Written evidence from Centre for Public
Scrutiny and NHS Alliance (COM 134)
1. INTRODUCTION
1.1 The Centre for Public Scrutiny (CfPS)
and the NHS Alliance (NHSA) hope this joint submission will help
the Health Committee with aspects of the inquiry relating to accountability
for the commissioning functions of GP Consortia, the NHS Commissioning
Board and Health and Well-being Boards.
1.2 The submission draws on a joint paper
published earlier in 2010 by CfPS and the NHSA called Towards
Transparent, Inclusive and Accountable GP Commissioning, together
with the separate responses that both organisations made during
the consultation on the Health White Paper. All of these previous
papers were informed by the CfPS policy papers Anatomy of Accountability
and Accountability Works! and the NHSA policy paper Whose
NHS Is It Anyway?
1.3 The Health Committee is seeking to understand
how things might work if the plans for White Paper proposals for
commissioning are translated fully in to legislation. NHSA and
CfPS want to offer some commentary and practical suggestions about
how GP Commissioning could develop in a transparent, inclusive
and accountable way—strengthening the bond between local
communities and their health services.
2. KEY MESSAGES
2.1 Our key messages are summarised below:
— Relaxing central control and bureaucracy
provides flexibility and freedom for commissioners to better respond
to local views but "checks and balances" are needed
in relation to the new freedoms and flexibilities.
— GP Commissioners could lead a change
of culture by embracing principles of transparency, inclusiveness
and accountability and creating space for dialogue with citizens
and patients (directly or through their representatives) about
solutions to local health challenges.
— Mechanisms for councillors to hold
political leaders to account for their strengthened co-ordination
role around healthcare, social care and health improvement are
important but "external accountability" over commissioners
(and providers) should remain.
— There is a strong business case for
GP Commissioners to invest in accountability and scrutiny and
they should support people who have a role to hold them to account,
whether they are patients and local people, advocacy groups or
elected representatives.
— Embracing principles of transparency,
inclusiveness and accountability could help GP consortia develop
"democratic legitimacy", involving citizens, patients
and councillors in co-producing commissioning decisions, service
design and delivery.
— GP Commissioning would work best
where patients are involved in their own care, citizens are able
to influence service design and delivery and GP Consortia are
open and accountable for the decisions they take.
— Transparency, inclusiveness and accountability
need to be at the heart of quality, alongside safety and value
for money. The idea of a "quality premium" could be
extended to responsiveness. This might involve developing a local
"quality account for commissioning".
— There are lessons from the experience
of Health Overview and Scrutiny Committee reviews of Practice
based Commissioning that can help inform accountability arrangements
for GP Commissioning.
3. "LIBERATING
THE NHS"
3.1 The White Paper Equity and Excellence—Liberating
the NHS sets out a vision for a radically reformed approach
to planning and delivering healthcare. We welcome the general
thrust of the Coalition proposals to give local people more power
over their health services. Relaxing central control and bureaucracy
provides flexibility and freedom for commissioners to better respond
to local views, whether expressed directly by patients and the
public or through their representatives. However, we think that
"checks and balances" alongside these new freedoms and
flexibilities are important.
3.2 Taken together, the White Paper proposals
for taking decisions about planning and delivering services at
a more local level could provide patients and the public with
more opportunities for influencing decisions and have great potential
to change the culture of healthcare and health improvement by
judging progress in the future by focusing on "outcomes".
This reflects the approach to public sector performance management
set out in the CfPS policy paper Green Light[196].
4. WHY TRANSPARENCY,
INCLUSIVENESS AND
ACCOUNTABILITY ARE
IMPORTANT
4.1 People value the NHS, but the planning
and delivery process can feel remote. It is not always possible
to demonstrate how commissioning decisions relate to the needs
and aspirations of people and communities. Despite processes for
involvement and accountability being in place, the basic issue
seems to be that patient and public voices do not seem to matter
to the NHS as much as other influences upon it. Although there
will be local successes, patients, the public and their representatives
struggle to make an impact overall.
4.2 GP Commissioners could be a way to lead
a change of culture by embracing transparency, inclusiveness and
accountability and creating space for dialogue with citizens,
patients and their representatives about solutions to local health
challenges. This would reflect the Coalition Agreement principles
of freedom, fairness and responsibility—citizens empowered,
individual opportunities extended and communities coming together
to make lives better.
At a time when difficult decisions need to be
made about priorities, greater transparency, inclusiveness and
accountability could strengthen democratic legitimacy.
