ΤThe Healthcare Commission came out its 5th and last report on the State of Healthcare in December. The report summarised the overall picture as “positive, with targets relating to the health of the population either met or on the way to being met with life expectancy increasing and rates of premature death due to cancer and circulatory disease are falling. However the report went on to make the general point that “we have seen little change in the scores that trusts get for the experience of patients.”
What has to happen for the dials to move in the year to come? A recent report from the Kings Fund saw the authors Joanne Goodrich and Jocelyn Cornwell worry about how hard it was to find good evidence about the impact of patient-centred initiatives. They assess the evidence as all too frequently “patchy, fragmented and tends to be descriptive”. What is the mechanism that connects the intervention and a positive outcome? National policies and strategies are often no help at all.
The MAC Partnership have long been sure of a key part in that mechanism is. It is the people delivering the care. And they are helped enormously by users who know what they want and say so in a way that does not come over as aggressive and abusive. If staff feel good about the service they give, then they will convey that feeling to the people they serve. The greatest early failure of customer care was the imprisonment of unempowered and under-resourced people in the call centre factories manufacturing (if you get through) a response but never service, never a human connection to the person on the other end of the phone. One of the two heartening examples quoted in ‘Seeing the Person in the Patient’ shows how compassionate and empathic staff can deliver effective patient-centred care. The example comes from the Kenneth B. Schwartz Center a non-profit organisation based in the Massachusetts General Hospital and its biggest programme ‘The Schwartz Center Rounds®’.
If you want to understand more about these two virtues of compassion and empathy and how to apply them in a practical way in both your professional and personal life, in my experience you can do no better than to seek out UK practitioners and trainers of Nonviolent Communication® at this website.
A good point, I think, both to finish and to begin again. All the best in 2009 from all of us in the Partnership.
The NHS Operating Framework 2009-10 for England (OF) sets out a brief overview of the priorities for the NHS in the next financial year. PCT managers are sweating over the framework as I write, producing their operating plans for the same period to reflect these national ”must dos” and their own commissioning strategy objectives. And there will be no relief over the hols for many - in London we have to have our plans to the SHA by mid-January so Christmas reading can’t be avoided.
At its most basic the OF sets out four domains. Each of these can be mined for opportunities to advance involvement and engagement and to further partnerships between statutory and 3rd sector bodies. We shall be banging the drum about these opportunities with out clients in the New Year - and we believe NHS managers will be ready to listen, especially as World Class Commissioning competencies are making the same sort of demands.
1. The health and service priorities for 2009/10: This is about strengthening the focus on subsidiarity - the first use of that useful EU word I’ve seen in the NHS - while still delivering national priorities in the current 3 year comprehensive spending round . How they do it is up to each PCT. The “PPI prize” in this is succinctly put on the DH website: ”Patient experience is the final arbiter of success.”
2. A system designed to deliver quality: The Darzi mantra to make quality the organising principle of the NHS gets the emphasis here- and so it should. Each SHA has its “vision” of Darzi - including Healthcare for London - and the OF focuses on the levers and incentives to further build on these. Right at the front is staff engagement for the benefit of patients and the public. Hurrah! Finally the NHS has woken up at the 11th hour to the fact that its staff are the best enggement tool it has. For that tool to do its job, people working in the NHS must be treated fairly and rewarded well in return for consistently excellent performance.
3. The financial regime: The NHS has to go further to ensure it makes the best use of taxpayers’ money. The comprehensive spending round made it clear that the NHS tap would be turned down after two years of plenty even before the world financial system nosedived, so no one should be surprised by the admonition to continue to do better with less in the near future. “Delivering Darzi” is a big part of that of course. But so is learning how to get close to customers (aka patients) and realising that they have choices and voices, especially in primary care. That’s where the biggest changes have to take place. All the solutions to the “problems” of secondary care lie in primary care.
4. The business processes: Planning should be based on locally led decision making - subsidiarity again -and maintaining the emphasis on genuine partnership working at a local level with local government and other partners. For “other” in this part of the OF read not only 3rd sector bodies and social businesses but really any health and social care organisation which wants to get into delivering public services to the right level of quality and price under the NHS brand. The old certainties about whose job it is to do certain things are on the way out.
If you are wading through the OF because you have to, then persevere because it has some really positive things to say about new ways of doing public business. If you’ve given it a miss up to now, then think again and don’t judge the OF by its rather austere cover. Anyone wanting to make connections between NHS “must dos”, opportunities for user involvement and more ways to develop the mixed economy in delivering public services will find plenty they can use in here.
And keep an eye out for the PCTs’ Operating Plans 09-10 appearing from mid January to see how they are tackling all of this. Will they all be up to the challenge? If you find some outstanding examples of local planning, you can always post it here.
LINKSLEARNING - hot off the press
Fresh on the main Moore Adamson Craig site, is the first article under our LINKsLEARNING banner - how we set about building the Wandworth LINk website from scratch and at speed. Check it out here: http://www.mooreadamsoncraig.co.uk/LINks.php and if you have any questions about what we did, contact me (email info here).
