Written evidence from The Moore Adamson
Craig Partnership LLP (CFI 17)
NO COMMISSIONING FOR ME WITHOUT ME
1. SUMMARY
1.1 The Bill must make a clear distinction about
different types of accountability within the Health Service: accountability
to patients as individuals is one thing, accountability to the
public as the "moral owners" of the service is another.
The ways in which people should be involved in decision-making
are different in each case.
1.2 Patient and public engagement should begin
where the people are: in GP practices and information gathered
there should be aggregated up to higher levels as required.
1.3 Patient and public engagement has value and
credibility only if it can be clearly shown that is has a direct
impact on the provision of services. It must not become a tickbox
exercise and an end in itself. In their role as commissioners
GPs now have a new duty to involve the public as well as patients
and this means talking to the well, the young and those who are
not well known to the practice or frequent users of its services.
1.4 Patient participation groups in practice
can be very useful but require an ongoing investment of time and
energy if they are to be sustainable. There are many other ways
to find out what people are thinking.
1.5 Consortia board membership needs to include
representatives of both patients and the public. It is important
that they represent a significant proportion of the membership
and that the culture of the board ensures that they do not play
a tokenistic role.
1.6 Local HealthWatch must have a central role
in commissioning but should not be seen synonymous with effective
patient and public involvement which can only be achieved through
practices and consortia working directly with their own patients
and users of their services. We strongly oppose HealthWatch taking
on direct responsibility for complaint handling or complaint advocacy.
1.7 In order to address health inequalities it
is vital that commissioners at all levels find ways of involving
people who are on the margins and whose voices are not easily
heard. This challenge will be met only by close partnership working
in localities.
1.8 We fully support calls for an independent
health scrutiny function separate from whatever scrutiny powers
are taken on by the HWBB. This LA function should involve not
just elected councillors, but independent lay people appointed
as "assessors" to the scrutiny committee.
1.9 Joint working between health services and
councils will only work if there is an acknowledgement of the
culture differences between them and a determination to change
the culture of both.
2. BACKGROUND
TO THE
MOORE ADAMSON
CRAIG PARTNERSHIP
LLP (MAC)
We are an independent consultancy which specialises
in user and public participation in a range of areas where decisions
are made that have a direct impact on peoples' lives. At present
we have a particular focus on health and education.
We train lay and user participants and we support
service providers in increasing and improving public involvement
in the design and delivery of public services. In recent years
we have worked with Primary Care Trusts, GP practices, GP consortia,
Foundation Trust governors and a wide range of patient groups
including Local Involvement Networks (LINks) to promote effective
user and public engagement in health service delivery.
As individuals, all our partners are active participants
as well as consultants, investing their time in membership of
participatory bodies such as a GP patients' liaison group, a community
health services Provider Board and a residents' right to manage
company, and as a lay member on the PEC of a PCT.[21]
3. ACCOUNTABILITY
IN THE
HEALTH AND
SOCIAL CARE
BILL
With our focus on user engagement in health services,
we welcome the stated aim of the Bill to increase and improve
public and patient involvement in the design and delivery of services.
However, we remain unconvinced that the Bill as currently framed
will in fact bring this about. We support the principle of "no
decision about me without me" but would like to see it extended
into "no commissioning for me without me".
The NHS Constitution says that the NHS belongs to
the public but fails to elaborate on what this ownership means
in practice. The fundamental confusion about what accountability
means in relation to the health service is reflected in the Bill
and as a result GP consortia stand to be pulled in numerous different
directions by the National Commissioning Board, the local health
and wellbeing board, possible overview and scrutiny and (lest
we forget) the patients and the public.
The Bill fails to make a clearer distinction between
the accountability of a clinician to a patient and the accountability
of the NHS to the public. Although inter-related, they are not
the same thing and people will respond differently depending which
role they are fulfilling.
In our work with practices we increasingly find it
useful to encourage service providers to think of patients and
their families as customers and to develop their services with
the needs of these customers in mind. This takes the relationship
away from one of dependency to one of service and quality in which
patients have choice and influence: one where what matters to
the patient matters to the doctor whether it is the colour of
the wallpaper in the waiting room or the quality of end of life
care.