4.3 To be able to lead this change, GP Commissioners
would need to demonstrate a commitment to working with people
over the long term to drive health improvement and raise service
experience. This would need to go much further than working with
practice-based Patient Participation Groups, for example by embracing
community development initiatives. The forthcoming CfPS Accountability
Charter for public services will enable commissioners to further
demonstrate their commitment to transparency, inclusiveness and
accountability in every aspect of the commissioning cycle.
4.4 GP Commissioners, if they are to be
local leaders of the NHS, should recognise that there is a strong
business case for investing in accountability and scrutiny and
that they should support people who have a role to hold them to
account, whether they are patients and local people, advocacy
groups or elected representatives.
4.5 Transparency, involvement and accountability
need to be a central part of healthcare alongside quality and
safety.
6. TRANSPARENT
6.1 Providing information to help people
understand the context in which the NHS operates gives them a
powerful tool to take part in discussions and debates about how
the NHS works and how it responds to people's needs and aspirations.
Giving people information could lead to greater involvement but
there needs to be a balance between giving information directly
and pointing people to sources of information that they can analyse
themselves.
6.2 Examples of areas where GP Commissioners
would need to be transparent are:
— the state of public health;
— the challenges of planning and running
health services;
— how services are performing locally
and in comparison to other places;
— how decisions are taken about improving
services;
— how people can take more decisions
about their care and treatment;
— where people can find information
themselves; and
— how people can best get their voice
heard (ie what are the levers for influence).
7. INCLUSIVE
7.1 Greater transparency about the way the
NHS works, how services are performing and how services can be
improved could lead to greater involvement of patients and the
public.
7.2 Ways in which GP Commissioners would
need to be inclusive in planning and designing services are:
— sorting out what "involvement",
"engagement" and "consultation" mean in the
context of planning, delivering and improving services;
— being clear about how patients and
the public can best be involved in different aspects of the NHS
(locally, across boundaries and nationally) in ways that suit
them;
— understanding the difference between
representative and participatory democracy and how each can best
contribute to improvement;
— asking people about whether they
want to make decisions about their care;
— asking people's views about public
health and what can be done to improve it;
— asking patients (and their families
and carers) and communities about how they want health services
organised around their needs so that patients are central to decision-making
and taxpayers receive value for money; and
— supporting people to be involved
by working with them in ways that suit the individual or group.
8. ACCOUNTABLE
8.1 Better transparency is likely to lead
to increased involvement. But the outcomes of involvement must
be meaningful and patients and the public need to feel that their
contributions have made a difference. Taxpayers need to have confidence
that involvement mechanisms are working for everyone and are leading
to improved services that enhance value for money.
8.2 We believe that GP commissioners will
need help to commission effectively. In our opinion, local authorities
will be best placed to work closely with consortia to offer experience,
local knowledge and cooperation, as well as built-in accountability
through the overview and scrutiny function. Working closely with
local authorities would help GP Commissioners to better understand
and tackle health inequalities in their localities.
8.3 GP Commissioners would need to take
the lead for accountability across the system at a number of levels
(locally, across boundaries and nationally) for:
— the performance of individual clinicians
and staff in commissioned services;
— the safety, quality and value for
money of services;
— whether or not outcomes are improving
(in terms of public health and services);
— ensuring that local people's views
make a difference to service planning and delivery;
— whether or not people feel that they
can influence their care;
— the reasons for not changing things
in line with people's views;
— plans for improving outcomes in the
short, medium and long term; and
— saying sorry when things go wrong
and learning lessons for the future.
9. COUNCILS AND
SCRUTINY
9.1 A new role for councils to join up healthcare,
social care and health improvement would build on councillors'
vital role to provide assurance on behalf of local people that
all services in their areas are transparent, inclusive and accountable.
In relation to health, councillors have a unique democratic mandate
to act across the whole health and care economy, hearing views
from professionals, patients and communities, examining decisions
about priorities and funding across an area to help tackle inequalities
and identify service improvements. We welcome the recognition
in Equity and Excellence that councillors have a role in
making sure everyone is working together to improve things for
local people.
9.2 The statutory powers that health overview
and scrutiny committees currently have in relation to SHAs, PCTs
and NHS Trusts (to get information, attendance of officials at
meetings, get responses to recommendations for improvement and
refer contested service changes) have proved a powerful lever
for change across the country. Under the White Paper proposals,
councillors would be able to hold their political leaders to account
in respect of the strengthened co-ordination role for councils
but "external accountability accountability" over commissioners
(and providers) should remain.
