Category Archives: Democracy

Democratic control of NHS

I want to make an extended argument this morning about the importance of governance and accountability in the provider sector. And then explore what we need to do to safeguard that governance and accountability as we add a needed focus on local systems to our current focus on individual providers.

It’s worth starting by reflecting on why governance and accountability matter in our world.

They matter because:

• Providers are spending £70 billion of taxpayers money, 9% of all public spending;
• The services providers deliver are central to the communities they serve;
• In each of those communities, providers are one of the largest local employers and often the largest public sector employer;
• An NHS provider is one of the few organisations in our national life where treatment, care or support for ourselves and our loved ones can irrevocably and profoundly change our lives – for the better, and sometimes, sadly, for the worse;
• And healthcare is also a high risk part of our national life where providers need to reduce avoidable mortality and avoidable errors and where it is right that they should give appropriate account when things do go wrong. And this is an environment where things can, do and, to a certain extent, probably always will, go wrong given the level of risk involved.

How providers have developed effective governance and accountability mechanisms

I’m struck, as a relative newcomer to the NHS, by how much time and effort NHS foundation trusts and trusts have invested in developing effective corporate governance and ensuring appropriate accountability for what they do. And, by and large, how effective and well developed governance and accountability mechanisms in the provider sector now are.

The time and effort that has gone, for example, into creating effective unitary boards that confer identical rights and liabilities on executives and independent non-executives.  This means executive directors can be challenged by both their peers and independent non-executive directors as part of the continuing business of the board.  This allows boards to hold the executive effectively to account as part and parcel of its regular work, rather than as a bolt-on, which is often the case in other governance models.

The investment in an extensive set of Board sub committees that spend appropriate time scrutinising and assuring the detail of what is going on at ward and service level. The robust and rigorous quality assurance frameworks that look at patient experience and service quality. The effort invested in engaging and supporting frontline staff, to encourage them to raise issues of concern candidly in a spirit of improvement, not blame.  The gathering and scrutiny of extensive data to see what is happening at patient level, for example rigorous interrogation of HSMR and SHMI data to assess avoidable mortality. The time invested in assessing, managing and mitigating the ever present risk across what are very large and complex organisations.

For Foundation Trusts, the development of a whole new governance model of members and governors to ensure that the board is accountable and responsive to its local community. For all providers, the time invested in meeting the requirements of a wide ranging set of accountabilities: to commissioners; to regulators and system managers like NHS Improvement and the CQC; to local health and wellbeing boards and scrutiny committees; and, in the case of FTs, to parliament itself.

I deliberately rehearse the list at length because I think it’s important everyone in the service understands just how much time and effort has been and is being expended to ensure that governance and accountability in the provider sector are effective and fit for purpose.

Adding a local system focus to the focus on individual institutions

All of this activity has, of course, been focussed on individual provider institutions. That’s not entirely surprising given the emphasis the policy framework has placed on provider autonomy, patient choice, and appropriate competition between providers. The individual provider has been the lynchpin, the focal point, the centrepiece of the system, with a matching degree of focus on the individual CCG.

But we are now heading for a different policy framework with a different set of emphases. A framework where the local system, not the individual provider, is the focal point. Where secondary care, primary care and social care are much more integrated. Where competition between providers is replaced by collaboration between them, across a wider geographic footprint. Where the organisational focus is on accountable care organisations, MCPs, PACS, federated provider boards and Devo governance mechanisms covering whole regions rather than individual providers and CCGs.

We are pursuing this direction of travel at high speed. The Five Year Forward View set out the vision. The STP process is designed to create the strategic plans. The vanguards and Devo Manc are piloting ways of getting there. The 2016/17 planning guidance set out the early steps everyone has to follow. And the new NHSI oversight framework includes a whole domain, one of five, to assess how providers are enabling strategic change at a local system level.

More than that, all kinds of new ideas are now floating around. Combined authorities as a potential new organisational form. System control totals as a new way of allocating money. Acute bed days per thousand head of population as a new way of measuring performance. The STP process as a new way of overriding individual provider veto of plans that other providers support.

We mustn’t leave governance and accountability behind in the rush to local systems

The problem I want to highlight today is that I think we’re in danger of leaving the governance and accountability behind. In the words of one chief executive, whilst the vision, the strategy, the planning and, increasingly, the proposed delivery are hurtling towards the world of local systems, governance and accountability are still stuck in the world of individual institutions.

I think this carries significant risk.

If we are to move to new care models, if we are to adopt new integrated organisational forms, if we are to deliver services effectively across a wider geographic footprint we have to ensure that the governance of service delivery and the accountability for that service delivery remain robust and effective.

This means maintaining our investment in good corporate governance by organisations but developing a more robust approach to governance between organisations and being clearer on lines of accountability at the local system level.

And although the current narrative emerging from the centre sometimes implies that we are moving from an individual institutional focus to a local system focus, the reality is that we need both. It’s not an either/or. We have to find ways of making governance and accountability for individual institutions and local systems complementary not mutually exclusive.

Worrying about governance and accountability isn’t pedantry

I know that some in the centre think that raising these issues is being pedantic, legalistic or is a way of blocking change. It isn’t. Good governance and clear accountability allow risk to be managed and mitigated. They need to be developed thoughtfully at times of peace to enable us to manage effectively in times of trouble.

We all understand the need for that local system focus. That’s why so many providers are leading vanguards. That’s why, in most places, providers are the key driving force behind the STP process. And that’s why providers are at the front of developing new organisational forms be it the Royal Free developing a provider chain, Salford developing an accountable care organisation or Southern Healthcare developing an MCP with its local GP federation.

Important questions that must be answered in adding a local system focus

But many of you are now asking questions about governance and accountability in these emerging structures that need urgent answers:

• What happens if an STP footprint develops plans that require an individual provider to sacrifice its individual interests for the greater good of the local system as a whole – how is that reconciled to the provider Board’s, its NEDs’ and its Governors’ statutory duties?
• What happens if some parts of an STP agree to a plan but others don’t? How far and when is it reasonable for the interests of an individual provider to be trumped by the needs of a wider local system?
• How much and what delivery will be put through STP footprints when?
• How will accountability actually work if money and delivery is allocated, managed or measured at the level of a local system rather than an individual institution?

These are just a few questions from a more extensive list. Urgent work is now needed to
develop robust answers to them.

If this work isn’t done there is a danger that while providers are prepared to plan at an STP footprint level, because it’s just a plan, they won’t be prepared to deliver services, handle money, agree to service reconfiguration, or be held to account for performance at that local system level. In other words, we can’t do what we now need to do without some concentrated work on how governance and accountability will function with this new, additional, focus on local systems.

Principles for answering the key questions on governance and accountability

How do we go about answering these questions and doing this work? I would like to finish by suggesting three principles:

Co-production between local and national
The first is that any work must be co-produced by the centre and local institutions. Too much of the existing policy structure has been developed by the department and its arms length bodies without appropriate consultation with frontline organisations. Front line organisations have the statutory responsibility for local delivery and they have to make the framework developed by the centre work on the ground. It is vital that skills and expertise are pooled. Particularly when much of the expertise, knowledge and skill on governance and accountability resides in provider boards and other local organisations. It doesn’t sit at the centre.

Compliance with the law
Secondly, the answers we develop must have a sound and explicit legal basis.  While we all understand the wish to avoid primary legislation, we simply cannot pretend that the 2012 Act does not exist.  In a complex and risk laden sector like health care, front line boards must have the protection of a governance and accountability framework that is compliant with the law. We all know that when things go wrong, which is likely to happen more frequently if we are experimenting with new ways of working and as the overall strategic environment deteriorates, the first recourse is the law. What were the legal responsibilities and have they been met? Our system leaders need to acknowledge that provider board directors have duties set out in statute that cannot be wished away or ignored. If we don’t have a legally compliant framework we are exposing our senior leaders to unacceptable risk. And when we do the difficult things we know we have to do, like reconfigure services, they will simply fall apart in our hands at the first legal challenge if they are not legally robust.

