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.

Engaging Health & Social Care Communities Online

Just published on the main Moore Adamson Craig site – a case history of building the website for the Wandsworth LINk:

Engaging Health & Social Care Communities Online – setting up a website for Local Involvement Networks (opens as Adobe PDF file).

Expanding LINks?

Forget the DH site, the place to look for what’s happening in public and service user engagement is increasingly Communities and Local Government (CLG), which is churning out more useful stuff about civic engagement and community participation across the board. But should we welcome this uncritically, especially when it involves LINks? For instance, I noticed this in the most recent Consultation Institute newsletter:

“Gung-ho CLG seems so enthused by LINks that it seems keen to expand the concept beyond health and social care and is inviting Councils to submit proposals. Where this leads is anybody’s guess but the idea of networks of interested stakeholders is a powerful concept.”

Is this an idea linked (no pun intended) with CLG minister Hazel Blears – she of the recent community empowerment white paper and participatory budgeting experiments - to extend LINks straight across everything a Council does?   Sounds like the kind of thing that the ”government in waiting” might be keen on too.  And it is just the sort of development that some Councils might want for the wrong reasons.  A single tick box solution to involvement and consultation based on “we talked to LINk” is appealing but it is reductionist and simplistic.  We should be wary of this expansionist offer at least until we have some solid achievements with LINks in health and social care to point to and much more experience with the methodology of contacting, listening, understanding and transmitting views of local citizens.  But as the CI newsletter rightly says, the idea is powerful and something to think about for the future.

In the meantime here is a just published CLG report on barriers which people feel keep them from being able to influence local decision making.  Quite relevant for LINk and our understanding of participation generally I think. The biggest factor (barrier) is how much people trust their local council – perhaps an obvious conclusion but one that must be addressed where the answer is “not much”.

Readers could also dip into the CLG report on the New Deal for Communities pilots.  It is mercifully short and summarises lots of what we know already – so it provides a good and recent benchmark – about barriers and incentives to participation.  It talks about the “1% solution” we have previously discussed on this blog.   There is an allied report on what works well in communicationswith specific groups in the community.

This is all good stuff for us to know for LINks and Hosts should have these reports on their electronic reading lists.

An invitation to help us refocus our purpose and our offer

The Partnership is having one of those moments of corporate introspection when we look at what we do and think about the best way to explain it to our clients – present and future – and to ourselves too.

(jump to our strap-line competition here)

So we have done a bit of brainstorming and come up with twenty suggestions on how we might define what we offer to clients and encapsulate that in a pithy and memorable way. The new phrase will go as part of a new look on our website.

We need an outside eye and would like to invite you to help us choose which one describes us best. Our current account of ourselves and what we do can be seen at www.mooreadamsoncraig.co.uk and the associated blog site here (www.publicinvolvement.org.uk) site.

This is, as many readers will at once realise, is an example of the approach know as ‘crowdsourcing’. The phrase first appeared in an article in Wired in 2006 and the author Jeff Howe defined it as

“the act of taking a job traditionally performed by a designated agent (usually an employee) and outsourcing it to an undefined, generally large group of people in the form of an open call.“

Let’s Go Crowdsourcing

The current calls for user engagement and involvement can perhaps be seen as being part of that phenomenon with organisations formerly closed to the user interest and totally ‘captured’ by provider interests, open themselves up and unblock their ears to the external voice.

The new LINks organisations are intended to be important players in collecting and amplifying the voice of the crowd of users. The regulators in health and social care – at the moment plural as in the Healthcare Commission and the Commission for Social Care Inspection but soon to be singular: the Care Quality Commission – are touring the country to meet LINks people and work with them on the best way to feed into their assessment and inspection programmes. At the Cambridge event in September, it was very heartening to sit around the table with so many organisations focussing on how to make this work. The third sector who are working both as Host organisations as well as LINk member were well represented – Voluntary Norfolk was there (but not Compulsory Norfolk – no doubt no one had told them they had to come).

How we all laughed and there was remarkably little cynicism as in “we have been here before“. It would be wonderful if the regulators and indeed the Department of Health and other central government departments did work out a relationship with the local LINks that did not make the latter the poor bloody infantry of the regulatory system acting as unpaid data collectors for their assessment programmes while local issues and programmes were ignored. Instead there is room for a mutually profitable concordat between the individual and local voice of the user and those working at the national (English) level. Perhaps this time the views of the crowds outside the system really will count.

Back to our strap-line competition

Our suggested strap-lines / phrases are listed below and you are invited to pick your top 3 choices and the one you feel works best. Closing date 15th October 2008. Thank you.

The winners i.e. all those choosing what we think is the best out of our suggestions or even more excitingly coming up with one of their own which the Partners think hits the spot will be recognised as a hero/es. The choices of the Partners are open to discussion, scorn and mockery but we are very thick skinned given the amount of that sort of deplorable behaviour in our own meetings. So feel free to speak out and create.

Read the strap-lines and tell us your views here, or contribute by leaving a comment.

Insert your LINk link now – the NHS is on Facebook

The lead article in the HSJ of 18th August looked at how NHS organisations are using this Web 2.0 social networking site to connect with patients, staff, Government ministers and the public.

Some are using it to tell people more about the personal side of their lives. We are told that the Health Secretary Alan Johnson

“is taking his excellent staff out for a very liquid lunch”.

Hmm – rather inviting comments from the alcohol units police but we get the point – Government ministers are human and have humans working for them.

