Memorandum from the NHS Confederation
THE NHS CONFEDERATION
The NHS Confederation is a membership body that
represents over 90% of all statutory NHS organisations across
the UK. Our role is to provide a voice for the management and
leadership of the NHS and represent the interests of NHS organisations.
We are an independent organisation.
The NHS Confederation welcomes the opportunity
to give evidence to the Public Administration Select Committee
on the role of public involvement in the improvement of public
services in the United Kingdom. This evidence sets out our views,
based on feedback from a cross section of our member forums.
OVERVIEW
Evidence shows that the delivery of health and
social care is improved when the views of people using services
are taken into account. If the Government is going to achieve
its targets on patient choice, the wider public must increasingly
inform the way services are developed. NHS providers and commissioners
of services become more skilled at market testing and customer
insight.
Involving patients and the public in the planning
and development of services is crucial and should be a given for
any organisation involved in the commissioning or provision of
public services.
However, we must maintain a distinction between
the duty to involve people and the duty to consult. All NHS providers
of services should have a duty to engage and involve patients
and the public but, particularly where service review or change
is considered, however only commissioners, with their accountability
to the local community and links to Local Authority Overview and
Scrutiny processes, should be duty bound to formally consult.
Commissioners and providers should ensure that
the need for, the design and the quality of local health and social
care services are regularly market tested, including surveys to
measure patient and public satisfaction.
The NHS Confederation generally supports the
direction for public involvement set out in the recent Department
of Health White Paper, A Stronger Local Voice (July 2006).
We also believe that a locally co-ordinated
approach has advantages for other public bodies for which public
consultation is an essential component of development and evaluation
of service delivery.
2. Is it possible to set minimum standards
for public services? Is so, how is this best done?
The NHS Confederation believes that it is possible
to set minimum standards for public services. Standards for the
NHS need to take into account three levels of service delivery:organisations,
clinical specialties and individual clinicians (or other professionals
in other areas of public service).
Standards should focus on cost effectiveness,
efficiency and probity but also on quality and safety. Standards
need to enable organisations to demonstrate continuous improvement,
value for money, responsiveness, quality and fairness.
The work of the Healthcare Commission in the
development of core and developmental organisational standards
to replace the old star ratings system for health bodies has already
enabled greater public scrutiny of the quality and cost effectiveness
of local services. It is substantially more comprehensive than
the star ratings system. Core standards must be achievable within
acceptable timescales and developmental standards must be measurable
and truly indicative of progress in quality improvement. Patient
outcome measures, as part of this year's? Healthcare Commission's
Annual Health Check, need to be robust and include experience
rather than just satisfaction ratings.
At specialty level, service quality standards
have been developed through the National Service Frameworks for
key clinical conditions such as diabetes and mental health. In
addition Healthcare Commission thematic reviews covering services
such as tobacco control, substance misuse and heart failure have
enabled the public to compare the quality of service across organisations
in these areas.
Standards need to constantly evolve over time.
This is because the longer they stay the same, the more organisations
reach the bar but have no incentive to continually improve. Again,
whilst patient experience plays a role in the process at present,
there is an argument for further strengthening this part of the
review system.
Recent benchmarking work in the field of cardiac
surgery measures has shown how data about individual clinicians
can be used to inform patient choice and demonstrate where standards
of care are attained or exceeded. This is very much work in progress
and the information given, whilst highlighting patient outcomes,
does not necessarily focus on patient experience measures. It
is to be hoped that this can be developed as the breadth of procedures
covered by this data increases.
The NHS Confederation believes that the above
examples represent first steps on the road to robust minimum standards
for the NHS and have resonance in other public services. However,
it would urge that any minimum standards do not increase the bureaucratic
burden on organisations. Currently over 50 organisations currently
regulate, inspect or request information from NHS trusts. Standards
should be an integral part of the delivery of public services
and their measurement should be streamlined to enable information
to be available more contemporaneously to enable consumer choice
and public accountability to be strengthened.
3. What role do measures of customer satisfaction
have in assessing the standards of public services? How should
user views be monitored? How can the cost effectiveness of user
surveys and feedback mechanisms be assess?
Whilst customer satisfaction measures have for
many years of course had a role in assessing the standard of public
services, the NHS Confederation believes that this only provides
half of the story. Patient experience and outcomes must be measured
as well.
There is evidence that, whilst satisfaction
with individual professionals delivering care is usually very
high, the overall patient experience can be less so. For example,
a patient may rate their GP highly but find the surgery building,
service access, reception staff and booking systems less acceptable.
Their overall experience might therefore be poor even though their
interaction with the GP is good and would be rated so in customer
satisfaction terms.
