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.

Big Society: big break or big bore?

Few of us who work in the public engagement world could fail to have been intrigued by the new government’s apparent enthusiasm to involve The People in its decision-making.  Intrigued, and in most cases I suspect, more than a little sceptical.  Do they really know what they are letting themselves in for? And do they really mean it?  Is public consultation finally going to earn its place in the sun or is it going to be trampled underfoot in the rush for the exit?

Consultations – A Thousand and One Commitments (not quite)

So it was off to the Consultation Institute to find out more about the new government’s plans for public engagement.  It was a lively session aimed mainly at professionals in the public sector who are responsible for running consultations with a few private sector consultants thrown in for good measure.  The Institute has analysed the government’s plans and has managed to find 31 commitments to review, 11 to consider, 10 to investigate, 6 to explore, 4 to examine and a whole raft of policy areas which programme director Rhion Jones described as “consultation significant”.  Regular readers may be interested (and unsurprised) to note that top of the list are communities, environment, energy, health, schools and transport as well as government transparency and political reform.  So is it an exciting new dawn for public engagement for those of us working in the field?

Where Are the Bodies Buried?

Working on the premise that it is good to start as you mean to go on, let’s take a look at the government’s first big discussion with the public:  Spending, or rather the Ending of Spending.  Clearly there is no time to waste on this one and government has wasted none in writing a couple of weeks ago to six million public servants to thank them for all their hard work and ask them to go online and tell them where the bodies are buried – or at least grass-up their colleagues for wasting money on new coffee machines, buying overpriced staples or taking up space with their presence in a town hall backroom.  A fine example of the benefits of mass engagement through new technologies.  Maybe this should operate like the Public Disclosure Act and people should be required to tell their managers of their unvoiced concerns before rushing off to tell Messrs Cameron and Clegg, but then again, that would slow down this very speedy consultation process.  We at MAC always encourage our clients to provide attractive incentives and rewards to consultees.  A two year pay freeze and the chance of a place near the front of the dole queue (for yourself or a friend) was not exactly what we had in mind.

Semtex Shake Up

Time is understandably of the essence for the new government and evidence to date would suggest that there won’t be much pussy-footing about with 12 week consultation periods. Just remember how much consultation has taken place around the launch of Free Schools all set to kick off next term. Precisely none.  Not much respect for the old adage that consultations should probably wait til everyone gets back from their holidays either.  Most of the big decisions about spending will have been made by the end of August.  But perhaps this is no bad thing.  As Rhion Jones said, if the last fifteen years had shown that institutions had perfected the art of good consultation and engagement we might be seriously worried, but perhaps this whole consultation business needs a bit of Semtex under it.  MAC partners have often had to deal with raised eyebrows when we suggest “quick and dirty” consultations.  They  are often just what is needed and work well as long as you talk to the right people and ask them the right questions.  (Perhaps something a little more revealing than Yougov’s recent  question about getting rid of “unnecessary” bureaucracy which produced a stonking 97% approval rating).  Of course the real answer is to create an ongoing dialogue in which a consultation is just a part of the relationship not an expensive one-off event – but that more mature approach may have to wait a bit.  MORI provides some very useful practical advice on how to get the public on board in these discussion in its post budget Tough Decisions setting out its top ten tips on priority setting with the public.

Big Decisions Little People

With the public sector being cut so fast and so ruthlessly from above is anyone going to have time or the will to stop and listen to what ordinary people have to say?  And will they know what questions to ask them?  It looks pretty much like the big decisions have already been made at government level and they are being made right now in town halls and primary care trusts as I write.   Even if some “real” people do manage to make their voices heard above the storm, it will probably be the ones who shout loudest and the ones we have heard before.  The voices that will be drowned out will be those of the most vulnerable and the those most likely to be adversely affected.

A Third Want In

There may be little room for the sort of consultation we all want to see over the next few months.  I guess I am not the only one who fancies a holiday.  But we need to take some heart from the fact that the government is still making noises about wanting to move decision-making closer to the people.  Big Society may not have gone down so well with the press but there is some evidence that real people are attracted to the idea.  According to MORI, about a third of the population wants is involved or wants to get more involved with a further  third wanting to be kept properly informed.  Several delegates at the event highlighted the importance of getting councillors, health board non-execs and other key local “public” players to champion this work within their organisations.  The challenge for all of us may well be to find new and better ways of “doing” engagement and consultation and, yes, spend less time and money on it.    High value engagement is what we need – engagement that asks the right people the right questions at the right time and which leads to real change and real improvements.  So no more empty halls, stewed tea and uneaten biscuits please!

Don’t slip up on those new acronyms

I can’t exactly remember why Billy Connolly took to wearing these splendid Big Banana Boots in the nineteen seventies.  I do remember my parents going to see him and telling me how unsuitable he was for nice young girls (which is what I was then, more or less).  All I know is that I can’t see a banana now without thinking of them.  What a delight that they now have pride of place in Glasgow’s splendid celebration of people power, the People’s Palace. 

Now the humble banana has taken on a new role in the venacular of citizen empowerment.  BANANA has apparently replaced NIMBY (Not In My Back Yard) as the acronym of choice when describing public resistance to building projects: Build Absolutely Nothing Anywhere Near Anything.  Another acronym which manages to encompass all the weaseliness you would expect from public officials trying to put a positive spin on recalcitrant members of the community is LULU: Locally Undesirable Land Use.  But my special favourite is CAVE: Citizens Against Virtually Everything – sometimes it feels like there are a lot of them about. 

 

What we need now is a nice acronym for the sort of people who make a positive contribution to public life: Sensible Undervalued Citizens, Keen, Empowered and Rational.  Got any suggestions?

“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.”