Written evidence from Terence Lewis, Lewis
Governance (COM 31)
I am a Chartered Secretary. Governance is a
board level activity. My business is to identify the causes of
poor corporate performance and to correct these through effective
governance. Central to this is ensuring a proper prioritisation
of stakeholder interests within the board governance structures.
Many performance failures within the NHS that affect the patients
experience of care can be traced to poor commissioning of services.
This is largely due to the commissioning process receiving little
input from the "customer" and is compounded by the almost
total absence of any NHS trust board level accountability to this
stakeholder constituency for quality, choice or the patient experience.
Hence, poor governance.
Even in the area of clinical governance, post
Bristol and Shipman, there have been too many examples of governance
process failures—with severe consequences for the patient—culminating
in Mid Staffs.
My following first-hand experience within the
Department of Health and the NHS informs this submission:
2001-06 PCT non-executive director.
2004-07 Non-executive director, directorate level,
Department of Health.
2006-07. White Paper Task Group member, Our Health,
Our Care, Our Say.
2007-09 Deputy Chair, Commission to Review Mental
Health Services in the North West.
2008-09 Next Stage Review
Since 2000, a major focus to secure delivery
of the NHS Plan, along with value for money from the investment
being made and committed, was to be the commissioning process.
Significant policy points in policy development
to improve commissioning were Shifting the Balance of Power, Commissioning
a Patient Led NHS, World Class Commissioning and the Next Stage
Review.
Each of these policy initiatives had at its
centre the creation of a service that would be patient centred
and locality sensitive, and commissioning was intended to secure
these objectives.
World Class Commissioning established 11 competencies
that were required of Primary Care Trusts. These were:
2. Work collaboratively with community partners.
3. Engage with the public and patients.
4. Collaborate with clinicians to inform strategy,
service design and resource utilisation.
5. Manage knowledge and assess current and future
needs.
6. Identify and prioritise investment requirements
and opportunities.
7. Stimulate the market to meet demand and secure
outcomes.
8. Drive continuous improvement in quality and
outcomes through innovation.
9. Secure procurement skills that ensure providers
have appropriate contracts.
In the three years since WCC became operational
as policy, performance reviews have been undertaken by Strategic
Health Authorities. These have revealed poor levels of performance.
The most recent, published last month, again shows disappointing
performance and against competency 3 little progress at all.
Competency three requires PCTs to:
Proactively seek and build continuous and
meaningful engagement with the public and
patients, to shape services and improve health.
Why do PCTs need this competency in order to become
world class commissioners?
PCTs are responsible through the commissioning
process for investing public funds on behalf of their patients
and communities. In order to make commissioning decisions that
reflect the needs, priorities and aspirations of the local population,
PCTs will have to engage the public in a variety of ways, openly
and honestly. They will need to be proactive in seeking out the
views and experiences of the public, patients, their carers and
other stakeholders, especially those least able to act as advocates
for themselves.
No where has the letter or spirit of this competency
been delivered. Consequently, the services improvements and changes
identified by patients and the public and incorporated into Our
Health, Our Care, Our Say were frustrated. The public consultation
around this White Paper was the most comprehensive ever.
Competency 3 was seen as having a significant
role in securing local leadership, close working between social
care and health, innovation, market stimulation, more 3rd sector
services, contract delivery and compliance and VFM. In much the
same way as the customer influences similar domains in the private
sector.
The failures to truly engage patients in commissioning
choices and the measurement of service quality are acknowledged
in the current WP Equity and Excellence Liberating the NHS. Indeed,
the value of several of the competencies of WCC, together with
Lord Darzi's recognition that the patient experience must be one
of the three key measures of service quality, are to be found
in White Paper. Equally, it is recognised that those at present
holding responsibility for the delivery of commissioning competencies,
and the audit of quality outcomes, have fallen short. Key competencies
have not been abandoned but accountability for their delivery
has been made clear and placed in other hands. The following extracts
from the WP and commissioning consultation document illustrate
these points:
NOTHING ABOUT
ME WITHOUT
ME.