The relationship between GP commissioners and the
public they service is entirely different. This is a relationship
in which the public should be seen as the "moral owners"[22]
of the service as a whole and where the governance relationship
is about commissioners making decisions about how money is spent
in partnership with, and on behalf of, the public.
4. START AT
THE BOTTOM:
IN GP PRACTICES
The emphasis on responding to the views and needs
of patients means that we have to start where the patients are.
GP practices provide one of the most useful proxies for the local
patient population and it is our view that both patient and public
involvement in the health service needs to start in practices.
Bearing in mind the caveat mentioned above about
the interests of patients and the public often being different,
new commissioning arrangements mean that practices will need to
start seeing the people on their lists as both patients and members
of the public. It will therefore not be enough to engage only
with the sick, those with long term conditions and those who regularly
attend the practice. Practices will also need to find ways to
engage with the well populations on their list, the young and
those who seldom visit their GP, and to talk to them in their
role as moral owners of the service as well as recipients care.
Information gathered in practices should be aggregated
up to consortium level and to higher levels such as the local
authority or nationally as required by the different needs of
commissioning.
5. INVOLVING
PATIENTS AND
THE PUBLIC
IN DECISION-MAKING
AT ALL
LEVELS
The key to all successful involvement in decision-making
is for the focus to be on the ends rather than the means. There
is a tendency in the NHS to focus on processes and new initiatives
without measuring their impact. This has been particularly noticeable
in the area of patient and public involvement/engagement in recent
years. Unless public and patient involvement can be shown clearly
to have influenced outcomes then it should be deemed to have failed.
It is vital to demonstrate clearly to people that their input
has been taken into account. Conversely, repeatedly failing to
act on the intelligence which patients and the public provide
has the effect of making people cynical.
"Involvement" activity becomes a "tickbox"
exercise and an end in itself resulting in initially highly committed
people becoming disinclined to engage and more likely to be publicly
critical. As these people often have complex and influential networks
within local communities this can be very damaging both to reputation
and morale for providers and commissioners.
6. LOOKING BEYOND
PATIENT PARTICIPATION
GROUPS
Debate about how best to involve patients (and the
public) in GP practices often focuses on patient participation
groups (PPGs). Our experience has shown us that such groups can
work well but they are few and far between and those which succeed
depend very heavily on the support of key individuals within the
practice, usually a practice manager or one committed GP. On the
whole however practices find these groups hard to sustain and
demanding of time and energy.
Many GPs are resistant to setting up such groups
because they believe that they are unrepresentative of patients
and a whole and that they focus on the "wrong" issues.
Whilst we would not necessarily agree with this analysis we recognise
that such perceptions take time and effort to overcome.
We are in favour of such groups where they can be
made to work well: group members are often highly committed and
have much to offer representing not only their own interests but
those of others very effectively. With the right support and investment
in their capacity to deliver, PPGs are capable of informed debate
and of making important contributions on a wide range of issues
from the day-to-day delivery of care to high level commissioning
decisions.
However, without considerable ongoing support and
the dedication of significant resources such groups can become
and both expensive and unproductive. We are well aware of the
frustrations often felt by patients and members of the public
who are members of groups that do not function well and where
their input is not valued and used.
It is vital that the processes which are established
ensure "penalty free" participation and that people
are able to see how they are making a difference. The question
of reward and recognition for lay people needs serious consideration.
Although some people prefer to contribute their time on a voluntary
basis, others are unable to take part unless their basic expenses
are covered. At some higher levels payment should be considered
both because it demonstrates that the individual's input is valued
as highly as that of the other paid people in the room and because
it increases the likelihood of attracting high calibre individuals
and those not in the sort of paid employment that allows them
paid time off work for such activities. Another important benefit
in kind which should be afforded to lay people is high quality
training and opportunities for personal development including
appraisal and feedback. Lay people contributing to practice groups
and other time-consuming activities such as focus groups should
be treated as valued members of the team whether they are paid
or acting in a voluntary capacity.
Although patient groups will have their place in
some practices, the onus should be on practices both as providers
and commissioners to develop other and different approaches to
seeking patient input such as texting, virtual groups, social
networking and other simple methods for staff to gather feedback
directly from patients.
