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.

November’s Newsletter: No downturn here – M-A-C blogging team’s creative outputs breaks all records

10 posts since 30th September represents an all-time record as M-A-C engages with the issues and causes dear to our collective and individual hearts.

Our first ever post back in 2003 was about our central interest – user involvement. A theme echoed in this month’s output with Andrew’s post Engagement isn’t enough. Two posts later, we were taking a look at Ann Abraham’s approach to her then quite new job as Health Ombudsman. Complaints and the way they are managed and treated and what they mean for the organisations trying to deal with them are another abiding interest – see the piece on 24th looking at how common themes can emerge from different surveys of the complainant/ customer experience.

It is not all about the familiar themes – since 2003 we have broadened our interests to embrace two new areas – Policy Governance and parental involvement in schools. In the case of the model developed by John and Miriam Carver, Policy Governance® has taken a while to get off the ground in the UK. Most of the work and case histories reflected US practice and we have not had a good UK example of how this approach to corporate governance can help organisations here. Now the Southend University Hospital NHS Foundation Trust have led the way for others to follow. Val Moore reported on this on 27th October.

Finally, Caroline Millar reports on how the new models of participation – involvement, engagement – are impacting schools, parents and teachers. Her piece focuses on the consultation on complaint handling in schools and how parental problems are handled (or not).

We call ourselves a consultancy that specialises in the user interest. What keeps us interested and involved and in business, is how that interest can manifest itself in so many different contexts while the principles underlying best practice can be so similar. Different diagnoses, different solutions but underpinning them all are the common questions – what do users think of this? Has anyone asked them? Has anyone listened? Has anyone done anything with what they have heard? What happens when people have a problem? Easy really.

The final question that comes up when looking back over 5 years – has anything changed?  Well Andrew inspired us all with a 2006 look at what the NHS will be like by 2015. We are almost halfway there and what has come true? Well the Department of Health seems to see things the Andrew Craig way. Allowing people to pay for their drugs was something Andrew took a look at in March this year when he pointed out that ‘topping up’ was something that Beveridge seemed to have explicitly anticipated when he wrote about the State leaving “room and encouragement for voluntary action by each individual”.  As far as the management ethos of the NHS as a whole is concerned, we will wait and see how PG will change all that.

In the meantime, it is still worth repeating a little Olympic-flavoured M-A-C joke from 28th November 2006 -

A parable of NHS reforms

(Elements are borrowed from several sources and sexed up a bit by us)

An NHS rowing team raced against a Japanese team. There were eight people in each team, of similar fitness, but the Japanese team won by a mile. How could this have happened asked John Reid? Top NHS management established a committee of analysts, which reported that the Japanese had seven rowers and one captain, whereas the NHS has seven captains and one rower. The experts called for restructuring of the NHS team. The new team comprised four captains, two service managers, and a director who also did the rowing. After a second lost race to the Japanese, the single rower was dismissed on the grounds of incompetence, and the management team received a bonus for strong leadership. A new NHS boat is currently being designed , but is reported to be running behind delivery schedule due to IT problems.

Let us see what has changed by the Olympic year of 2012 assuming we have not had to make a choice before then between funding bread and circuses or the NHS.

Complaint Data – common themes confirmed in different surveys

It gets a little dispiriting if you work with complaints and complainants to see the same old messages emerge in survey after survey as the years go by. If I was a complainant, I would be tempted to be very rude to the next person who wanted me to complete a survey about the experience I had with my complaint. The questionnaires or the questioner have a little spiel along the lines of “your experiences will help us greatly in improving the way we handle complaints”. Really? There seems to be little sign of that.

The National Audit Office has taken a look at complaint handling in both health and social care services in anticipation of the creation of a single complaints system in 2009. Our friends at the Customer Care Alliance and Surveylab have just published their annual look at the complainant experience across a variety of markets and providers based on a survey done during July, August and September 2008. 10,102 responses were received from a random sample of UK consumers and some 230 of them had their most serious problem with health care services.