— ..compared to other sectors, healthcare
systems are in their infancy in putting the experience of the
user first, and have barely started to realise the potential of
patients as joint providers of their own care and recovery. Progress
has been limited in making the NHS truly patient led. 16 We intend
to put that right.
— The new NHS Commissioning Board will
champion patient and carer involvement, and the Secretary of State
will hold it to account for progress.
— Information generated by patients themselves
will be critical to this process, and will include much wider
use of effective tools like Patient-Reported Outcome Measures
(PROMS), patient experience data, and real-time feedback.
At present, PROMs, other outcome measures, patient experience
surveys and national clinical audit are not used widely enough.
We will expand their validity, collection and use. The Department
will extend national clinical audit to support clinicians across
a much wider range of treatments and conditions, and it will extend
PROMs across the NHS wherever practicable.
— We will also encourage more widespread
use of patient experience surveys and real-time feedback. We will
enable patients to rate services and clinical departments according
to the quality of care they received, and we will require hospitals
to be open about mistakes and always tell patients if something
has gone wrong.
….. patients will be at the heart of everything
we do. So they will have more choice and control, helped by easy
access to the information they need about the best GPs and hospitals.
Patients will be in charge of making decisions about their care.
COMMISSIONING CONSULTATION
DOCUMENT
Patients and the public
6.1 One of the principal aims of GP commissioning
is to make decisions more sensitive and responsive to the needs
and wishes of patients and the public. Good communication and
engagement with the public will, therefore, be vital. Both GP
consortia and the NHS Commissioning Board will need to find and
evolve efficient and effective ways of harnessing public voice
so that commissioning decisions are increasingly shaped by people's
expressed needs and wants.
This is the central theme of NHS commissioning—understanding
the health needs of a local population or a group of patients
and of individual patients; working with patients and the full
range of health and care professionals involved to decide what
services will best meet those needs and to design these services;
creating a clinical service specification that forms the basis
for contracts with providers; establishing and holding a range
of contracts that offer choice for patients wherever practicable;
and monitoring to ensure that services are delivered to the right
standards of quality.
For the past decade, commissioning responsibilities
have largely rested with primary care trusts (PCTs) and to some
extent the primary care groups that preceded them. The previous
Government made belated attempts to strengthen PCT commissioning
through its programme of "world class commissioning".
But the weaknesses of the system have lain much deeper than the
capacity of staff working in PCTs. Commissioning has been too
remote from the patients it is intended to serve.
Our proposals for GP commissioning and the NHS
Commissioning Board mark a fundamental break with this past. Most
commissioning decisions will now be made by consortia of GP practices,
free from top-down managerial control and supported and held to
account for the outcomes they achieve by the NHS Commissioning
Board. This will push decision-making much closer to patients
and local communities and ensure that commissioners are accountable
to them.
As can be seen from WCC and the Next Stage Review,
the commitment to the accountability of the NHS to the patient
for commissioning decisions, and the quality of services, has
grown stronger. Yet little has changed in terms of patient input
or influence. The causes of failure in this part of the "business"
are significantly rooted in the absence of significant consequences
for the trust. Consequently performance in this domain is of little
importance to the board.
It is my experience that the disconnection between
policy and practice can occur when policy is "interpreted"
by stakeholders before being implemented by the Service. Those
occupying senior positions within stakeholder groups will frequently
have followed a similar career route through the NHS and it would,
perhaps, be surprising if they were not to share a preference
for "company solutions" when deciding these questions.
This interpretation of policy, and the timescale
for its implementation, can take place in a range of ways The
exchanges involved can occur in places and ways that do not include
patients and carers, or where they have only a token presence;
by this I mean, lacking the resources and support to have an equal
and authoritative voice.