Bradford in the lead
We report on new developments in Bradford where the first of 152 GP-led Health Centres has opened. Andrew Craig points that there is a big window of opportunity for social enterprises to be set up with the latest news that Ministers have agreed a 3-year guarantee of uncontested contracts for new social enterprises in the health sector. So future social entrepreneurs need to get in quick before the arrival in this market (the current term) of what Andrew characterises as “aggressive super Foundation Trusts moving into primary and community health care“. http://www.publicinvolvement.org.uk/2008/12/do-the-citizens-of-bradford-know-something-about-primary-care-that-londoners-dont/
Best Practice
Also in the lead is the Motor Neurone Disease Association. The Year of Care commissing tool features as case history No 1 in the National Audit Office’s report on End of Life Care (http://www.nao.org.uk/pn/07-08/07081043.htm ) as an example of best practice in the area.
The Public Accounts Committee is taking evidence on the report on 17th December 2008.
After that they and all the rest of us can perhaps wind down for a decent holiday and a Happy Christmas - something we wish for all our readers.
Just published on the main Moore Adamson Craig site - a case history of building the website for the Wandsworth LINk:
Engaging Health & Social Care Communities Online - setting up a website for Local Involvement Networks (opens as Adobe PDF file).
The first of the new 152 GP Led Health Centres around England opened last week in Bradford. The provider is an established Yorkshire social enterprise called Local Care Direct. Staff and local people are members and owners of the company. Sounds like we could be behind the times in London yet again if Bradford turns out to point the way forward in this new form of social healthcare business.
Is the social enterprise idea something that the patients and public can latch onto? We think so. For social enterprises to arise from within the NHS, the Next Stage Review gave primary care staff the “right to request” this and guidance on how to do it. The latest news is that Ministers have agreed a 3-year guarantee of uncontested contracts for new social enterprises in the health sector. That could be a very strong incentive for some practices to ring the Social Enterprise Coalition about how to get started.
If I were a primary care business having sleepless nights because of aggressive super Foundation Trusts moving into primary and community health care, this sort of armour plating and guaranteed time to develop viable co-created business with my customers (formerly known as “patients”) would be attractive. Let’s see if anyone takes up the ministerial offer in the Metropolis.
The long-anticipated additional guidance for NHS organisations on section 242(1B) of the NHS Act 2006, the duty to involve and good involvement practice, appeared at the end of October - Real Involvement: working with people to improve health services. At 143 pages it is the most comprehensive statement yet about this legal duty.
If I read it rightly, this guidance puts a rather different interpretation on the local procurement of a nationally planned initiative from that which I thought applied. I now think I was wrong in believing the local NHS did not have to have public involvement in the local procurement process of developments that were not part of its own plans.
My assumption was that if developments were centrally directed and that all the local NHS did was implement something it had not planned for itself, then it could just get on with doing that without going through any formal engagement process locally. This key paragraph on page 51 suggests otherwise:
“If new services are planned and procured centrally by the Department of Health, for example intermediate treatment centres, and an NHS organisation is not responsible for those health services, it will not have to involve users or consult the OSC. However, where services are planned centrally and procured locally, the NHS organisation responsible for procuring the service must involve users and consult the OSC where necessary. In addition, it should be noted that an NHS body may have a duty to involve in relation to proposals or decisions which it has not itself generated: the issue is whether the proposal affects the services for which the NHS body is responsible. So a local NHS body may need to involve users if a national decision to procure a treatment centre has an impact on other services for which the body is responsible (see the judgment in R (on the application of Fudge ) v. South West Strategic Health Authority and others (2007)). “
PCTs are responsible for locally procured services and any new service is bound to have an impact on what exists already. If that is the “test” for the section 242 duty according to Real Involvement, then I think the requirement for engagement applies to the local procurement process, even if the initiative is a national one. The first thing that comes to mind in this context is the GP Led Health Centres (GPLHCs) being procured across London in each borough as I write this.
The whole procurement issue is fraught enough without this additional twist to complicate the public’s understanding. Also we have long argued against consulting or engaging with people if the deal is largely done and the important decision made. Consultation isn’t window dressing or rubber stamping.
The first thing to consult on is to get a better name for the procurement process itself. I’ve tried out “procurement” informally a few times recently in meetings and social situations to see what it meant to people. Nobody had a clue except the occasional person who has a particular type of commercial experience.
When “procurement” suggests anything at all, it has an association especially for older people with sleaze and prostitution. This is not the best understanding to be starting with when PCTs are trying to change services in London.
Trying out “tendering” wasn’t much better. Invariably it got a response that was about “privatisation” in one way or another. No one I’ve spoken to appreciated that tendering could be done by GPs or social enterprises (”social what”? people asked): “tendering” meant involving private companies.
That’s the level of incomprehension I fear we are up against. With legal and reputational risks existing around procurement already, let’s hope this gap in understanding doesn’t kindle into real problems. We are now seeing the moment when a vocabulary designed for those in the know to facilitate the internal debate needs to be recast for the purposes of public debate. This is not easy to do and cannot be done retrospectively.