The findings from the two surveys cannot be compared directly but some interesting common themes emerged – the same reason came top in the list of reasons why many did not bother to complain. Namely, the perception was that nothing would change as a result of voicing that complaint. The NAO survey which focussed exclusively on health and social care services asked more detailed questions about both the informal and formal processes. Young people were especially likely to drop the matter at the mention of a formal process. The people who persisted – this came through with the health care problems – were those who were looking after or complaining on behalf of someone else and there is an interesting suggestion with the social care data that readiness to voice dissatisfaction was linked to whether or not part at least of the service had been paid for. Class and age played their usual part in readiness to voice with ABC1s and 35-54 year olds the more likely to take the problem up.

Social care service problems are most often triggered by a social worker or home help and this personal flavour to the problem explains why people with a problem with for example the bad standard of treatment, worried about the effect of making a complaint, not wanting to damage a continuing relationship with the service provider.

What did complainants want? The CCA survey asked directly whether revenge would be nice. 7% of men said yes to that compared to only 1% of women. That same survey confirmed that what people wanted overwhelmingly was an apology (46%), an explanation (57%), and an assurance that the problem would not be repeated (40%). One of the most telling pieces of data in this study (the NAO did not ask the question) was that 54% of the people who were dissatisfied, shared that experience with friends/ colleagues.

Ministers despair that people do not believe what they are told about the health service. As we have said before, we listen to and more importantly believe our friends more when it comes to service experience. Service reputation lags well behind the public announcements – the speeches, the ads – because private user information (the wisdom of the crowd) discounts these official messages in favour of their word of mouth sources.

We will await the lessons from the early adopters programme for the new combined health and social care complaint handling arrangements and how well local providers put in place their own arrangements within the Making Experiences Count framework. The main pitfall to avoid when building new organisations is to push complaint handling to the back of the process building queue. This overlooks the fact that good complaint handling is an vital resource for users who have been dissatisfied by some aspect of the fledgling organisation’s service delivery. Bad first impression plus bad problem resolution equals poor reputation straight after launch – revisit our thoughts on who gets believed.

In the meantime,  service process designers and commissioners need to look out for the user who is ABC1, 35-54 years old, responsible for someone else’s care. Lives in London and the South East and has lots of friends. Your reputation rests in their hands. Sort them out quickly with an apology and an explanation and just as most of those users do not want revenge, avoid giving any impression that vulnerable users still in the system will suffer for being cheeky and complaining. Worth perhaps repeating that stunning bit of data from the UK Customer Care study showing the rewards of good complaint handling that satisfies your users.

No Authority? Then No Accountability – the Policy Governance® View on the NHS Constitution

The consultation on the proposed NHS Constitution closed last week. The UK Policy Governance Association (UKPGA) said it all for us in their submission.  M-A-C partners have been big fans of the “policy governance”® approach for public sector boards and Valerie Moore is an accredited PG practitioner. ( See our main website )

The UKPGA submission focused on two key aspects: accountability and local determination of needs. Those have to sorted out first before service users can be clear about what their entitlements to services are.  But the NHS Constitution lacks a statement of accountability – ie there is no answer to the question “to whom is it accountable and for what and how is that accountability to be exercised?”

M-A-C previously tried to interest our (then new) Prime Minister in this when we suggested to Mr Brown back in June 2007 that in his enthusiasm for the NHS, he needed to be clear about what the institution was for. We are glad to see that Ann Keen has assumed the mantel of “Minister for the NHS Constitution”, so we can address our views to her.

As we said to Mr Brown, so we say to Mrs Keen.  The end of the NHS in England – what it is for – should be understood as: “The health of all people in England is maintained as fully as possible for a sustainable tax burden”.

It should be that simple  – and it would be if we were clear that the owners of the NHS are the people who have paid and who do pay for it and who use it.  We also need to be clear that the “p word” we should use more of is “power” not “patients”.   If we were clear about those things, then getting the work done through good management would be a great deal easier.