This is a most unsatisfactory situation. If
the unambiguous commitments made to patients by the Government
in the White Paper are to be kept, then the patient must be enabled
to support the Government in achieving the service modernisation
and improved outcomes it wishes to see. First, this will require
enabling patients to make an informed and authoritative contribution
to commissioning decisions. Secondly, it will require making the
Commissioning Board accountable to patients through the SoS for
patient involvement in commissioning. Thirdly, the CQC, GPs and
service providers will be responsible to patients for the quality
of commissioning and service outcomes. With the demise of SHAs
there will be no other stakeholder to monitor these matters. These
measures would have the effect of making the priorities of the
patient stakeholder as significant as those of others. If it is
clear to an organisation that the patient experience is as important
to the determination of its performance as, say, balancing the
books, governance to achieve these objectives will follow. To
develop this point may I make the following comments?
Good governance ensures an organisation secures
sound performance in those areas that will affect its standing
in the judgement of stakeholders. Loss of this confidence can
affect an organisation's survival. A key part of this process,
in both public and private sectors, is ensuring that, de facto,
the customer/patient is an ever presences at board meetings, because
confidence in the organisation in this group of stakeholders is
key to its success. The NED has a pivotal role in this, but in
my view boards of foundation trusts have been constructed with
too strong a business and financial bias at the expense of patients.
This model has been replicated in many PCTs. I believe the consequences
of this are evident from the allocation of responsibilities in
the White Paper. In my view, it is imperative that NHS boards
contain, as well as a range of other expertise, NEDs who "know
that business", understand, value and espouse the public
service ethos and whose responsibility it is to secure the confidence
of the patient stakeholder group in the Trust.
This would not undermine the efficient running
of the Service, but would ensure the interests of all stakeholders
are given equal value in the decisions made about services and
their delivery. My interest is primarily in the field of mental
health, but I believe my experience there and the conclusions
I have reached, hold true in other parts of the system.
It has long been my belief that DH writes good
policy that reflects the priorities of a government that has won
the right to act in our name. However, as I have indicated, this
is not the end of the story. Good policy before being implemented
is often interpreted by key stakeholders—a process from
which patients can be excluded.
The interpretation of policy, and the timescale
for its implementation, will take place within and between the
Department of Health, the NHS, regulators and organisations representing
other stakeholders, and they will take place in ways and places
from which service users and carers can be excluded or have only
a token presence. If this situation persists, not only will users
of services continue to be discriminated against, but will once
again see policy "watered down". As serious, will be
the dilution of dynamic policy intended to increase the influence
of patients in the commissioning and provision of services; and
to enable them to hold to account—the role of the "customer"
in all parts of the private sector.
To address this key issue, an organisation to
represent users and carers needs to be funded and established
at national level. Such an organisation would replicate for patients
and families the ability to establish the professional skills
and knowledge to represent their interests and equal to that at
the disposal of other stakeholders in advocating for their constituencies.
I would suggest that Healthwatch be established in this way.
The disadvantage at which patients presently
find themselves in this respect, enables the potential for policy
such as WCC, HQCfA and now the White Paper, to improve services
and re-align the prioritisation of stakeholders, to be frustrated,
Instead a "company solutions" is developed without the
challenge such a patient body would provide.. These solutions
often require less "stretch" for organisations in terms
of ways of working, innovation, identifying new providers, being
absolutely clear about VFM and ensuring the quality of the patient's
experience is at the heart of governance to assure quality services.
In the private sector solutions to meet the need for change, and
the challenges this presents, must have the interest of the "customer"
at their heart. In the process, a significant degree of impact
on the interests of other stakeholders may have to be accepted.
In the public sector, there often is poor first focus on the patient's
interest due to lack of impact on the organisation arising from
a poor patient experience. Regulation has a significant role to
play on behalf of the patient, but regulators must be clear about
that they are measuring the quality of performance with a significant
focus on those outcomes important to patients.
It is to be welcomed that the CQC annual "health
check" is to be discontinued and instead inspections will
be in response to "real time" intelligence from patients
and families on the quality of services and their experience of
them. The situation revealed in the Francis report makes clear
that dynamic and informed patient participation must be secured.
Systems are already in place to make this possible.
October 2010
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