Replicate what works at individual institutional level
Thirdly, the principles of good governance we have already developed at individual institutional level should be reflected in the governance we now need to develop at a local system level. These include appropriate autonomy from the centre; clear lines of accountability, including to local communities; appropriately robust and detailed assurance and risk management systems and processes; and a degree of independent challenge from a non executive function. A number of you have rightly pointed to these as significant issues in the current STP planning process governance. Chairs and NEDs, for example, have been unclear about the role they should be playing here.

The role that NHS Providers will play

NHS Providers as an organisation will play its part in this important debate. We’ll continue to raise these issues at system level, even if they make us unpopular. We will develop provider sector thinking in this area as we will do with a separate session with Chairs at the end of today’s conference. We will discuss these issues in the relevant networks. We’ll incorporate these themes into the emerging Board Development Programme we have agreed to create with NHS Improvement. And we will continue to share good practice and emerging thinking on paper as we have done in the joint publication on lessons and tips from new care models that we are launching today with Hempsons and which you will find on your chairs.

This was first published on the NHS Providers site

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North West Leicestershire is about to publish its Local Plan. An inch thick, this pedestrian document tells us that this Council will co-ordinate a wide range of other organisations to ensure infrastructure is provided at the right time and in the right place to absorb the impact of new housing developments and provide for the health needs of people moving into the area.

The best predictor of future behaviour is past behaviour.

At a recent Policy Development Group, a cross-party committee of elected Members pursued the fate of £1.3M of developer contributions for health that remained unspent, some of it at risk of being paid back.

Lacking a root cause analysis local GPs, NHS England and Council planners were involved in a blame game. The tangle of red tape, risked developers laughing at the public sector as they re-pocket money returned with interest.

Teasing this mess apart has allowed some funds to escape the log-jam and NHS England we are now spending some s106 money on Long Lane Surgery in Coalville and on a surgery in Measham. But I am not taken in by this snippet of good news. Nor do I trust in future solutions such as moving to a Community Infrastructure Levy. My GP informants still describe a legal system that makes easing this money out of the bureaucracy so difficult that most clinicians give up.

Remaining focused on funding GP premises, when so much else is pushing healthcare into the abyss, is almost certainly not enough. A Local Plan with vision would look beyond the immediate needs of service providers, such as GPs to the wider determinants of public health.

Loneliness is a killer. Thanks to the developer-centric demands of the National Planning Policy Framework, the Council’s plans for cultural facilities in Policy IF2 grudgingly allow their expansion if the community can prove an increase in demand.

After the closure of the iconic Snibston Discovery Museum perhaps I should not complain that the Plan appears to major instead on preventing existing community buildings from being demolished.

My colleagues in public health should be pleased to see that the Plan does have a detailed section on transport infrastructure. The Royal College of Physicians reports that there are 40000 deaths a year due to poor air quality mostly from exacerbations of asthma and COPD. We know that we have road junctions that repeatedly breach air quality guidelines including the Copt Oak and Broom Leys junctions.

According to the RAC North West Leicestershire along with neighbours South Derbyshire are in the top 10 Districts where working people are obliged to use their private car to go to work.

It is axiomatic that wealthier communities are healthier communities. Ensuring people in North West Leicestershire can access properly paid employment has to be a key public health strategy.

In supporting this Plan going forward for consultation, I am therefore particularly pleased to support Policy IF5 in which North West Leicestershire, in direct contrast to the County Council, commits itself to supporting the provision of public transport on the Leicester to Burton line.

Providing East-West connectivity and putting the former mining town Coalville of back on the railway map, as HS2 looks increasingly unaffordable, it would be good to get national support for this important public health intervention.

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THE CASE FOR A SECOND CHAMBER WHICH WOULD ADD SOMETHING TO PARLIAMENT AND PROMOTE EMPOWERMENT

THE PROBLEM

The House of Lords is a large unelected body commanding little legitimacy.

THE CONVENTIONAL SOLUTIONS

  1. Make it a smaller elected body.

OR

  1. Abolish it

WHY NOT THE CONVENTIONAL SOLUTIONS?

Either of them would ensure that Parliament consisted exclusively of full time politicians owing their place to party political processes.

This is hardly empowering.  This is not the mood of our times.

THE ALTERNATIVE SOLUTION

A Second Chamber which consists entirely of people who are NOT FULL TIME POLITICIANS.

  • That doesn’t mean that they can’t be elected.
  • It doesn’t mean that they can’t be part-time politicians.
  • It does mean that they must live a life in which Parliament is a small part – a voluntary form of public service, rather than a job.

HOW COULD THIS WORK?

500 seats each shared by 24 people (12,000 people in total) attending for 8 hours a fortnight would create a Chamber that could meet for 16 hours a day (8am to midnight) six days a week

HOW WOULD IT BE ELECTED?

This proposal is compatible with any of the electoral methods proposed – you just elect more people. However the considerable increase in the numbers to be elected does open up new opportunities.

A POSSIBLE ELECTORAL METHOD

The following is an electoral method which takes advantage of the much larger number of people involved in a part time chamber to combine some of the competing electoral proposals.

As just one possibility

Out of 12,000 people sharing 500 seats we could have

A fifth (2,400 people sharing 100 seats) elected by the method advocated by Billy Bragg, seats allocated to political parties in proportion to the votes they receive

  • Political parties receiving more than 1% of the vote would receive a number of seats proportionate to the number of votes.

  • For a transitional period the party’s life peers would have a claim on these seats but no new political life peers would have this right.

  • After the transition

    • up to a quarter of the seats would be nominated by the party,

    • up to a quarter would be indirectly elected by the party’s elected representatives and governing bodies,

    • at least a quarter would be elected by the party’s members and

    • at least a quarter would be elected by the entire electorate in a geographical single member constituency (a sort of open primary but after the General Election not before it)

  • Each party group would make its own arrangements to rotate attendance

A fifth (2,400 people sharing 100 seats) elected by STV with quota to link national and local government. This is the Senate of Regions and Nations idea made more local still (taken down to district level) and linked to the idea of election by STV with quota

  • Electing 2,400 people means 1 representative per 27,000 people (about 23,000 electors).

  • This means that it is possible to use district councils as constituencies and still have multi-member seats in which STV can work.

  • Those elected could serve on the council as well as in the House of Lords – the title alderman could perhaps be revived.

  • In two tier areas they could serve on both the district council and the county council – indeed in large counties they might entirely replace county councillors.

  • In devolved nations some arrangement could be made, appropriate to the situation of the individual nation, to involve them in the national parliament. For example they could share a number of seats in the national parliament on the same 8 hours a fortnight basis as they use in the House of Lords

  • Some arrangement could also be made to involve them in devolved arrangements in regions

  • They could therefore knit together the different levels of elected authority.

  • They would form themselves into groups to arrange the rotation of attendance. The LGA would arrange the rotation of those who could not find a group

One tenth (1200 people sharing 50 seats) to consist of faith representatives

  • Elected by multi-faith partnerships

  • The established churches in England and Scotland could organise these partnerships and the rotation of attendance but have no other special role.

A fifth (2,400 people sharing 100 seats) to consist of a citizen’s jury (1,200 people sharing 50 seats) and its expert advisers (1,200 people sharing 50 seats)

  • Each month 90 jurors would be chosen by lot to serve for one year and 10 would be chosen by the National Jury, from amongst those due to leave it in the next three months, to have their term extended by a further year

  • The National Jury would appoint 1,200 experts to support it in its work. Half of these would be filled by 24 places (one seat) reserved for experts appointed from each of the major professions (Health, Finance, Law, Engineering, Architecture & Planning, Other Professions), scientific disciplines (Physical Sciences, Biological Sciences, Geographical & Environmental Sciences, Social Sciences, Applied Sciences, Other Disciplines) and bodies of knowledge of especial relevance to the work of a legislature (Economics, Public Finance, Public Health, History, Politics & Social Policy, Statistics & Interpretation of Evidence, Constitutional & Public Law, Human Rights, Ethics, Government & Public Administration, Politics & Political Philosophy, Policy Application of Science, Behavioural Sciences). The remaining 25 seats (600 individuals) could be appointed from any area of expertise or achievement.