Andrew Duggan of the Countess of Chester Hospital Foundation Trust wants to use Facebook to engage with young people and is quoted as saying that

“an important objective for us at the moment is engaging with younger people; our staff, patients and (foundation trust) members of the future”.

He acknowledges the fact that this group is traditionally difficult to engage with.

This is the sort of challenge that local involvement networks (LINks) have to meet as well. The younger people are – as the phrase goes – ‘digital natives’ as opposed to digital immigrants i.e. anyone who has not grown up in the digital age. They are most comfortable working in the sort of e-environment that Facebook and others of that ilk e.g. My Space and Bebo provide.

The challenge of course is not so much the technology. It is easy to set up what Facebook calls ‘pages’ where companies and organisations can post news and promotional messages for fans who have signed up to the page. Quantities of said fans are then supposed to post their reactions to the content. The difficulty lies in coming up with the hook that gets users signed up, interested and posting. Remember the internet phenomenon ‘the lurker’ – those who observe silently but never join in? I shall ask the MAC instant family-based research panel of digital natives – some pictured below and ranging in age from 5 to 26 – what would get them interested in a NHS site? We will report back.

 

It sounds interesting and fun and one for the Wandsworth LINk to take on board at once. Watch their space.

100 already – a quick century for the Wandsworth LINk

Wandsworth’s Local Involvment Network launches today

Since our announcement last month, M-A-C has been busy working with the Wandsworth Care Alliance to launch Wandsworth LINk. The website www.wandsworthlink.org.uk went ‘live’ this morning.

We have caught our first LINks – the Wandsworth Care Alliance and the Partnership are chosen to be the LINks Host in Wandsworth

That Fabulous Beast
Loyal readers will remember from past blogs our somewhat over-extended metaphor of that fabulous beast the greater spotted LINks seen prowling the precincts of Westminster – was the beast to be set free and be seen all over England as the new embodiment of patient participation? Would it flourish and survive where so many other species of patient engagement have failed and died out?

Well in Wandsworth, we will be helping answer those questions. We will be establishing the best of habitats for this new animal working with the Wandsworth Care Alliance and Wandsworth Borough Council to set up the Wandsworth LINk – one of the first in the country.

We have been writing about LINks in our blog for a long time now – the first article was in July 2006 and with regular mentions since then. We are now about to discover the difference between being the commentator and taking the role of participant. The thread that unifies the two is being able to learn and draw some lessons from the work.

We are getting off to a very fast start since Wandsworth is an area that Val Moore and Andrew Craig know very well. They are already plugged into the local health economy in a number of ways – at the grassroots as members of the Balham Park Surgery Patients Liaison Group and then at an institutional level, Andrew Craig as the Lay Member on the PEC and Val Moore as a non-exec at St Georges Hospital.

All the partners will be working on the project and we look forward to doing a good job assisting the Wandsworth Care Alliance as it builds a new structure for the users of health and social care services in Wandsworth.

Business as Usual
In the meantime, we will be continuing the blog with our usual eclectic mix of articles – last month, we gave our views on the new proposal for a single door entry point for citizens who have a complaint and returned to the source with some musings about Beveridge’s original plans for the NHS. The last newsletter pointed out our propensity to value things like post offices only when they are threatened with extinction. This one has focused on new life for patient engagement in the form of the new LINks structures.

Eirlys Roberts – a personal tribute

So with these thoughts of death and renewal, it is the moment to pay my own tribute to Eirlys Roberts who died on 18 March aged 97. Maurice Healy one of her adjutants at Which? described her correctly in his Guardian obituary as “the mother of the modern British consumer movement“. Michael Young, later Lord Young of Dartington, is credited as the founder of Consumers’ Association, publishers of Which? Magazine. Founding was what Michael was good at – if what he set up survived, it was because he found/left in place people like Eirlys with the passion and skills needed to make sure the infant organisations survived and prospered to give a life time’s work to people like me.

The prose style Eirlys required all the Which? writers to observe, was in her words “to use concrete nouns, not abstract ones, the active not the passive voice, short sentences, short paragraphs and short Anglo-Saxon words“. Each piece destined for Which? was edited at least 4 times and pared back to the libel-free, truthful minimum. An Eirlys editorial session was a risky and exhausting encounter for those of us with a disdain for boring detail and a taste for wordy generalisations.

I joined Which? in 1969 just before the launch of Money Which? The Which? Guide to Contraception had been published shortly before. The Eirlys style was a fabulous formula for success – money and sex discussed in that clear, rational Which? style that helped the middle classes conquer their embarrassment at their materialistic and sexual urges and gave them permission to be interested in both subjects, discussing the relative qualities of their fridges at the dinner table, probably even in bed. (The quality and price of white goods in those less affluent days occupied the place in people’s conversations that entire houses and kitchens do now.) Reason reigned and consigned the vulgar emotions of envy and acquisitiveness conjured up by the adman to the bin (did we test those I wonder?).

I took those words of Eirlys’s from the Times obituary where as a classicist, she would have been amused to share the obituary page with Charlton Heston, the great charioteer of Ben Hur.

Vale Eirlys and thank you for that style and way of thinking – remnants of which I still cling to even now particularly when discussing patient engagement scenario situations at the cutting edge of positive citizen participation strategies rolling forward to the big picture event horizon of Local Involvement Networks. Clear enough?

LINKSWORKS – Supporting User and Public Voice Networks for the NHS And Social Care