In a recent publication, "Lost in translation"
(NHS Confederation, 2006), the Confederation points out that
patient and public satisfaction with NHS services can be very
different, with patient exceeding public satisfaction in areas
such as nursing care, involvement, cleanliness, convenience and
choice (based on the findings of a MORI poll cited in the report).The
key inference of this finding is that those directly receiving
services from the NHS and with a better working knowledge of its
delivery, rate its services more highly.
The report also points out that 48% of those
surveyed found out about the NHS from TV or radio with only 18%
getting their information from medical professionals. This gives
further weight to the need for increased involvement of the public
in the planning and delivery of services as a method of delivering
a fairer picture of public perception of the NHS.
The NHS Confederation would therefore argue
that a system based on the evaluation of outcome measures for
user experience, of which customer satisfaction is one, would
give a better view of how customers really rate their health and
indeed other public services. Such a system would enable co-ordination
of complaints information, comments from users and user survey
responses with information from consultations and individual feedback.
6. Should users be more directly involved
in service delivery? Is so, how can this be achieved?
We believe that there is a key role to play
for service users in the design and delivery of healthcare and
other public services. Indeed there are examples of healthcare
organisations where this has been a reality for many years—most
notably in mental health. The development of the Foundation Trust
membership model, a form of social enterprise, ensures that patients
and the local public can have a say in the management and direction
of the organisation.
The 54 authorised foundation trusts now have
over 1,000 staff, patient, public and stakeholder governors and
half a million members, with the number set to grow dramatically
over time as more acute and mental health trusts are authorised.
Foundation trusts are working with their governors
and members in a wide range of ways to give patients and the public
opportunities to shape hospital services. This includes governor
and member focus groups on key aspects of the patient experience,
surveys, governor led constituency meetings with members, open
days, health awareness events, newsletters, dedicated websites
and e-communications. These involvement mechanisms have resulted
in practical changes to local services and created a culture where
patient and public involvement is a mainstream part of the day
to day work of the trust.
Service users are already involved in many consultation,
planning and user groups, for instance in the development of new
facilities e.g. under the Local Finance Improvement trust (LIFT)
and in the evaluation of services through customer satisfaction
surveys and ongoing local public forums etc.
However, the NHS Confederation would argue that
this process is mostly ad hoc and inconsistent and could be improved
through clearer local involvement strategies, more transparent
planning processes and the development of a menu of involvement
techniques which can be tailored to particular local situations.
We believe that involvement should have a non-organisational
focus, ie there should be opportunities for it to be centred around
the experience of individual patients/users through the local
public service system and not purely institutionally related.
This would inform the whole care pathway from GP appointment through
to aftercare from community health services.
We support the proposals for the establishment
of the Local Implementation Networks (LINks) made in "A
Stronger Local Voice" as the focal point for future patient
and public involvement in healthcare. These should enable patients
and the public to become involved in the planning development
and reconfiguration of services on a more consistent and accountable
basis.
We would urge that LINks are set up in as robust
a manner as possible with clear remits, roles, responsibilities
and lines of accountability and governance frameworks. The connection
to and relationship with Overview and Scrutiny Committees as the
method of local accountability is vital. Something may be learned
from this model which could apply to other local public services.
Public involvement should also be strengthened
in debates around prioritisation so that the pros and cons of
so called rationing decisions can be given more openness and transparency.
In this, the use of local media and wider consultation forums
eg those run by local government and linked to Overview and Scrutiny
processes will be crucial.
Professional education and training will not
necessarily include training around public or patient involvement
skills. We would therefore urge that professional training programmes
should include training on public involvement and the change in
emphasis such involvement will put into the user/professional
relationship.
7. Are there certain types of decision which
are more suited to consultation than others?
On the whole, the NHS Confederation does not
believe that there are any types of decision that are more suited
to public consultation than others.
However, we would wish to identify two different
types of involvement and consultation, one where major decisions
need to considered within a short timescale, and another which
is about a more long term direction for local services and issues
of quality, equity and responsiveness.
For the former, we consider that, in particular,
decisions concerning prioritisation and reconfiguration should
have a wide consultation and an open public debate.
For the latter, we believe that ongoing consultation
through a process such as LINks is appropriate, dependent on robust
systems for ensuring feedback to local communities so that the
key cause of "consultation fatigue" ie the lack of action
once consultation has been undertaken can be addressed.
With this system in place, commissioners should
have the information they need to detect dissatisfaction and remedy
this through the contract with providers long before the stage
when a petition, as proposed in the Commissioning Framework, should
need to be raised. Indeed, where public involvement is robust,
a petition could be seen as a breakdown of the process and (one)
only necessary as a last resort.
CONCLUSION
The NHS Confederation believes that the development
of robust and comprehensive public involvement mechanisms is vital
to the development of the service, at local and national level.
We believe that emphasis needs to be placed
on user experience rather than customer satisfaction as the health
system becomes more outcome rather than target driven.
Public involvement must take place at both the
commissioning and provision of services stages and cover both
long term service design and strategy and the short term prioritisation
decisions necessary to ensure value for money.