  • For a transitional period existing non-political life peers would slot into expert places to maintain continuity and to reduce the number of appointments that need to be made at the outset.

  • An elected Secretariat of the National Jury, elected by the jurors, would arrange the rotation of attendance

One tenth (2400 people sharing 50 seats) to consist of youth representatives

  • Members in this category would attend once a month rather than once a fortnight to minimise disruption of education so 50 seats would be shared by 2400 people not 1200.

  • Half the seats would be filled by the members of the UK Youth Parliament and by former members for one term of office after leaving. The Youth Parliament would arrange the rotation of attendance.

  • The other half would be filled by student representatives. Seats would be divided proportionally between student unions who would arrange the elections by STV with quota. NUS would arrange the rotation of attendance

One tenth (50 seats, each shared by a number of people) to be filled by representatives of organisations chosen by the people.

  • Any organisation could stand other than a political party, an organisation with a political test of membership, an organisation formed primarily to influence a particular party, or a public body under the control of Ministers

  • To stand organisations would need either 100,000 members or 100,000 nominators (or a mixture of the two e.g. 60,000 members and 40,000 nominators who are not members)

  • Trade union and charity law would be amended so trade unions could stand whether or not they have a political fund and charities could stand

  • Voters would vote for 20 organisations. The 50 with the largest number of votes would appoint a group of people to rotate one seat

  • Elections could take place concurrently with the European elections.

One tenth (50 seats, each shared by a large number of people) to be filled by representatives of the major interest groups of the realm.

  • An Assembly would be created for each major interest group of the realm

  • Membership would be based on standing, achievement, representative function, office or election by a larger group and as far as possible would be automatic or by election not a special appointment

  • These Assemblies could be based on relationships to the economy (Land & Title, Capital, Labour, Management, Consumers), professions (Health, Finance, Law, Engineering, Architecture & Planning, Other Professions), bodies of knowledge (Science, Social Sciences, Applied Sciences, Other Disciplines, Universities, Schools), cultural movements (Arts, Media, Sport), honours (Life Peers, Other Crown Honours) types of public service (Administration, Advocacy & Dissent, Charities)

  • Each Assembly would meet monthly and identify two delegates to attend each meeting of the Chamber

As an optional extra, arrangements could also be made to allow the public to vote electronically, having watched the debate on television. Individuals unable to watch at the right time but wishing to participate could do so by appointing proxies.

This is an additional possibility. If 25,000 public votes equated to 1 vote in the House of Lords (rounded up for the option which obtained the most votes and down for the other) then the public vote would overtake the vote in the House when more than 12,500,000 people participated. A new participatory politics would emerge around the campaign to secure proxies.

SOME PROCEDURAL IMPLICATIONS

Business planning would need to be done at least a month ahead to allow members to make appropriate arrangements. Saturday afternoons could be reserved for urgent business which could not be planned a month in advance.

Speaker and officers It would be necessary to have a panel of deputy speakers and also to elect an Executive Committee to oversee organisational arrangements. Groups of members would also need whips and officers to arrange rosters or coordinate procedures. These members would be able to attend even when not rostered, although they would only be able to vote when rostered.

Existing life peers Political life peers (those appointed specifically as working peers and those who have held elected office or served as Ministers) would slot in as members of the delegation from their party. Special arrangements would be made for those whose party has ceased to exist or has ceased to be entitled to seats – two seats would be shared between these members. Crossbenchers would slot in as expert advisers to the National Jury. Individuals who have not been appointed specifically as working peers or held elected office or served as Ministers, but who have taken a party whip would be individually considered by the National Jury who would decide whether to appoint them as advisers or to treat them as political peers – those treated as political peers would join their party delegation.

New life peers In future life peerages would be an honour rather than a legislative appointment, although an Assembly of Life Peers would be one of the assemblies entitled to send two representatives to each meeting of the Chamber.

Participation by members who are not rostered Normally members who have good reasons for attending should be rostered to attend but it is possible to think of circumstances where this might not be possible, especially for members in small groups where several might have a reason to attend or where a member holds a dissenting opinion. To deal with this, the Speaker of the House of Lords should have power to invite an unrostered member to attend in a non-voting capacity if that member has business on the agenda or a specific and particular contribution to make or is a member of a committee which is meeting.

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We thought we had a political narrative on the shape of the NHS. David Cameron famously slams “pointless reorganisations” in 2011 but foolishly allows Andrew Lansley to run amok with his Health and Social Care Act in 2012. Jeremy Hunt is then brought in to steady the ship – Lansley having been deemed politically toxic – and we all settle down to making the 2012 structures work as best we can. Yet now we have a new kid on the block – George Osborne, chancellor of the exchequer – shaking up the NHS in revolutionary ways and with no scrutiny or transparency. What’s going on?

The starting point is Osborne’s surprise decision to devolve the £6bn NHS budget of Greater Manchester to a combined authority of the constituent local councils pending the arrival of a directly elected mayor in 2017 – a huge leap from the previous “city deals” that were confined to matters like planning and transport. The chancellor said this deal “set a trail for the rest of the country to follow” and, in responding to his recent arbitrary deadline for devolution bids, several combined local authorities have taken him at his word – Cornwall, Gloucestershire, Liverpool and London, among others, have all tabled bids to control their NHS funding.

This potentially amounts to an administrative revolution in the NHS that makes former shadow health secretary Andy Burnham’s pre-election proposals for stronger health and wellbeing boards look decidedly tame. The cities and local government devolution bill wending its way through parliament would, for example, give the secretary of state for communities and local government the power to transfer the functions and properties of other public bodies to these incipient, unelected combined local authorities. As things stand there is no exemption for NHS bodies from this clause.

We really need to start asking some serious questions about this silent administrative revolution:

What is the purpose?

Apart from some vague ideas about integrated care and service transformation, no clear reason for these changes has been expressed or debated. Indeed, since the various deals are undertaken as secret bilateral negotiations between central government and regional political elites, there is not even the opportunity to scrutinise and challenge whatever assumptions are being made.

Where are the providers?

Even in the case of Greater Manchester – the golden boy of devolution – the deal has been a secretive top-down arrangement between regional commissioners, national NHS agencies and the treasury. GP leaders in Manchester have described the announcement of the devolved NHS budget as “a total shock”, while third sector and independent providers of social care (accounting for almost all of it) have been completely sidelined. History tells us that top-down reforms alone rarely result in sustainable change at the frontline.

Where are the citizens?

In principle it would be reasonable to assume that devolution is something to do with empowering citizens of regions and localities, but democratic governance is absent. The public will be mystified at the multiplicity of directly unelected bodies like combined authorities and joint commission bodies running their affairs, and in due course greater control will be in the hands of a single directly elected mayor. The latter will certainly help to pinpoint responsibility but heroic leadership is a flawed model of governance. Already there is a wave of resistance in Greater Manchester by a range of activist groups, trade unions, MPs and the third sector. What sort of devolution deal has no seat at the table for citizens?

Where is the money?

It is far from clear who will hold the purse strings in a devolved NHS, how overspends will be addressed and how the boundary between free healthcare and means-tested social care will be negotiated. There will be no additional funding and the chancellor and health secretary will be only too happy to lay responsibility for rationing at the door of the devolved authorities. In this way a Tory government with a mission to run down the role of the state will have effectively removed the ‘N’ from the NHS and paved the way for a balkanised healthcare system across the entire UK. Politically contentious decisions on clinical thresholds for accessing services and support will no longer land in the lap of Westminster politicians.

