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.

National initiatives, local engagement and the latest NHS guidance on the duty to involve

The long-anticipated additional guidance for NHS organisations on section 242(1B) of the NHS Act 2006, the duty to involve and good involvement practice, appeared at the end of October – Real Involvement: working with people to improve health services. At 143 pages it is the most comprehensive statement yet about this legal duty.

If I read it rightly, this guidance puts a rather different interpretation on the local procurement of a nationally planned initiative from that which I thought applied. I now think I was wrong in believing the local NHS did not have to have public involvement in the local procurement process of developments that were not part of its own plans.

My assumption was that if developments were centrally directed and that all the local NHS did was implement something it had not planned for itself, then it could just get on with doing that without going through any formal engagement process locally. This key paragraph on page 51 suggests otherwise:

“If new services are planned and procured centrally by the Department of Health, for example intermediate treatment centres, and an NHS organisation is not responsible for those health services, it will not have to involve users or consult the OSC. However, where services are planned centrally and procured locally, the NHS organisation responsible for procuring the service must involve users and consult the OSC where necessary. In addition, it should be noted that an NHS body may have a duty to involve in relation to proposals or decisions which it has not itself generated: the issue is whether the proposal affects the services for which the NHS body is responsible. So a local NHS body may need to involve users if a national decision to procure a treatment centre has an impact on other services for which the body is responsible (see the judgment in R (on the application of Fudge ) v. South West Strategic Health Authority and others (2007)). “

PCTs are responsible for locally procured services and any new service is bound to have an impact on what exists already. If that is the “test” for the section 242 duty according to Real Involvement, then I think the requirement for engagement applies to the local procurement process, even if the initiative is a national one. The first thing that comes to mind in this context is the GP Led Health Centres (GPLHCs) being procured across London in each borough as I write this.

The whole procurement issue is fraught enough without this additional twist to complicate the public’s understanding. Also we have long argued against consulting or engaging with people if the deal is largely done and the important decision made. Consultation isn’t window dressing or rubber stamping.
The first thing to consult on is to get a better name for the procurement process itself. I’ve tried out “procurement” informally a few times recently in meetings and social situations to see what it meant to people. Nobody had a clue except the occasional person who has a particular type of commercial experience.
When “procurement” suggests anything at all, it has an association especially for older people with sleaze and prostitution. This is not the best understanding to be starting with when PCTs are trying to change services in London.

Trying out “tendering” wasn’t much better. Invariably it got a response that was about “privatisation” in one way or another. No one I’ve spoken to appreciated that tendering could be done by GPs or social enterprises (“social what”? people asked): “tendering” meant involving private companies.

That’s the level of incomprehension I fear we are up against. With legal and reputational risks existing around procurement already, let’s hope this gap in understanding doesn’t kindle into real problems. We are now seeing the moment when a vocabulary designed for those in the know to facilitate the internal debate needs to be recast for the purposes of public debate. This is not easy to do and cannot be done retrospectively.

One of the elements in getting the LINks off the ground where we under-estimated the amount of work required, is the need to explain and define so much about the vocabulary of the new health and social care services and the organisms that deliver them. People cannot conceive of the future if they do not understand the present.

Users cling to the words they know and the experiences they have had. Sometimes we have to wonder if resistance to change is generated by simple incomprehension of the terms of public discourse. People cannot agree with what they cannot understand even if there are benefits for them in the changes suggested.
Procurement of GPLHCs in London may well produce an example of that which will be tricky to handle, given the Government’s concurrent emphasis on involving patients and the public in decision making and service developments.

Andrew Craig Gets Back to Basics and asks ‘What would William Beveridge say about topping up NHS care?’

In a personal piece reflecting on his own healthcare needs, Andrew challenges current thinking on ‘topping up’ and consults the welfare state’s urtext.

I have been back to the source for all things enlightened about the British welfare state – Sir William Beveridge’s magisterial and visionary 1942 report – produced in the darkest days of the Second World War – entitled Social Insurance and Allied Services. I wanted to check on what he had said about people topping up their NHS care by paying a little bit extra on top of what they get from the state as their entitlement.