9.3 If created, Health and Well-being Boards
would be able to veto Consortia commissioning plans. We welcome
this as it builds on current scrutiny powers. However, we don't
agree that councils' co-ordination role through Health and Well-being
Boards should replace health scrutiny. Health and Well-being Boards
will be taking decisions about health, social care and health
improvement. They cannot hold themselves to account about how
effective they are at doing this. The current "health scrutiny"
powers represent the strongest model of democratic accountability
in public services. They enable councillors to engage with commissioners,
providers and patients and the public across primary, acute and
tertiary care. Councillors have shown that they can operate very
successfully locally and across boundaries (particularly when
tackling service reconfiguration and health inequalities).
10. OTHER FORMS
OF DEMOCRATIC
ACCOUNTABILITY
10.1 We have made the case for transparent,
inclusive and accountable GP commissioning. To be successful and
to make their potential commissioning role sustainable, GP commissioners
will need to work with a much broader range of people and groups
than they are currently accustomed to. They will need to build
transparency, inclusiveness and accountability in to corporate
governance and to include non-professionals in their arrangements,
reflecting the current "non-executive" role on NHS Boards.
Potential ideas for including non-professionals on GP consortia
boards are:
11. LOCAL HEALTHWATCH
11.1 If Health and Well-being Boards are
created, the influence of local HealthWatch is sensible and important.
We would also like to see a clear statement that GP Consortia
should allow local HealthWatch to influence every stage of the
"commissioning cycle". So far, LINKs have not been very
successful at holding PCTs to account. Local HealthWatch may be
no more successful with GP Consortia. In our opinion, links between
local HealthWatch and councils will be critical for effective
accountability and dialogue.
12. PARTICIPATORY
DEMOCRACY
12.1 We feel that "accountability"
could become more engaging and effective if it was explicitly
stated that Local HealthWatch and GP consortia should develop
participatory accountability, involving citizens and patients
in co-producing commissioning decisions, service design and delivery.
This would support the concept of the "Big Society".
13. "CULTURE"
VERSUS "LEGISLATION"
13.1 We agree that changing the culture
of commissioning, so that GP Consortia see their role as responding
to the local communities they serve, is far more important than
simply imposing formal structures and processes to make them pay
heed. GP Commissioning would work best where patients are involved
in their own care, local communities are able to influence service
design and delivery and GP Consortia are open and accountable
for the decisions they took. Although appropriate legislation
is can be a useful "backstop" against which to judge
transparency, inclusiveness and accountability, what will make
the system work is good relationships at GP practice, neighbourhood
and organisational level.
13.2 There may be many ways in which a change
of culture can be fostered. Much will depend on how Local HealthWatch
operates. The more confrontational it is, the more defensive commissioners
might become. This approach would not benefit anyone—lessons
from LINks, health overview and scrutiny committees and NHS bodies
that have worked together constructively need to be shared across
the system.
14. CONFLICTS
OF INTEREST
AND COMMERCIAL
CONFIDENTIALITY
14.1 Practice based Commissioners as both
commissioners and providers of services have been a concern since
the inception of PbC. Concerns may well be more acute if members
of GP Consortia are involved in profit-making companies bidding
to provide services and this could be a continuing concern if
Consortia "buy-in" commissioning support from organisations
that also provide services. Experience shows that it is very difficult
for the public and their representatives to scrutinise private
sector involvement in delivering public services.
14.2 There would need to be provisions to
open up these kinds of arrangements to public and democratic scrutiny,
possibly through exploring the option of local authorities providing
commissioning support to Consortia.
15. RESPONSIVENESS
PREMIUM?
15.1 Transparency, inclusiveness and accountability
need to be at the heart of quality, alongside safety and value
for money. The idea of a "quality premium" could be
extended to responsiveness. Some funds would be held back and,
if Consortia could be shown to be responsive to its population,
would be handed over to be distributed as it saw fit. This would
presume that there is a method for distinguishing between those
Consortia that were more responsive from those who were less so.
This might involve developing a local "quality account for
commissioning"—Local HealthWatch and health overview
and scrutiny committees could help to define the measures to be
used and hold Consortia and Health and Well-being Boards to account
for success. This focus on responsiveness needs to be built into
the work of the CQC.