7. GOVERNANCE
ARRANGEMENT IN
CONSORTIA
The governance models adopted by commissioning consortia
should start from the basis that patients and the public are the
moral owners of the services. We therefore support the views put
forward by other respondents that the boards of consortia need
to be constituted in such as way as to ensure that the interests
of the wider population are foremost. We are concerned that, as
with current NHS governance arrangements, there is a risk that
board decision-making will be dominated by clinicians and managers
keen to ensure that their particular specialisms and interests
are represented. If this happens the public interest will inevitably
take second place.
We are strongly of the view that the boards of consortia
must not have tokenistic representation of patients and the public.
There is little value in having one "lay" person at
table full of professionals and it is an invidious position for
any individual to be in. But even with a majority of lay and public
members (such as on PCTs) it can be seen that clinical and executive
status and expertise trumps lay and public status in very many
cases. This will only be changed if there is a significant shift
in attitudes and behaviours of boards and as this will be new
territory for many GP commissioners there are opportunities to
make such changes from the outset.
In our "bottom up" model described above,
we would see public and patients in practices represented on the
board. There has been much emphasis on clinical and managerial
leadership in GP commissioning and we would like to see this complemented
by strong lay leadership which is valued and supported by commissioners
and nationally. Lay leaders will need recognition, support, training
and rewarding - just like their opposite numbers.
No matter how boards are constituted in terms of
the individuals who sit on them, the important thing is that there
is an constant onus on the whole commissioning process to make
decisions based on proper health intelligence gathered from a
range of sources of which public and patient views and experiences
form an important part.
While many methods can (and should) be used to gather
this information it is what is done with the data that matters
most. Patient experience data and patient and public views should
be gathered systematically both by providers and by commissioners.
8. INTEGRATION
BETWEEN HEALTHWATCH
AND OTHER
PATIENT/LAY
INVOLVEMENT
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 patients.
We have argued strongly against Local HealthWatch
(LHW) taking on a direct responsibility for complaints handling
or complaints advocacy, as such functions would skew LHW's main
purpose.
HealthWatch England as a subset of the Care Quality
Commission needs to have a strong and clear remit - complementary
to that of the National Commissioning Board - to ensure that effective
patient and public involvement happens in each consortium and
HWWB in England.
9. INVOLVEMENT
TO ADDRESS
HEALTH INEQUALITIES
HealthWatch, GP practices, local commissioning consortia
and local authorities should all be finding new and better ways
of gathering the views of those whose voices are seldom heard.
Many of these will be the people most affected by health inequalities.
There should be a requirement to demonstrate that this is happening
and that these people are having a direct impact on service planning
and delivery. This work presents real challenges but this is an
area where close working with other agencies (social services,
education and 3rd sector bodies etc) will pay real dividends.
10. LOCAL GOVERNMENT
SCRUTINY OF
HEALTH SERVICE
We fully support calls for an independent health
scrutiny function separate from whatever scrutiny powers are taken
on by the HWBB. This LA function should involve not just elected
councillors, but independent lay people appointed as "assessors"
to the scrutiny committee. These assessors should be publicly
recruited to a uniform job description rewarded on a national
basis consistent with local authority best practice. They should
be accountable to their appointing Council for discharging their
function fairly and impartially.
11. GPs Commissioners and Local Authorities Working
Together
There are significant cultural differences between
Councils and health services and although there are examples where
LAs and PCTs have worked well together they are still the exception
because of differing cultures. Joint strategic planning will have
no impact unless the culture can be changed. Where GPs are concerned,
for many, their Council is foreign territory even though they
depend on its social care and other social services functions
every day. It is therefore going to be very important for Councillors
to get out and visit the new commissioners.
The JSNA process will act as a unifying experience
and the positioning of public health with LAs will assist the
process, since nothing can be achieved without public health intelligence.
This is the key ingredient to put with user-led intelligence to
achieve intelligent commissioning.
February 2011
21 For further information about MAC partners and to
read our blog, visit www.publicinvolvement.org.uk Back
22
We borrow this term from Carver Policy Governance® model which
aims to promote owner accountable, ethical and effective governance. Back
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