So we were pleased that the UKPGA’s submission stressed the need for a statement of accountability as

“a central plank of the Constitution which should represent the terms on which the public’s authority is passed to the organisations that, together, comprise the NHS. “

The Statement of Accountability should

“Give guidance to enable NHS boards to deal with the competing demands for accountability from:

1. Parliament as representative of the national public interest
2. Government as the executive of Parliament
3. NHS regulators as monitors of compliance with parliamentary legislation and government policy
4. Local communities as representative of the local public interest
5. Patients as consumers of NHS services
6. Staff as employees of NHS organisations
7. Other stakeholders.

“Whilst it is perfectly right and proper for the NHS to be accountable to the public-as-consumers for any promises it makes to them, it is also vital that it is accountable to the public-as-owners for making only those promises that it can afford to keep if it is to remain a sustainable organisation.” As UKPGA further explained, “No person or institution can be held accountable for something over which they have no authority. Thus NHS organisations cannot be accountable to their local communities if they have no authority to vary their nationally prescribed responsibilities.”

Access to healthcare services cannot be without reasonable limitation if the NHS is going to be accountable. The NHS Constitution should therefore be amended as suggested by the UKPGA: “You have the right to expect your local NHS to assess the health requirements of the local community and to put in place the services to meet those needs as considered necessary.”

The last three words are crucial to accountability because “local NHS boards [must] have the freedom to interpret the phrase “as considered necessary” and [be] able to prioritise and interpret nationally prescribed responsibilities in the light of local community needs.”

The “planned differences” [discussed on our post of 14th October] that result would be evidence that the local NHS was simply doing its job.  Holding it to account for the promises that it could afford to keep would then be much more straightforward for us as the owners.

Contact Stuart Emslie at the UKPGA at either ukpolicygovernance@gmail.com or 07932 376562.

Paying for Participation

We have talked before about the role of cash incentives in getting people engaged with their Health Service. So when we saw this on the BBC News site, we wondered who else was using this or other cash-type rewards? It opens the intriguing concept of cash-based competition between public bodies – many now with statutory duties to consult – to access the views of us fish in the pool of public opinion. Whoever has the biggest feeding bucket with the most fish food gets the most opinions? See the story below:

Vouchers offered for NHS opinions
http://news.bbc.co.uk/1/hi/england/london/7658352.stm

Residents in east London are being offered vouchers by the NHS as incentive to get involved in improving their health service.

NHS Waltham Forest said it would give vouchers worth £25 to the first 500 people who turn up to the public event to discuss local healthcare.

Residents who attend the event at Walthamstow Town Hall can redeem the vouchers at local shops.

The NHS insisted spending £12,500 as an incentive was “good value for money”.

September Re-entry (September newsletter)

The title of the newsletter would sound better in French: ‘la rentrée’ – a season in France when the State re-awakens after its long summer off and the supermarkets are filled with bargain notebooks and pens – the ones that are all squares and no lines. It is much more than ‘back to school’ and money off school shoes.

On Leadership & Management in Business

Shoes are on my mind because I have been reading the latest book by John Timpson of Timpson Shoe Repairs. The book talks about the reasons for the survival of Timpson Shoe Repairs when so many other larger and equally well-established companies have gone to the wall. The high street is a pretty spooky place if you think about it filled with the ghosts of retail chains – ou sont tous les magasins ‘d’antan’? as François Villon would have put it looking at the C15th retail scene. The British Shoe Corporation was once the Colossus of the high street with 26% of the shoe trade. All gone. Timpson Shoes itself has bitten the dust. You will have the ones you miss in mind – was it Timothy White’s? Mac Fisheries perhaps? John Collier? Salisburys for a nice bag? All this is very timely as corporations crash and burn.

The Timpson answer to the question is not 42 but 28 bullet points on p186. My own take on his survival is that John has kept things under his control – no external shareholders, no private finance companies to keep happy. He bought the company back under family control and runs it the way he and now (other son) James wants. Timpson Shoe Repairs can do their own thing. This is refreshing as we watch so many managers struggle with the new demands for accountability and transparency while trying to innovate. Compare the ease with which a private retailer shuts shops and 100s of them with the long drawn-out agonies of the post offices closure programme. Are there not better ways to manage public change especially with failing institutions?

There is a Department of Health Consultation out on this very topic about the best way of coping with failing NHS providers as they move, in the careful parlance of the document, from being ‘underperforming’ to ‘seriously underperforming’ to – the horror! the horror! – ‘challenged’.

