit complicated.  Should training be compulsory or not? Perhaps it should, then again maybe not. Should chairs of governing bodies, or even governors themselves be paid?  Well, there are differences of opinion.  A study of the principles of Policy Governance® and some clarification about Ends and Means might be a good starting point.

No freedom without responsibility

The race towards “liberating” schools was initiated under the Labour Government and the baton has been taken up enthusiastically by the current government.  Academies, Trust schools and New Model Free Schools are all removing education from local government control and theoretically at least putting power into the hands of “the schools”.  Contrary to the populist idea that more power is being handed to headteachers, what is actually happening here is that more power (and more responsibility) is being put into the hands of school governors.  Who those governors are, how they understand their role and how effective they are has never mattered more.

New structures need forms of accountability

As the report suggests, partnerships and federations may well be the answer, especially if this can be seen as a way of creating a smaller number of governing bodies made up of people who are better equipped to handle the job.  But this approach will only make sense if new ways are found to ensure that individual schools are properly accountable to pupils, parents and their wider communities. The MAC line on this is set out on pages 29 and 30 of the report – and yes, I think it does still make sense:

Governing bodies need to focus on the outcomes and outputs not the processes. They need take action and be accountable to the owners, including parents, for the decisions they make.

Governance structures which include consultation, Parent and Pupil Councils, the better use of parent experience data and improved partnership working lie at the heart of getting accountability and parental involvement right.  Like all other public services, schools need to get their heads around what accountability means in practice.

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

Parent power – just another piece of populist spin?

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?

Whose schools are they anyway?

“Text cloud” for this post below, created by www.wordle.net

Whose service?

There has been a whole lot of very interesting debate over the last few years about who the health service belongs to but what I’d really like to know is, who does the education service belongs to?  I recently contributed to a government review of governance in schools (supposed to be published in October 2008 but still eagerly awaited).  I was there to put forward the case for parental involvement but met with a depressingly familiar reaction from the teaching professionals:  just who do these parents think they are ?

Who’s baking, who’s being heard?

Most schools will tell you they work hard to involve parents.  But scratch below the surface and you will find that many are adhering to a conveniently self-serving model of parental involvement where in fact parents do most of the work.  An “involved” parent is one who gets their child to school on time, helps with homework, encourages respect for teachers, bakes cakes for Parent Teacher Association events and turns up to parent evenings i.e a parent who is seen but not heard.  Have a look at the average home school agreement and you will get the message “parents and their children must….(do what the school says)” , “the school will…(do what it likes)”.

But the government is now seeking to give parents much greater influence in what happens in schools.  Since May 2007 all schools have had a duty to take account of the views of parents and are encouraged to set up Parent Councils to help them to do so.   They even produced a useful, if poorly publicised, toolkit to help them to do it. But as yet, there has been no research into how many schools have set up Parent Councils or similar parent-led bodies or what, if anything, their impact has been.  Are schools really beginning to take account of parental views or is it still the case that teacher (or the local authority) knows best?

Whose Views?

Some people argue that having parents on governing bodies ticks the box as far as parental involvement in decision-making is concerned.  This might work if anyone was at all clear about the role of parent governors. They are elected, but what is their role: to represent the forty or so parents who voted for them, to represent all parents, or simply to be themselves?  Do they really know what other parents think and if so, how?  Does the presence of parent governors mean that schools are absolved of their responsibility to find out for themselves what the generality of parents think or want?  And we should not forget that many schools struggle to find any parents who are willing or able to sit on their governing body at all (and having spent four years as a governor myself I could suggest a few reasons why that might be).

Who’s Sorry Now?

Over the past three and a half years I have been closely involved in setting up and running a parent-led Forum at my daughters’ school.  We had some successes but overall we felt that no-one appeared to be interested in our experiences or those of our children and that the school saw no real reason to respond to our concerns.  Last February we asked parents to identify the top ten areas where we felt things needed to improve.  They were all the same things we had been complaining about since the Forum’s very first meeting. Once again the school ignored us.  A few days later the Ofsted inspectors arrived and wrote a damning report which (surprise, surprise) identified all the same failings that the parents had been rabbitting on about for years (plus a few more that we could feel but not quite put our unprofessional fingers on).

When a school is in “Special Measures” it can seek the Secretary of State’s permission to get rid of the governing body (in many schools the only place where parents can have their voices heard on matters of strategy) and replace it with something called an Interim Executive Board (IEB).  This is what has happened in my daughters’ school  and in our case the chair and the majority of the membership was made up of paid staff from the local authority – the very local authority that had got us into this mess in the first place.  There is no requirement to include parents on the IEB or even for it to listen to parents and yet the IEB has all the same powers as a properly constituted governing body.  They can change pretty much anything they like and even, as in my daughters’ school, appoint a new Head Teacher without consulting anyone.

In whose name?

Anyone who knows anything about what happens when a school “fails” its OFSTED inspection, will tell you that what follows is a period of huge stress and anxiety for everyone involved – including parents - and yet at this very time when major change is taking place, parents can be effectively cut out of the process.   Our Parent Forum had to ask numerous times over a period of several months before the IEB even agreed to publish its minutes and we have not seen them yet although it is almost a year since the governing body was taken over and then disbanded.  We have also been asking to see a plan for the future of our school – what is going to change? why? when? and how will we know whether the raft of changes and new initiatives has made a difference?  No sign of that yet either although according to the school it was drawn up last July and they have been working to it since then.

The government is talking about streamlining governance arrangements in schools which probably means small governing bodies with people appointed for their skills rather than being elected by staff or parents. Pretty much like our IEB.  In governance terms this makes a lot of sense, creating small focussed and professional bodies with the skills to run these important institutions properly.  But our experience of such a body shows that little importance seems to be put on hearing the voice of parents – which is strange. These days, a skill set that does not include the techniques of gathering and acting on user and stakeholder opinion can be dismissed as dangerously introverted and incomplete. It is an old-fashioned management concept that refuses to share power and sees the participative approach as a threat to the quality of decision-making.

Whose Schools? (See where we started)

One way to address this might be to make Parent Councils or similar bodies compulsory in all schools and require governing bodies to listen to them.  Properly run and resourced Parent Councils, perhaps with their own dedicated staff, would foster new dialogues between parents and school senior managers and governors.  Institutional changes aside, we need to bring about a change in the culture of our schools and local authorities so that they understand that they are running schools for the benefit of children, their families and wider society and that they will only succeed in doing this when they by working in meaningful partnership with parents and carers and hearing what they say.