16. BUILDING
ON EXPERIENCE
FROM PRACTICE
BASED COMMISSIONING
AND HEALTH
OVERVIEW AND
SCRUTINY
16.1 There are lessons from the experience
of Practice based Commissioners and from health overview and scrutiny
committee reviews of PbC that can help to build robust accountability
mechanisms for GP Commissioning. GPs are not currently under any
obligation to engage with patient and public involvement mechanisms
but there is some good practice to report, especially about how
councillors have used their health scrutiny powers to work with
general practice and commissioners at several levels to achieve
better outcomes.
16.2 These examples of practice show what
can be achieved by bringing people together right across the health
and social care economy to tackle inequalities and improve services.
This is a key role for councillors with their democratic mandate
and community leadership role—this means of legitimising
decision-making should be maintained. CfPS has published a guide
about scrutiny of Practice based Commissioning that can be a useful
learning tool for the future. It highlights three areas where
GP Commissioners could be held to account during transition and
in the longer term:
— understanding local needs and aspirations
and capacity to change the status quo of service provision;
— supporting people with long term
conditions; and
— improving health and well-being.
16.3 The CfPS guide notes that GP Consortia
may need more support than assumed in the field of patient and
public involvement. Developmental support is likely to be required
for GP Commissioners to be fully equipped to involve people who
use services and citizens in service planning. This is a specific
issue for councillors and local HealthWatch to discuss.
17. QUESTIONS
FOR GP COMMISSIONERS
17.1 We have developed 6 key questions that
can help to shape transparency, inclusiveness and accountability
in discussions about the White Paper proposals for GP Commissioning:
— who can help GP Consortia to build
in principles of transparency, inclusiveness and accountability
during the transition to any new arrangements and beyond?
— what are appropriate outcome measures
for GP Consortia and who can develop these?
— how would GP Consortia evaluate whether
the services they commission meet local needs and how could they
change services that don't meet needs?
— who would judge whether Health and
Well-being Boards are successful coordinators of healthcare, social
care and health improvement?
— how could the NHS Commissioning Board
be held to account for the local impact of its decisions, especially
around regional and specialist services?
— how could GP Consortia help councils
to develop and support effective local HealthWatch, building on
lessons learnt from LINks?
18. IN SUMMARY
18.1 CfPS and NHS Alliance generally welcome
the patient and public involvement aspects of the Coalition's
plans. Certainly the rhetoric is very strong. However, it is not
clear how in practice the new arrangements would offer more effective
responsiveness on the part of Consortia, Health and Well-being
Boards or the NHS Commissioning Board.
18.2 We have set out some broad principles
that we believe should underpin transparent, inclusive and accountable
GP Commissioning. Embedding these principles is vital, particularly
when existing performance management regimes are being relaxed
and structural and cultural reform is planned.
18.3 We believe that by placing a duty on
GP Consortia to follow principles of transparency, inclusiveness
and accountability through a range of ways including local HealthWatch
and councillors, patients and the public can have confidence that
£80 billion is spent wisely in ways that meet their needs
and aspirations for their health and for health services.
18.4 We therefore offer some suggestions
that may help strengthen accountability and make GP commissioning
more responsive:
— a "responsiveness premium"
linked to judgements about quality may be useful;
— local HealthWatch should be able
to influence all aspects of the commissioning cycle and be able
to influence judgements about quality;
— a role for councillors to scrutinise
their political leadership and the way that Consortia work at
practice, neighbourhood and organisational level should be retained
and assured;
— democratic legitimacy through involving
non-professionals on GP consortia boards could be strengthened
through:
— the Care Quality Commission should
have a clear role in monitoring the responsiveness of GP Consortia;
and
— metrics need to be developed that
enable responsive GP Consortia to be identified and rewarded,
while less responsive groups can be supported and developed.
November 2010
WEBLINKS FOR
BACKGROUND READINGThe
Anatomy of Accountability http://www.cfps.org.uk/what-we-do/publications/cfps-health/?id=37
Accountability Works!
http://www.cfps.org.uk/what-wedo/publications/cfps-general/?id=128
Whose NHS Is It Anyway?
http://healthcaregovernance.typepad.com/files/whose-nhs-is-it-anyway.pdf
Green Light http://www.cfps.org.uk/what-we-do/publications/cfps-general/?id=118
Scrutiny of Practice based Commissioning
http://www.cfps.org.uk/what-we-do/publications/cfps-health/?id=121
Practical lessons from health scrutiny
http://www.cfps.org.uk/what-we-do/health/expert-advisory-team/
http://www.cfps.org.uk/scrutiny-exchange/library/health-and-social-care/?id=2699
196 Weblinks for publications mentioned in the submission
are at the end. Back
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