Devolution to English regions is a clever political tactic – nobody is really against it, the rest of the UK already has it in varying degrees, Labour has been left flat-footed and regional political elites are keen to grab whatever powers and responsibilities are on offer. It may well, in principle, be a good idea to regionalise the NHS – there are arguments for and against. The problem we have is that this debate is not taking place. The NHS and local government is being transformed at pace and scale, yet most people have no awareness of this, have had no consultation and even less involvement. Lansley’s NHS bill was famously paused in order to reflect and gather fresh evidence. Maybe it’s time to do the same with the cities and local government devolution bill?

This was first published by the Guardian

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What is the best we can hope for from the new Government – whoever is in charge? I have three hopes. First, greater commitment to the real purpose of the NHS – equity. Second, less structural reform, and more real innovation. Third, the emergence of alternative voices and perspectives – from communities, from the groups facing disadvantage and from the professions themselves. Overall I would like the NHS to see itself as a community – not as an organisation – a community that takes social justice seriously.
In A Better Plan for the NHS, Health and Care Ed Miliband and Andy Burnham say “The NHS is our country’s most precious institution and Labour’s proudest achievement.” This is strong stuff, but it is understandable that the NHS holds this place in the hearts of many. Before his death, my granddad wrote his memoirs – the memoirs of a working-class man from Manchester – he describes coming home from the war:
“We had a National Health Service by now. It was introduced by the Labour Government who swept to victory after the war was finished. This was a great innovation. Free medical attention, dental and ophthalmic treatment and free medicine, no more doctors’ bills to worry about… The British people like the system…”
This is surely at the heart of what makes the NHS great – free health care – no discrimination between the rich and the poor – equity. Yet, when we compare the principle of equity with the reality of the NHS – in its incarnated form – there are so many paradoxes:
  • The creeping return of charging, means-testing and privatisation.
  • The huge income inequalities – some have truly had their mouths stuffed with gold.
  • The institutionalisation imposed on disabled people and people with mental health problems.
  • The enormous centralised bureaucracy at the heart of the NHS.
  • The elitism and detachment from community and democratic accountability.
  • The exploitation of our wealth to draw medical expertise away from developing countries.
The real NHS is a little less loveable than the ideal NHS. So, of course, the temptation is to ‘reform’ the NHS; but this is so dangerous.
One of the most interesting consequences of the British healthcare system is its centralisation in Whitehall with political control handed each term to one (or usually more) Secretaries of State. Each one then discovers that almost everything good about the NHS is far too complex and detailed for them to do anything about. So politicians find there is next to nothing of meaning that they can do – so in order to be appearing to be doing something they must do big things without meaning – hence structural reform.
Over the life of the NHS we have seen two waves of meaningless structural reform. The first wave from 1945-1990 was bureaucratic reform – dividing and re-dividing the NHS into districts, regions, units etc. The second wave began in 1990, and we are still in it now, and it is market reform – creating phony market mechanisms, commissioning systems, contracts and increasing privatisation. If we cannot end this wave then we may eventually see the collapse of the NHS.
When I think of this process the image that always comes to mind is of a child playing with an expensive and complex toy, and a tired parent saying, “Now, stop fiddling with that – or you’ll break it!” However I do not blame politicians for this problem. In a sense we are the parents, but we keep giving control of the NHS to one individual because that’s the way we think democratic control must work. This goes back to the founding story of the NHS – we treat it as if it was founded by politicians and we hope that it is safe in their hands (or we fear that it isn’t). We forget the decades of work to create the NHS done by communities, campaigners and activists, work which the Socialist Health Association documents so well.
So, the big question, going forward is whether we can turn away from meaningless bureaucratic controls, and phony market systems, and instead find our way onto a better path. There is nothing inevitable about this – we have just lived through the worst Government in over 75 years – who seem to have set about destroying the welfare state – and there is  good chance they will get in again. Alternatively the Labour Party is trying to position itself as close to the Conservatives as it can get away with, in the hope of winning back power.
It is a dispiriting scene; but there are some rays of hope, and with hard work these could be magnified into something stronger.
1. We could take the principle of equity more seriously
As it stands champions of the NHS stand upon the highest peak of the welfare state and watch as the rising waters of injustice swallow up the social security system and social care. It is hard to be optimistic. But, we could wake up and realise that it is not the NHS that matters – but justice itself. We could recognise that the principle of equity both needs better protection and a wider scope. For instance, I’d like to see a movement to unite behind a constitution – not for the NHS – but for the welfare state as a whole; and not some meaningless policy document – but fundamental legislation to underpin the whole system.
One emerging opportunity is the renewed effort to ‘integrate’ of health and social care. Eventually we will find (again) that integration is the wrong way to frame the challenge. However we will find that there is a much more important distinction to be made, between circumstances where individual budgeting is useful, and where it is not. It will turn out that the line between these two circumstances will be drawn quite deeply within the NHS. Figuring out where personalisation should begin and where it should end will turn out to be one of the key policy questions.
Now this could be a disaster. For it could allow the excessive means-testing of social care to creep into the NHS by the back door. Hence, many resist the extension of ‘personalisation’ into the NHS. However, what if, instead of resisting individual budgets – advocates of justice attacked the root problem – means-testing itself. If the NHS is good – why do we allow severe means-testing of social care? There is no moral case for social care means-testing. Society only needs one system of means-testing – it’s called taxation. There is nothing fair about taxing disabled people and older people and calling it a ‘community care contribution’. This is just an extra tax that targets disabled people. Instead of resisting personalisation advocates of justice within the NHS could make common cause with those of us opposed to social care means-testing.
We could go even further and ask questions about the benefit system, income distribution in health care, the pharmacy industry or regional injustices. Equity is a powerful and positive concept – and if we really care about it then we should be prepared to ask tough questions about where it applies and how to make it work.
2. We could declare commissioning dead and look for real innovation instead
I don’t know whether anyone will be brave enough to declare commissioning dead, but there remains no evidence that it has created any significant improvements and perhaps it would be useful to challenge the whole concept. Certainly, the last set of structural reforms, despite the rhetoric, have largely moved more power and control to Whitehall – leaving a rather complex structure of local Well-being Boards and Clinical Commissioning Groups (CCGs) with only minimal influence over the real system.
However, while this may not be ideal in the long-run, I think it may be best to leave these structures alone, for they contain within them some positive possibilities. While power has not shifted to local clinicians or to local government, they are both at least now able to be part of a real conversation about local health services. This is real progress and it opens the door to further innovation.
Real innovation does’t come from Whitehall and it doesn’t come from commissioners. It comes from communities and it comes from practitioners themselves. The NHS will truly flourish when people can find room to develop new ways of working. Innovation – which must be essential to the on-going health of the NHS – is a creative people-led process and it needs a permissive environment which is not frightened by local differences, experimentation and the odd failure.
One area where much more innovation is possible is in mental health services. Today the mental health system is coming under increased scrutiny for good reason – not just because it has been severely cut – but also because it is fundamentally flawed. It has invested in the very things that don’t promote good mental health. Increasingly self-advocates and families are finding ways to develop better forms of support. For instance, the People Focused Group in Doncaster has demonstrated that mental health is advanced more by peer support than professional services. Such groups are finding allies within CCGs precisely because clinicians understand the frailties of the current system better than anyone. These kinds of people-professional alliances will be essential to restoring the NHS to health.
3. We could welcome more diversity and greater connection to local communities
Increasingly the NHS needs to look beyond the confines of services and of organisations. We need to identify and build upon the capacities of our communities and we need to be able to build new alliances. For instance, WomenCentre in Calderdale and Kirklees had generated multiple benefits for local women and families – health benefits and other social benefits – in ways that are much more efficient than typical models of public service. However the organisation is not a ‘service’ to be commissioned; it is a community – women supporting women. If the NHS is to thrive it needs to be able to listen to and respect this kind of perspective.
The NHS needs to learn that its commitment to justice can’t just be a matter of organisational form or the repeated use of the formula ‘free at the point of use’. A real commitment to justice means taking seriously how you work as an individual, how you work with others and how you work to improve things in the wider community.
Perhaps the most important challenge – however crazy it might seem – is to stop looking to politicians for the answers. Politicians are not the answer, and they are not the problem. They are mostly good people trying to do the right thing. (Sorry – I know that will be heresy for some.) However, they work within the confines of the feasible – and it is we who define what is feasible.
If professionals, advocates and local leaders come together to define better solutions then politicians will open the doors to let change happen. But, if we sit in our silos and complain then we will find that policy is dictated by the assumptions of the powerful, the wealthy and by commercial interests. The NHS is in our hands – but if we choose not to think, not to act, not to get organised – then we will find ourselves… well we will find ourselves precisely where we are: in trouble.
The NHS can be a community. It can be a place where people take justice seriously. If, as individuals, we begin to act as if we can make a difference, as if we are not just cogs in a system, then we may be astounded at what we can achieve.
These are only some weak rays of hope. Whether they turn into anything more depends on us.
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I know nothing about writing blogs – but I know what I don’t want for the NHS in Manchester;
1.  I do not want the NHS to be “devolved” to a bunch of Council Leaders with no clinical knowledge whatsoever of healthcare, treating patients and saving lives.
2.  I do not want accountability and responsibility for the “National” Health Service to be “devolved” from the Health Secretary to a cabal of “unelected”  Quangos like Monitor and NHS England (and its 9,”Commissioning Support Units”?) stuffed full of their “free-market” acolytes, “privateers”, “McKinseyites,” Accountants, and Management Consultants – hell bent on using the NHS as a “cash-cow” to line their own pockets!
(Note: A recent FOI request by “Private Eye” to NHS England about its spending on “Management Consultants” whilst slashing health budgets was rejected on the grounds of “commercial confidentiality”!  However it must show expenditure over £25,000 which revealed that in 2013/14 it spent:
*  £2.8 million on McKinsey (and its ‘sham’ “Healthier Together”)consultation.
*  £13 million to the Big 4 (“bent”) accountants PWC, KPMG, EY and Deloitte. (Deloitte pocketing – £7 million;  KPMG – £ 3.48 million and PWC £1.84 million).
I do not want the NHS budget squandered on even more “unelected quangos” of pointless bureaucrats like the proposed “new strategic body”:
The Greater Manchester Strategic Health and Social Care Partnership Board – supported by:
A joint commissioning board drawn from the 10 local authorities, clinical commissioning groups (CCGs) and NHS England.
Question: Where are the “Hospital”Representatives on the above commissioning boards? The Specialists, Consultants, Surgeons, Specialists, Oncologists, Cardiologists, Neurologists, Urologists,  Radiologists, Radiotherapists, Pathologists, Psychologists, Geneticists, Haematologists, Paediatricians, Clinicians, Doctors, Nurses, Midwives, Allied Health Professionals, Paramedics et al – THE FRONT LINE OF THE NHS WHO ARE TREATING AND SAVING MILLIONS OF LIVES DAY IN DAY OUT…???
I do not want the NHS budget to be squandered by a “Cabal” of uninformed, uneducated “non-medical” Councillors and their crony “Business Consultants” on local authority vanity projects” commissioned by Bernstein, Leese and their “overpaid”, “under-worked”, money-grabbing cohorts!
I do not want an “unelected” Mayor to be foisted on Manchester – against the will of its residents who previously REJECTED AN ELECTED MAYOR IN 2012!!!  How dare George Osborne and Howard Bernstein override the will of Mancunians by “imposing” a Mayor we didn’t vote for and don’t want!  MANCHESTER MUST BE GIVEN A REFERENDUM TO VOTE ON THIS ISSUE!
I do not want the National Health Service to be turned into a Regional Health “Business Opportunity” for grubby Council Leaders, Quangos, Privateers and Accountants!

