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.

“Local socialism” trumps “post code lottery” in the NHS debate

I’m thinking about starting a list of unhelpful phrases about the NHS and top of the list is going to be “post code lottery”.

“London NHS care is postcode lottery” screamed the Evening Standard recently in response to a study from the Kings Fund showing variations in what London PCTs spend on cancer, heart disease and other things. Cue tabloid shroud waving and health-campaigner handwringing: funding differences  = dreadful unfairness to people in areas where spending does not match the highest levels   =  heartless NHS bureaucrats putting people’s health at risk (shame!).

Simplistic league tables comparing health spending in uncritical ways don’t help public understanding, whether it is between London boroughs or between so called “developed” economies. The US spends more than anyone to achieve often mediocre outcomes and high wastage in their health transactions.

Is there really any significance for the health of their respective populations that Ealing comes “bottom” in England for cancer spending per patient and  Redbridge is the highest spender?   If that level of spending reflects an analysis of health needs and an allocation of resources according to population characteristics and desired outcomes, then the local spend is probably right for each place.  It is the job of PCTs as commissioning bodies to do just this kind of localised analysis and investment to meet health needs and improve health outcomes.  This point is sadly lost on most people and our politicians fear trying to explain it even when it has robust justification. No politician – Town hall or Whitehall – wants to put their neck on the media block for what the public perceives to be “unfair” even when it really is equitable.

Self-styled health campaigners and quite a few politicians wallow in emotive  “death sentence” language claiming differential spending always means differential quality of care.  On the contrary, it could just mean that all areas are not the same. We don’t have homogenous, equal-sized populations with identical needs.  The fact is that uniformity of spending would be inequitable because it would smother action to meet local needs and reflect local views.

Local decision making - reflecting what patients and the public want and what public health intelligence says is needed and effective  -  is incompatible with national uniformity of spending.  I don’t want Whitehall dictating how  Wandsworth PCT should spend its resources on meeting the health needs of our population.  I want local people to have an informed say about it and for clinicians, public health specialists and managers close to the issues who know the data and the effectiveness of the interventions to inform the PCT’s decisions for investment.

With this in mind, I was cheered this week to see well known South London GP Brian Fisher tackle this politically charged subject head on in a succinct letter in Health Services Journal on “local socialism” – certainly an attention grabbing title on a very serious topic.

“Unplanned and irrational differences in provision may be unacceptable”, but Ministers need to get over their fear of “planned differences” as Dr Fisher terms them.  Rational and robust “differences” show that the NHS commissioners are doing their job, not the reverse.  We need the health literacy and political maturity to understand and welcome that.  And the thing that would make it much better is when local communities get involved in decisions about levels of health and social care funding.  The participatory budgeting pilots reported in a recent issue of the HSJ point the way to greater local decision making, not less.

So here is my “Memo to Ministers”: stop taking your cue from the tabloid sub-editors and the self-interested campaigners. Get the facts first and then support the people taking the tough decisions at the front line.

As Brian Fisher sums it up: “We need to reassure Ministers and the Department of Health that localisation is usually the result of good practice.”