At least the problem is being faced up to which is always an achievement in the NHS that bulky leviathan where change and innovation mean that institutions and managers are often ‘challenged’. And what politician wants to be associated with closure of services the voters want? In this complex environment, the race goes so often to the small and fleet of foot who like Timpson Shoe Repairs know their business and their users and can make things happen.

On Leadership, Management & Innovation in Health Services

Which is why 2nd September was such a good day in Leeds for Andrew Craig and our client the Motor Neurone Disease Association. The Association has developed a new product called the Year of Care (YoC) Pathway Commissioning Tool in two years which more than meets the challenges of World Class Commissioning.

Andrew had the pleasure of representing M-A-C at the Motor Neurone Disease Association Year of Care Pathway launch and “thank you” event at the Thackray Medical Museum in Leeds earlier this month. It was well attended by mainly Leeds PCT and Leeds Social Services people and also people with MND and carers who had helped with interviews, focus groups and general validation of the draft pathway we undertook there.  Mick Ward, Head of Strategic Partnerships and Development across the PCT and Adult Social Services, gave the main speech and was excellent. This is just the kind of joint leadership that is needed to make progress for people with long term neurological conditions across the health and social care cultures. He committed the PCT and City Council to being in the MND Year of Care early implementers group so we shall be seeing more of him in the next twelve months. He related the YOC to the World Class Commissioning competencies and stressed the leadership, service transformation and market development aspects inherent in WCC. Clearly he sees the bigger picture. Andrew said he couldn’t have written it better himself! The Association has produced the ‘Learning from Leeds’ report by M-A-C as a 4 page colour brochure with pictures which looks terrific. Lunch was good and it was sunny and warm in Leeds. What more could one want?

For a flavour of the MND Year of Care pathway see the snapshot and read the press release

We will be putting more details about this work which we are proud to have been associated with on our website in due course. For more details of this event and an earlier one at the House of Lords as part of the NHS 60th Birthday celebrations, see the MND Association website.

Baroness Finlay of Llandaff, a Professor of Palliative Medicine said at the House of Lords event that

“This is one of the most important documents for patient care I have seen. This is exactly what the new NHS needs, a practical working tool to help achieve patients individual choice and improve their quality of life.“

Well done MND Association and while it may be strange to make a comparison between this terrible condition and shoe repairs, both achievements come from doing the best you can for your customers/users when you can with the resources available to you. Of course that will always involve other people – whether partners in PCTs and local Councils or staff and managers – but someone has to take the risks and do it first.

Survival often means not following the herd.

The challenge is to find the right leader and I will leave you with the definition of leadership given by the anonymous bard or bards who have handed down the text of The Wanderer, one of the most plangent and moving Anglo Saxon poems on the theme of ‘ubi sunt?’ mourning the good times in the past and musings on the qualities that make for success.

Wita sceal geþyldig                                          A wise man must be patient,

ne sceal no to hatheort                                    He must never be too impulsive

ne to hrædwyrde,                                            nor too hasty of speech,

ne to wac wiga                                               nor too weak a warrior

ne to wanhydig,                                              nor too reckless,

ane to forht ne to fægen,                                 nor too fearful, nor too cheerful,

ne to feohgifre                                                nor too greedy for goods,

ne næfre gielpes to georn,                               nor ever too eager for boasts,

ær he geare cunne.                                        before he sees clearly.

Bonne Rentrée and if Anglo Saxon verse is too cutting edge for you, take a look at our September post on how the Health Service and others are using the new social networking technology. One for your LINk perhaps?

P.S. We have been asked how to retrieve old blogs now that we have moved to the new style of presentation. These are all still available. The answer is on the right hand side of the blog page – try this link

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.

Santé sans (Euro) frontières peut-être?

M-A-C has always backed more service user choice – and we are delighted to see it enshrined in Lord Darzi’s “Next Stage Review” commitment to providing patients with greater access to information and freedom to control their own care. It is therefore perplexing – but not unexpected given previous form – to see the Department of Health speaking for the English NHS decrying what it sees as the likely effects of the new European Directive “On the Application of Patients’ Rights in Cross Border Healthcare” launched earlier this month. Aren’t they in favour of patients having more choice? Only on their terms perhaps.