What I DO WANT:

Is a National Health Service free at the point of use for everybody regardless of ability to pay – with responsibility for its administration, services and funding in the hands of the elected Secretary of State for Health and the Department of Health.
A Health Service, run by Clinicians, Specialists, Surgeons, Nurses and Doctors “WHO CARE FOR PATIENTS, WHO CREATE LIVES, REPAIR LIVES, SAVE LIVES” – AND WHO MAKE THE NHS THE GREATEST INSTITUTION  THIS COUNTRY HAS!

 

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By happy coincidence we organised a dinner last night for leaders in the NHS in Greater Manchester to discuss Devo Manc and the NHS.

Those present welcomed the announcement that control of the NHS budget is to be handed to Greater Manchester authorities and  look forward to working much more closely with these elected local authorities.  Under the right conditions this could be an opportunity to ensure that our Manchester Health Service – MHS  – brings much greater benefits to patients and communities.

MHS patients must be equal partners in decisions about their own care and of their families.  The MHS should be much more democratically accountable than the NHS has been in the past.  Manchester still has huge inequalities in health. The average age at death of people living in the most deprived parts of the conurbation is ten years less than among those living in the most prosperous areas.  The NHS has never been able to tackle inequality on its own but the MHS will be the biggest employer in the region and with local councils must use its muscle to reduce inequality.  At the same time we want to see an end to wasteful and damaging competition between hospitals.

MHS should bring much closer working between social services, citizens, patients, carers, families, communities, hospitals, family doctors, pharmacists and other clinicians, researchers and the voluntary sector and to establish real parity of esteem between mental and physical health.

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The procurement exercise in Staffordshire which outsources the commissioning of £1.2 bn of NHS services has at last made the mainstream media.  An announcement has been made that it has been decided that the next stage of the procurement will now get under way with a full blown EU procurement (competitive dialogue).  The decision was made in private for reasons which are unclear, so there is no public record.

The procurement has of course already been under way for some time with the request to submit pre-qualification questionnaires in March. But there was absolutely no information about any of the details. Leading up to the announcement there has been a flurry of activity as the CCGs involved try to put right the numerous defects in the way they have gone about this exercise.  They have also got together to establish a special web site to promote what they are doing – though it too lacks the necessary information.

There is no record in any CCG minutes of how the key decisions were made and no papers setting out why; but there is no obvious justification for such secrecy.

The formal procurement is for two contracts; one for Transforming End of Life Care and the other for Cancer Care.  The contracts are for 10 years and are for an “integrator” (lead contractor) to manage existing contracts for two years and then to take full responsibility for the management of the provision of care.  The integrator can be a private body and given the requirements this is the most likely outcome.

Before the procurement a lot of good work had been carried out around the need to improve services and to integrate provision and in general the aims are not disputed.  The way the CCGs have gone about approaching the implementation of worthy aims is hugely controversial and potentially unlawful.

It is totally unclear how the decision was taken to use a major competitive procurement exercise rather than use the existing powers that commissioners have to arrange the provision of services.  The decision to go down a route that opens the door to a private provider effectively taking over the commissioning role has never been discussed.

The fear that private sector organisations would take over CCG responsibilities and make decisions over provision of services was much discussed during the passage of the H&SC Bill and after the pause there were reassurances that this could not happen – well it is happening.

The clear danger of having 10 year contracts of this sort is clear even to those who are relaxed about greater private provision.  The NHS is undergoing a period when major changes are necessary as care moves from hospital to the community and as barriers between social, physical and mental health are dismantled – everyone agrees on this.  But if commissioners have given away their right to manage provision they can’t respond they can only look to contract variations and disputes with their lead contractor.  It is pretty fundamental that decisions about the allocation of resources and the priorities that are set cannot be made by private sector organisations under some contract – it just doesn’t work like that!

The duties on CCGs to have proper arrangements in place to allow discussion with patients and the public are clear enough.  How services are commissioned and how decisions are made about who provides what are clearly matters on which patients and the public (and staff) have the right to be involved.

As with other procurements that have fallen apart we again see CCGs charging ahead without having in place the necessary framework of proper information disclosure and governance and paying, at best, lip service to public and patient involvement.