The NHS Confederation welcomes the opportunity
to take part in this debate and in the Public Administration Select
Committee's investigation.
Annex A
EXAMPLES OF PATIENT AND PUBLIC INVOLVEMENT
RICHMOND AND
TWICKENHAM PCT
Mystery shopping project on sexual health services
information used by young people
This project demonstrates a supportive way in
which young people can be involved in actively evaluating services
using a "Mystery Shopping Project" approach. This method
involves turning up at services presenting as an ordinary service
user, and then completing a survey. The aim of this piece of work
was to listen to, take seriously and act upon the recommendations
offered by young people. The project involves both consultation
work and participation of young people.
This project was done in partnership with the
RT PCT Young People's Sexual Health Worker, Education and Children's
Youth Participation Worker, Voluntary Services, Family planning
services and Young People's Walk In Services in Richmond, GUM
Clinics from the Hounslow, Kingston and Wandsworth PCT's and young
people. 22 service evaluations were completed, and tangible recommendations
were made for the future delivery of services. A full report and
video of the exercise are nearing completion.
EALING PCT
Patients and carers choose a home tube feeding
service
Ealing PCT has used a tender process for home
tube feeding services that involved patients and carers. Home
tube feeding is successfully used for a large number of people
who are unable to meet their nutritional requirements orally for
a prolonged period of time. Ealing PCT and Ealing Hospital worked
together with service users in the tender process for an enteral
feeding contract. Companies set up a market place with stalls
in Ealing town hall and gave presentations to patients and carers.
The majority of participants were carers rather
than patients as patients needing the feeds tend to be either
very young or very old and it is usually the carers who use tube
feeding products. In the tender process carers were encouraged
to challenge the companies' claims about service quality—something
they are not generally used to doing.
The patients/carers' responses were weighted
over those of staff and this helped influence the final decision
which identified savings in the region of £220,000.
FRIMLEY PARK
HOSPITAL NHS FOUNDATION
TRUST
Foundation Trust Governor/Member Constituency
Meetings
Frimley Park Hospital is involving local patients
and the public—their members—in constituency meetings
which have now been running for over a year. These are led by
their governors, elected by the members themselves. Six constituency-based
meetings were held in the autumn of 2006 spread geographically
across the local area. Nearly 400 foundation trust members, patients
and members of the public attended these events. Each meeting
had a clinical focus and also incorporated a strategic planning
update followed by the governors conducting an Open Forum session.
A board member attended to hear the public's comments and take
questions.
Following the success of the meetings, governors
have agreed that they should be held 2-3 times a year. Frimley
Park is one of the first foundation trusts to hold members' meetings.
These are now seen nationally as an example of good practice and
others are developing similar ways of meeting, and listening to,
their local populations.
LANCASHIRE TEACHING
HOSPITAL NHS FOUNDATION
TRUST:
Oversubscribed for "Focus on"
Lancashire Teaching Hospitals NHS Foundation
Trust has held a number of successful members' events based on
clinical subjects, which have proved so popular that each has
been oversubscribed. They have followed a "Focus on"
theme, so far covering diabetes, bowel cancer and the work of
its cancer centre. A networking session between members and governors
is included within the programmes and feedback forms are made
available.
STOCKPORT NHS FOUNDATION
TRUST:
Championing youth governors
The constitution at Stockport NHS Foundation
Trust allows membership from the age of 16 onwards. However the
trust is keen to ensure that the views of children and young people
are actively heard. They have a dedicated appointed Youth Governor
on their Board of Governors, recruited from, and supported by,
the local Corporate Youth Service. They have also established
a Young People's Engagement (YPE) Committee—with membership
from governors and representatives from internal and external
agencies, chaired by the youth governor.
BROMLEY HOSPITALS
NHS TRUST:
Preparing local people to become foundation trust
governors
Bromley Hospitals NHS Trust is in the preparation
stage of applying for foundation trust status. It currently has
a public, patient, carer and staff membership of 8,700. Its membership
is strong and the trust continues to recruit members and is actively
preparing local people to become foundation trust governors. Those
expressing an interest in becoming governors are invited to attend
potential governor workshops to introduce them to the trust. The
high level of interest has resulted in two evening workshops in
the last six months and a further one planned for January 2007.
SOUTH STAFFORDSHIRE
HEALTHCARE NHS FOUNDATION
TRUST
Governors' and Members' Involvement in Service
Development
Carers, as well as staff, at a mental health
in-patient facility for older adults at South Staffordshire Healthcare
NHS Foundation Trust are helping to improve facilities for patients.
They have recently been central to discussions and decisions on
such projects as creating a garden and a Reminisce and Relaxation
room for the use of service users. Members agreed that these would
be of great therapeutic value and would enable a calm and harmonious
environment to be created on the Unit.
January 2007
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