The EU Directive isn’t very radical and rather watered down compared with earlier drafts, but it is welcome nonetheless to have existing rights (though most people never knew they had them) focused in one document. The sticking point about an NHS patient travelling to another EU member state has always been getting “prior authorisation”. But that is dealt with in the Directive.

About 1 in 5 Luxemburgers regularly receive state-funded care in another member state. But for us Brits, arranging this can turn out to be a “through the looking glass” experience. Some years ago I chaired a complaints panel involving a request to reimburse a patient who had had a stapedectomy (middle ear surgical procedure to improve hearing) done at a well known otology centre in Beziers, France, because the local NHS couldn’t say where or when it would be done here. All the consultants she had seen in the UK agreed the treatment was clinically indicated and the health authority repeatedly insisted that it could be done here in England. But no one was able to tell the patient – whose hearing was deteriorating – who would do it, where and when. Faced with that sort of dithering, the patient did what any sensible person would do and packed her bags for the trip to Languedoc.

When she returned after a successful result and claimed the costs back from the NHS, they refused indignantly to entertain her claim – after all the stapedectomy could have been done here and she did not have prior authorisation. Naturally she complained and that is when the fun really started. When the case finally got to me at the appeal panel stage, I am ashamed to say that I could not have imagined such bureaucratic contortions as my own health authority went through as it struggled to claim that black was white in order to avoid admitting that they had left the patient with no alternative but to travel for her operation unless she wanted to accept deafness in one ear. The panel found for the patient and recommended full cost reimbursement as compensation, which the health authority board to its credit agreed to pay on an ex gratia basis. And they had the sense to agree to a second Beziers trip for the other ear to be seen to when that too caused trouble a while later.

Did we learn anything from this? I never saw another complaint like it and I hope that this particular patient’s experience is not longer typical, but the DH’s latest hand wringing about the evils of two-way “health tourism” isn’t reassuring. The European Court of Justice has made crystal clear in a string of rulings that national health systems cannot refuse to refund costs of overseas treatment if patients have waited longer than clinicians advised, even if waiting list targets were met. The EU sees this as benefitting people with relatively rare or complex conditions and who could say no to that?

Of course, travelling for health care isn’t risk free, and there are costs above that of the treatment itself. Also, I’m not advocating (even if anyone would pay for it) crossing borders for botox, tummy tucks and such like. But I can see a number of very good reasons to encourage people to travel around in Europe for something they cannot get done speedily at home:

1. They will get a better idea of comparative standards in health services in other member states – rather like having the Euro helps compare other things we consume. That’s both good and bad perhaps, but it might put paid to the situation we have now where most people say their own NHS experiences are pretty good, but if asked how things are in the country at large they are convinced that the end if nigh for publicly funded healthcare. Travel broadens the mind in more ways than one and better health literacy back here at home might result;
2. It will encourage partnership and break down paternalism, of which there is still too much about in the NHS despite all the rhetoric to the contrary;
3. It could bring in revenue to the NHS because acute trusts’ capacity will have to be filled somehow as PCT commissioners redirect resources and services outside the hospital gates. If I were a Foundation Trust business director, I’d take this as a serious new business opportunity and get the map out to see which member states had the longest waiting lists for specialities I’d like to sell more of. But before I placed the adverts in the local papers, it would be a good idea to get the hospital’s cuisine up to higher level!

EU member states now have to translate the framework of the Directive for healthcare without frontiers into national law. Let’s hope the UK makes some sensible progress towards that goal and stops moaning about it. And it will be interesting to see if our proto-federal island kingdom can speak with a united voice on this one: what England’s NHS thinks about healthcare without frontiers, may not be the same as the views of Wales, Scotland or Northern Ireland at all. Comments from those jurisdictions would be very welcome on this point.

And a final bit of nannying – if you haven’t got your new European Health Insurance Card yet (replaces the late and un-lamented Form E111) apply for it here http://www.ehic.org.uk now!

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