It is not just essential but also arguably a legal requirement for the CCGs to stop what they are doing and to consult properly about what they are proposing to put in place.  If after such discussions they decide to proceed through competitive procurement of a lead contractor model then they have to ensure openness and transparency in every step they take along the way.  They have to involve patients and users in setting out requirements, defining criteria and in evaluating the responses from potential providers.  They have to make public all the necessary information and stop hiding behind spurious claims to commercial confidentiality – it is up to the CCGs to make arrangements to ensure openness not hide things.  They have to show that what they do is consistent with the policies they have established (and formally agreed) and with the various assurances that have been set out by Ministers and the various quangos who oversee the NHS and what it does.

Only if this is done can anyone have an honest view on whether what results is really in the best interest of the patients and our NHS.

There is a real danger here.  If the route to integration is by using private providers as surrogate commissioners then the whole drive to a worthwhile aim is totally undermined.

 

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TEN MESSAGES on PUBLIC and PATIENT ENGAGEMENT

‘Power to the people!’ The Citizen Smith slogan seems to be all the rage in the Labour Party right now as it crafts a distinctive election strategy for the NHS. Pulling away from the role of markets and bringing local accountability into the NHS looks like a good policy double whammy, and the commitment seems genuine. In recent weeks:

  • Ed Miliband, in his Hugo Young lecture committed the next Labour government to ‘people-powered public services’, devolving power not just to users but also to ‘the local level’.
  • Labour’s draft consultation paper on health  expresses similar sentiments, emphasising that people should be ‘not mere consumers of services but genuine and active partners in designing and shaping their care and support’.
  • The detailed report of the Oldham Commission, set up by Andy Burnham, contains an eight-point depiction of ‘whole person care’, one of which is ‘I and my community have a real say in our local services’.

This is positive stuff and all consistent with the ‘grass roots’ outlook of Labour’s new strategy guru, David Axelrod. There’s only one problem – there is no policy! Nothing in the Oldham Report, nothing in the party draft consultation and only ill-thought out ideas from the Labour leader himself, such as describing Health and Wellbeing Boards as ‘independent bodies’ to be charged with ‘consulting the local community’.

This isn’t good enough, and Labour is missing an open goal in not being more explicit. Here are ten suggestions to get the ball rolling.

  1. Coordinate existing forums: There are too many weak and fragmented bodies right now – Local HealthWatch, foundation trust governors, lay members of CCG boards and others. Together they might add up to more than the sum of their parts but there is no way of currently doing this.
  2. Empower elected FT governors: Alan Milburn’s recent assertion that Foundation Trusts are ‘owned and controlled by the public locally’ is nonsense. FT Governors are toothless and invisible to their miniscule electorates – they need to be properly staffed and funded and given autonomy from the grip of their FT boards of directors.
  3. Real public engagement in NHS commissioning: Most CCGs are stuck on a failed engagement model centred on ‘public meetings’. The need here is to promote the development of genuinely participative models – citizens panels and juries, patient and community leaders, participatory budgeting and harnessing the power of digital engagement.
  4. A Patient Congress in every Clinical Commissioning Group locality: Some effort is currently going into the creation of a national ‘NHS Citizens Assembly’ that somehow might call the board of NHS England to account. Without local roots this will falter. A representative and (at least partly) elected local Patient Congress could be the missing link in democratic transmission to the Assembly.
  5. Proper support for Patient Reference Groups: There are hundreds of these small groups at practice level taking an interest in such matters as patient appointment arrangements and opening hours. Generally they are unpublicised, unsupported and unrepresentative. They need help to up their game.
  6. Deeper understanding of ‘the patient experience’: In line with the focus on ‘consumerism’ there is much current preoccupation with recording and measuring patient feedback via the Friends and Family Test. This needs to be deepened (to get a narrative rather than a tick-box score) and extended (to capture patient journeys rather than separate interventions).
  7. Open up the invisible quangos: While CCGs have all manner of obligations laid upon them to involve and engage the public, other powerful bodies can too easily slip below the engagement radar – Local Area Teams of NHS England, Commissioning Support Units, CQC and Monitor. All of these bodies have huge sway over local healthcare but remain unknown and unaccountable to local people. 
  8. Promote and enforce the NHS Constitution: Most people are blissfully unaware of the NHS Constitution and even if aware of it will be (understandably) unclear as to its status. There is an opportunity to turn it into an NHS Bill of Rights.
  9. Strengthen and fund Local HealthWatch: The Francis Report argued that the prime local forums for public engagement have gone steadily downhill since the first of them – Community Health Councils – was abolished by Patricia Hewitt. We need to get back to a CHC-type model, possibly along the lines of the patient congress approach. A robust LHW could be the organising vehicle for such a shift.
  10. Reinvigorate local government: It will only be possible to bring some healthcare remit back into democratically elected local government once it has constitutional autonomy and is free of the pro-market, centralised paradigm.

Lots of work to be done under these headings, but time is running out. There aren’t many political open goals awaiting a shot on target but surely this is one of them? Shoot!

Professor Bob Hudson,

School of Applied Social Sciences, University of Durham

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The Co-operative Party are proposing an amendment to Labour’s Health Policy see the Your Britain website.

Insert on pg 6 at line 42:
“In 2003 the previous Labour government established Foundation Trust Hospitals in England with the aim of making hospital services more accountable to local communities by giving Trust members a real say over their running. Ten years on the consensus is that, whilst more than 2 million people are members of Foundation Trusts, the model has not achieved its full potential and there is a need to re-awaken the original ambition behind it. One Nation Labour believes in more ‘people-powered’ public services and so a future Labour Government will consider ways of strengthening the role of members within Foundation Trusts and work to better engage and involve NHS staff in Trust membership.”

We’ve never been very comfortable with the ideas around Foundation Trusts.  In 2010 we agreed a statement including these words:

  • Local NHS facilities should remain publicly owned and Foundation Trusts should be a model for community multi stakeholder ownership.
  • The governance structures within which Foundation Trusts operate are flawed and are insufficiently undemocratic and must be extensively reformed.
  • Both purchasers and providers should be responsive to their local community and commissioning of services should be under proper democratic control
  • Whilst we accept that there will be a major increase in the number and scale of Foundation Trusts we do not accept denationalisation. Foundation Trusts must remain clearly part of the NHS family with a duty of partnership with both commissioners and other NHS partners. There must be explicit restrictions on sale and use of assets, on varying terms and conditions of employment and on non NHS income.

Our statement went on to propose a long list of improvements we wanted to see in the governance of Foundation Trusts. Things haven’t improved since.  Although many of our members are involved in Foundation Trusts, as members, governors, employees and board members, few seem convinced that the present model has much to be said for it. If we move away from the idea that each NHS Trust is competing in a market with all the other Trusts then perhaps this is not the place for a democratic voice?

 

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Ways Forward For Public and Patient Involvement In England 2014

Practical Approaches To Patient And Public Involvement

The Briefest Of Summaries Of The Best Ways Forward In PPI For England

Current policy as outlined in Participation Guidance  is generally good with clear requirements for the system as a whole. However, much more can be done.