Did he predict that this would introduce the danger of a ‘two tier’ health service? Would Sir William agree with the modern day guardians of the NHS that “topping up” and “two-tierism” were heinous crimes to be discouraged at all costs? Far from it. The proponent of our universal and comprehensive welfare system did not say it had to be “all or nothing.” Quite the contrary. In fact what he did say on the subject sounds like it I could have heard it on Radio 4 only yesterday.

It only took the Beveridge Report until its ninth paragraph to state this as one of the “guiding principles” of the recommendations which led to universal social security and health care:

“social security must be achieved by co-operation between the State and the individual. The State should offer security for service and contribution. The State in organising security should not stifle incentive, opportunity, responsibility; in establishing a national minimum, it should leave room and encouragement for voluntary action by each individual to provide more than that minimum for himself and his family.” (ref. http://news.bbc.co.uk/1/shared/bsp/hi/pdfs/19_07_05_beveridge.pdf )

Unsettling – but creative

I understand why some clinicians and NHS managers find this clearly stated principle of “voluntary action by each individual to provide more than that minimum for himself and his family” unsettling. But we have to realise that this is fundamental to the thinking which underpinned the creation of the welfare state – and it looks like this principle is moving closer to centre stage once again in our social policy thinking.

Respectable voices such as Chris Ham’s are calling for “a Beveridge Report for the 21st century” to guide the settlement between state and personal contributions in a new welfare dispensation and we are standing by for the Green Paper on social care funding which is expected late spring/early summer.

New health partnership with primary care needed

We have just seen the GPs grudgingly and grumpily accept the new contract about extra hours but what about the person over 60 – and I’m one – who would like to pay for lots more than the routine 10 minutes from one of the GPs in his own surgery? I would like to talk about what I would like by way of routine diagnostic tests so that I can establish a baseline to compare with five, ten and more years down the line. Should I not be able to do this if I want to stay in control of my own health and thereby help the NHS at the same time by spotting potential problems before they turn into acute needs?

The more organised among us do this sort of thing with solicitors when we get older, so why not with doctors (and a GP would be cheaper even adding in the costs for the tests I might decide on). BUPA will do this sort of thing, but why can’t we pay the NHS for it and talk to a GP who knows us and has all our records up on the screen? That’s a choice I would like available to me – and “choice” seems to be important these days in the NHS what with GP surgeries opening in a Greater Manchester Sainsbury’s leading the Guardian to declare that the future of British primary care is now “down past the deli counter and opposite the lipstick stand”.

Oliver Twist got better than this

But here’s the rub. The Government has a line against “co-payment” towards the cost of care which effectively nullifies one’s NHS entitlement and punishes you – should you foolishly persist in proffering money – so that the full cost of treatment falls on the hapless patient. The Department of Health justifies this with a spurious appeal to equity: “If those who can afford it start ‘topping up’ their care it will create a two tier NHS. What about those who can’t afford [insert name of current wonder drug or high tech treatment]?” Anyone who thinks that there has not been in effect a two, three or more tier NHS since 1948 hasn’t got out much lately. Even Oliver Twist got a better reception than this and he wasn’t offering to pay a groat for the extra gruel!

You can search the NHS Acts in vain for the prohibition on co-payment. That’s because it is a bureaucratic diktat and not law.

Incentivise responsibility and opportunity

As someone who can foresee himself as a social care consumer somewhere down the line, I welcome a more creative and flexible approach that does not betray the intentions of the begetters of the NHS but rather reflects them while taking account of how we live life now.

And so I also welcome the appearance of GP services in Sainsbury’s if they really do provide much more flexible access to primary care for more people. I think that Sir William would also approve of “docs in store” for one very good reason. If we are serious about getting many more people off benefits and back into paid work, then there are going to be even more capacity and access issues around conventional primary care sooner rather than later. What better way to incentivise people to take responsibility and the opportunity to consult the doctor – younger men in particular – than just after they visit the deli counter so they don’t have to skip work, have their pay docked or risk losing their hard won job?

We are committed to the widest possible debate about the health service with a particular interest in encouraging users to make their views known. We look forward to making a contribution to the new Beveridge Report for the 21st century in which the voice of the active citizen and service user will be prominent.

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