PRINCIPLES:

  • Democratic legitimacy needs to be increased in the NHS. In particular, commissioning and planning for the local and national NHS should increasingly be in the hands of elected people.
  • Perhaps more than democratic accountability, we need participatory accountability. That is, a system that supports, encourages and welcomes communities and individuals being part of the prioritising, planning and monitoring of services as equals and agenda-setters.
  • As part of this process, the NHS needs to develop techniques and approaches for a proactive dialogue with the people it serves, locally and nationally.
  • PPI needs to be integral to all aspects of commissioning and providing
  • Commissioners and providers need to show that they have listened and responded and they need to be monitored on their response
  • We need to include in the discussion both individual involvement (the process of consultation between patient and clinician) and collective involvement (the participation of communities and groups in the planning, development and monitoring of services)

WHAT NEEDS TO BE DONE TO IMPROVE INDIVIDUAL PARTICIPATION

  • Active care planning
  • Training for clinicians in promoting shared decision-making and self-care
  • Promoting the dissemination and use of
    • Decision Aids
    • Online patient record access
    • Condition-specific patient education programmes
    • Group appointments
    • Coaching and question-prompts for patients
  • Realigning incentives
  • Changing external and legal factors

WHAT NEEDS TO BE DONE TO IMPROVE COLLECTIVE PARTICIPATION

  • Promote and disseminate the use of community development as a joint process between Clinical Commissioning Groups, Local Authorities, HealthWatch  and Health and Wellbeing Boards
  • GP surgeries to become more responsive to their populations
  • GP surgeries and CCGs to work more closely with local 3rd sector groups
  • Feedback from patients to become increasingly:
    • a key safety lever
    • part of the payment process for providers
    • part of choosing services
  • A strong independent HW
    • ring-fenced funding
    • continuity
    • effective data collection and evidence-based feedback to commissioners
  • More responsive and accountable commissioners, responsiveness monitored by NHS England
    • An increasing focus on communities and patients as experts in identifying local issues and solutions
    • PPI at every stage and every part of the CCG including prioritising, finances, planning, monitoring
    • Patient Participation Groups to collectively advise the CCG
    • Stronger representation on the CCG of councillors and lay people
    • Consider other options for CCGs governance:
      • with Foundation Trust-type arrangements
      • elected representatives
    • Commissioning community development
    • Prioritising individual involvement
  •         A stronger push at national level to share power with patients and citizens
    • NHS England to demonstrate responsiveness in its own commissioning
    • Community development to be promoted by making it easier to jointly commission
    • A shift towards Health and Wellbeing Boardss initially vetting CCG plans, then taking on more of the commissioning responsibilities. Then eventually LAs taking over commissioning with CCGs as key partners.

WHY IS PPI IMPORTANT?

See a good summary

INDIVIDUAL INVOLVEMENT

This means participation in the consultation between patient and clinician (nurse, GP, hospital doctor, AHP)

There is moderately good evidence that care and outcomes improve when people are involved in shared decision-making and in self-care. It probably saves money too.

For the process to be effective, both the patient and the clinician need to be involved in the dialogue and support has to be offered to both. Shared decision making relies on two sources of expertise:

  • The health professional is an expert on the effectiveness, probable benefits and potential harms of treatment options
  • The patient is an expert on herself, her social circumstances, attitudes to illness and risk, values and preferences.

Both parties must be willing to share information and accept responsibility for joint decision making. The clinician must provide patients with information about the diagnosis and treatment options and the patient must tell the clinician about their preferences

“A colleague with rheumatoid arthritis likens the experience of living with chronic illness to flying a small plane. If it is flown well, one gets where one wants to go with the exhilaration of mastering a complicated set of challenges. If it is flown badly, one either crashes or lands shakily in the wrong airport,reluctant to ever leave the ground again. The patient must be the pilot, because the other possible pilot, the health care professional, is only in the plane a few hours every year, and this plane rarely touches ground.

If chronically ill patients must pilot their planes, then the role of health care is to ensure skilled pilots, safe planes, flight plans that safely get the pilots to their destinations, and air traffic control surveillance to prevent mishaps and keep them on course. “

This implies a substantial shift in clinical activity across the whole of the NHS.

Practical interventions to make individual involvement routine

  1. Care planning. Not just having a care plan, but an active process of jointly planning care for people with Long Term Conditions. See the House of Care for more details.
  2. Training clinicians in shared decision-making (SDM) and promoting self-care. There is evidence that this changes behaviour, to some extent in the long-term. Unless clinicians alter our approach to the consultation, little will  change. There are quite a few training courses now and lots of work on practicalities by the Health Foundation.
  3. Decision aids for patients need to be available in every Out Patient Department and every GP clinic. Decision aids help to increase patient involvement in decision making and increase patients’ confidence in the process. Some studies suggest they also produce a better match between patients’ preferences and the treatments chosen, leading to increased satisfaction. There is no evidence that they make patients more anxious. Several trials have shown that decision aids can lead to a significant reduction in rates of elective surgery with no adverse effect on patient satisfaction or health outcomes.The best ways of harnessing Decision Aids need to be established, taught and reinforced.
  4. Patient online record access. This is now government policy for it to be available to anyone who asks from April 2015. has been shown to improve relationships, improve patient confidence and understanding and self-reported efficacy, and reduce the demand for appointments and telephone calls to practices. There is some evidence that self-care and compliance is improved. Patient record access needs to be available for every patient across the UK. It is emerging that patients particularly value transactional services that can be linked with record access. These include:
  • reliable information linked with their own record
  • using access to ensure that professionals and family members are informed of all their current treatment and care plans
  • the ability to improve the accuracy of the record
  • the ability (in the future) to add to the record
  • the ability to book appointments and repeat prescriptions electronically through the record.
  • the ability to see how their care management relates to good practice in the field, for instance through links with the Map of Medicine.
  1. Condition-specific patient education programmes such as the Expert Patient Programme have involved people with asthma, diabetes or arthritis. Evidence is reasonable that they make a difference to outcomes and self-confidence to manage.These are programmes for patients. Clinicians may need support and encouragement to offer such groups on a routine basis. In addition, there may need to be support or incentives for clinicians to offer interventions such as asthma self-management on a routine, systematised basis, perhaps on a cluster basis.
  2. Group appointments. These are appointments where groups of patients with the same Long Term Condition (typically diabetes or asthma) are seen together by a clinician. The aim is both to teach people good practice but also to enable patients to learn from each other and for the clinician to learn from the wisdom of the group. Better health outcomes (blood glucose control and blood pressure) are reported for group-based educational approaches for patients with Type 2 diabetes.
  3. Realigning incentives so that professionals are required to involve patients in decision making. In this brave new world clinicians would be monitored for their ability to accomplish this task. Training would be provided in shared decision making and the use of decision aids and patient engagement would be incorporated into clinical guidelines, using patient feedback to check progress. Health professionals and managers would require the use of decision aids to achieve performance targets. Relevant metrics might include the percentage of patients who report having had the opportunity to make informed decisions. Such metrics could be incorporated into accreditation and reimbursement strategies.
  4. External factors and legal requirements, such as the requirement to demonstrate true informed consent (see for example the 2007 legislative changes in Washington State), could also provide a strong incentive to make the shift from traditional paternalistic practice. Those concerned with risk management could benefit from insights derived from research into shared decision making and risk communication. Clinicians are always vulnerable to legal challenge and being able to demonstrate that effective methods have been used to communicate risk may prove to be a useful defence in court cases.
  5. Coaching and question prompts for patients. These have included coaching in how to raise issues and express preferences, question cards that act as prompts on appropriate questions to ask the doctor, encouragement to keep diaries or lists of topics for discussion, and summaries or audiotapes of the main points discussed for the patients to review later.

As a result of prompts, evidence suggests:

  • improved knowledge and recall.
  • Increased involvement and question asking,
  • Increased perception of control.
  • Prompt sheets more effective than generalised information,
  • Patient focused approaches are more effective than those targeted at health professionals.
  • Mixed results for satisfaction.
  • Length of consultation unchanged, even where question asking increases.

However,

  • No impact on uptake of ante-natal tests.
  • Mixed results in relation to medication adherence and clinic attendance.
  • Mixed results in relation to treatment outcomes.

COLLECTIVE INVOLVEMENT

This refers to the involvement of people collectively influencing the planning and delivery of local or national healthcare services.

Democratic Accountability

The Secretary of State is the only elected person in the NHS. As a matter of principle, there needs to be more democratic involvement in the NHS. Critically, planning the NHS should be done with democratic legitimacy. Currently there is a real risk that planning will lend up being done by the private sector as Commissioning Support Units get taken over and gain more power.

The most obvious way is to involve local authorities more over time.

The first step would be to give Health and Wellbeing Boards more say and a veto over CCGs’ plans. Increasingly HWBs could take over local planning. Eventually Local Authorities would be in charge.

Advantages would be:

  • Holistic planning and procurement
  • Probably a stronger focus on the social determinants of health
  • Less duplication

Disadvantages:

  • Political vagaries interfering with evidence-based planning.

However, to listen to NHS staff discussing this, you’d think that Local Authorities could never commission or plan anything, hobbled by politics. This is patently not the case. And there is precious little evidence-based planning in the NHS (or anywhere) now.

Other options include elected Clinical Commissioning Groups, elected Boards for practices, Foundation CCGs, having the same sort of structure as FTs. However, as was found in Scotland, it is unlikely that new democratic structures like this would attract enough voters to be viable.

Participatory Accountability.

This is the process that happens to some extent now, with Patient Participation Groups, Health Watch and so on. NHS policy on this kind of participation is pretty good. The demands on CCGs to be transparent and to involve local people in planning are clear in the recent guidance and in the NHS Constitution.

However, practice on the ground remains poor, but is improving.

Practical ways of improving participatory accountability.

1. Community development to become a key approach.
Community development (CD) enables people to organise and collaborate to:

  • identify their own needs and aspirations
  • take action to exert influence on the decisions which affect their lives
  • improve the quality of their own lives, the communities in which they live, and societies of which they are a part.

CD aims to address imbalances in power and bring about change founded on social justice, equality and inclusion[i]. It increases community activity at two levels:

  • within the community itself: to increase social networks and productivity – more friendships, less isolation, more volunteering, more mutual aid, more informal care, better flow of information, more trust and co-operation, positive behaviour change;
  • between the community and local services and authorities: better communication, dialogue, feedback, engagement, involvement in service change.

The process begins by identifying the issues that matter most to those residents who speak up and take action, not by imposing an agenda pre-defined by health or other public service agencies. If the relevant topics are anti-social behaviour, housing or environment, those are the initial priorities for the work. All issues have a health benefit. As social networks expand, most major issues will emerge through one group of residents or another. As communities work together with agencies to solve the problems that matter to them, confidence grows, leaders appear, social capital improves and the benefits to health become apparent. Some impacts are direct, through the effects of participation on individuals; some are indirect, through service change and increase in social trust.

A resident-led partnership is often the vehicle by which this transformation takes place. This brings together local people with public agencies dealing with health, education, housing, police and other issues, in ways that have often not happened in that area before. As a local resident put it: “It’s no longer them and us – it’s us and us.”

CD is best carried out through expert community development workers but can be done by other front line service workers if they are trained for it. CD tends to be geographically-based (highlighting the most troubled communities in the area), but there are good examples of work with communities of interest, for instance people with diabetes, or the disabled.

One strand of CD is broadly known as the ‘asset-based approach’. Whilst medicine traditionally seeks needs and problems to which to respond, asset-based approaches look for the positives: the leaders, the skills, the strengths of individuals and communities, and builds on those.

2. GP surgeries more responsive to their local  populations

  • Every practice to have a patient participation group or panel.
  • Every practice to work with and collaborate with their local Healthwatch
  • Every practice to introduce easy to use feedback channels and to be responsive to this feedback
  • Practices to involve patients in the recruitment of doctors and other staff
  • The Care Quality Commission to monitor whether practices make changes in response to patients’ views.
  • Quality and Outcome Framework incentives re-introduced to encourage responsiveness, in particular:
    • Quality of care being in part defined by patients
    • Points assigned to responsiveness on areas other than merely access
    • Practices will be encouraged to work with local community development workers

3. More responsive and accountable commissioning

  • Patients’, citizens, community-based organisations and Healthwatch views to be incorporated into the commissioning process in the following areas:
    • Needs assessment
    • Choosing priorities for investment and disinvestment
    • Monitoring quality
    • Identifying problem areas and successful areas of service provision
    • Determining the shape of service development
    • Deciding on how to spend any savings
    • Patient participation groups link up to advise the CCG
    • Greater involvement of condition specific and community groups in the commissioning process. For instance  through local third sector, voluntary and community organisations
    • Community development workers to be commissioned  in each CCG, jointly with local authorities, through the HWB
      • CCG boards to be elected.  Perhaps along the lines of parent-governors in schools.
      • Participatory budgeting linked with the LA.
      • The CQC to demand evidence that local commissioners and providers have taken on board patients’ views in the areas specified above
      • CCGs’ commissioning plans to be signed off by Health and Wellbeing Board. Eventually, commissioning to be taken over by HWB and later, perhaps, the Local Authority.
      • Local Authority councillors to form half of every Board
      • Pilots to explore CCGs as Foundation Trusts

 4. A stronger push at national level to share power with patients and citizens

  • Ensure HealthWatch England is a representative organisation of Local HealthWatches. That it sit outside the Care Quality Commission. That LHWs be adequately funded with ring-fenced money. That LHW has more powers to change CCGs’ plans than now.
  • Shared decision making and sharing of information, including the sharing with patients of electronic patient records, to be incorporated as key components of training for  health professionals, and led by patients
  • An improved system for eliciting, analysing and responding to patient and user feedback, including a simplified complaints handling system,  a single phone number, and a requirement for NHS bodies to respond via internet platforms
  • Greater emphasis on community development in the agendas of health commissioners, local authorities, local strategic partnerships and HW, as a means of improving public health.
  • HW representatives to be represented on national forums for  the sharing of experience and good practice
  • Continued national support for the deployment of patient reported outcome measures (PROMs) and quality accounts as mechanisms for developing a more patient-centred service.
  •  Investment in HW to support their role of monitoring delivery of the rights guaranteed by the NHS Constitution.
  • Provider pay to be more dependent on patient feedback than now.
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The “Ten Years After”  paper from Cooperatives UK is a welcome attempt to reinvigorate the debate about the role of members in the Foundation Trust model (FT) model. There are nearly 2 million members of FTs across England – a mass membership of a size rivalling the T&G at its height, but with arguably less influence and profile than a small parish council.
 
The 2002 Department of Health policy document on FTs stated that “the members of an NHS FT will become its owners, taking on responsibility for their local hospitals from national Government… The members of an NHS Foundation Trust will, collectively, be its legal owners. This is a real and not a paper exercise in social ownership.” In retrospect, this is about as believable as the tooth fairy.
 
Many FT Chairs would be delighted to jettison the membership model – indeed Lansley’s “Liberating the NHS” included a plan to move to some “staff membership only” FTs, though the appetite for that swiftly dissipated.
 
Until 2010 the membership agenda was all about size. FT applicants were constantly pressured to acquire more and more members, with no clear policy or rationale about what to do with these 100s of 1000s of recruits once they had been signed up. The main beneficiary has possibly been Electoral Reform Services Ltd, who get paid to send out hundreds of thousands of ballot papers to FT members every year, in the certain knowledge that only a small minority will even be sent back. The only concrete right given to FT members is the right to participate in governor elections – but nationally over half of governor elections are uncontested. On the minority of occasions when elections do take place, turnout averages under 20%. The ‘model’ FT election rules are so outdated that they do not permit electronic voting.
 
Since 2010, the membership agenda for FTs has essentially been optional. In regulatory terms, there appears to be no downside to having a small or unrepresentative membership. Oxleas in South East London have around a third of the public members of an average FT but it didn’t stop them being one of the winners when the Trust Special Administrator came to town. There is nothing concrete in the Monitor Risk Assessment Framework (previously the Compliance Framework) that holds FTs to account on membership engagement. You can have zero contested elections and zero public attendance at governors and Board meetings, and it will have zero impact on your governance risk rating.
 
A public engagement model centred around the acute and tertiary sector is clearly flawed. An involvement model predicated on affording the greatest power to those who can attend the most meetings will also gain limited traction. But there remains massive potential to be unlocked from the 2 million FT members who to date in collective terms have been virtually invisible in society. So now is surely the time to be on the side of engaging and empowering patient, public and staff FT members. There are examples of good practice in FT membership engagement which can be easily replicated. Like it or not, the tools are there to incentivise FTs to more genuinely engage their members. If Monitor set down some basic standards for member engagement in the risk assessment framework that put some hard currency – ie, the governance risk rating – on the line, then you would see action from FTs quicker that you could say “industrial democracy.”
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