One of the elements in getting the LINks off the ground where we under-estimated the amount of work required, is the need to explain and define so much about the vocabulary of the new health and social care services and the organisms that deliver them. People cannot conceive of the future if they do not understand the present.
Users cling to the words they know and the experiences they have had. Sometimes we have to wonder if resistance to change is generated by simple incomprehension of the terms of public discourse. People cannot agree with what they cannot understand even if there are benefits for them in the changes suggested.
Procurement of GPLHCs in London may well produce an example of that which will be tricky to handle, given the Government’s concurrent emphasis on involving patients and the public in decision making and service developments.
This week the MND YOC (the Year of Care commissioning tool) got prominent exposure as a featured example of condition-specific good practice in the National Audit Office’s End of Life Care report. The Public Accounts Committee (PAC) will now conduct hearings on the NAO report on 17 December - open to the public - and then prepare its own report with recommendations for Government (to which the Government must make a published response).
There is something very satisfying about seeing work that MAC partners and associates have laboured long over for clients getting noticed in the right places. So it is with the MND YOC. Launched in the summer of 2008 after almost two years of work, it is now available electronically to all in the National Library of Health’s specialist neurological library, together with the “Learning from Leeds” report on how the views of people with MND, carers and staff made a real difference to the final version of the tool for commissioners.
The witnesses before the PAC will be the CEO of the NHS, David Nicholson, and the ”cancer czar”, Prof Mike Richards. Given the long-standing interest MPs have in the inequitable provision of end of life services around the country and the well-deserved tenacious reputation of the PAC under its chairman Edward Leigh MP, the encounter on the 17th of December should be worth watching. Expect to see a bit of squirming.
MAC is delighted to have helped the MND Association make a contribution to stirring up greater interest in this subject and we will be following the PAC’s work on end of life services closely.
10 posts since 30th September represents an all-time record as M-A-C engages with the issues and causes dear to our collective and individual hearts.
Our first ever post back in 2003 was about our central interest - user involvement. A theme echoed in this month’s output with Andrew’s post Engagement isn’t enough. Two posts later, we were taking a look at Ann Abraham’s approach to her then quite new job as Health Ombudsman. Complaints and the way they are managed and treated and what they mean for the organisations trying to deal with them are another abiding interest - see the piece on 24th looking at how common themes can emerge from different surveys of the complainant/ customer experience.
It is not all about the familiar themes - since 2003 we have broadened our interests to embrace two new areas - Policy Governance and parental involvement in schools. In the case of the model developed by John and Miriam Carver, Policy Governance® has taken a while to get off the ground in the UK. Most of the work and case histories reflected US practice and we have not had a good UK example of how this approach to corporate governance can help organisations here. Now the Southend University Hospital NHS Foundation Trust have led the way for others to follow. Val Moore reported on this on 27th October.
Finally, Caroline Millar reports on how the new models of participation - involvement, engagement - are impacting schools, parents and teachers. Her piece focuses on the consultation on complaint handling in schools and how parental problems are handled (or not).
We call ourselves a consultancy that specialises in the user interest. What keeps us interested and involved and in business, is how that interest can manifest itself in so many different contexts while the principles underlying best practice can be so similar. Different diagnoses, different solutions but underpinning them all are the common questions - what do users think of this? Has anyone asked them? Has anyone listened? Has anyone done anything with what they have heard? What happens when people have a problem? Easy really.
The final question that comes up when looking back over 5 years - has anything changed? Well Andrew inspired us all with a 2006 look at what the NHS will be like by 2015. We are almost halfway there and what has come true? Well the Department of Health seems to see things the Andrew Craig way. Allowing people to pay for their drugs was something Andrew took a look at in March this year when he pointed out that ‘topping up’ was something that Beveridge seemed to have explicitly anticipated when he wrote about the State leaving “room and encouragement for voluntary action by each individual”. As far as the management ethos of the NHS as a whole is concerned, we will wait and see how PG will change all that.
In the meantime, it is still worth repeating a little Olympic-flavoured M-A-C joke from 28th November 2006 -
A parable of NHS reforms
(Elements are borrowed from several sources and sexed up a bit by us)
An NHS rowing team raced against a Japanese team. There were eight people in each team, of similar fitness, but the Japanese team won by a mile. How could this have happened asked John Reid? Top NHS management established a committee of analysts, which reported that the Japanese had seven rowers and one captain, whereas the NHS has seven captains and one rower. The experts called for restructuring of the NHS team. The new team comprised four captains, two service managers, and a director who also did the rowing. After a second lost race to the Japanese, the single rower was dismissed on the grounds of incompetence, and the management team received a bonus for strong leadership. A new NHS boat is currently being designed , but is reported to be running behind delivery schedule due to IT problems.
Let us see what has changed by the Olympic year of 2012 assuming we have not had to make a choice before then between funding bread and circuses or the NHS.
When I first became a school governor six years ago, I was taken aback to discover that the thing which the school called its “complaints policy” (when they actually managed to locate a dusty photocopy at the back of a filing cabinet) was something which would barely be worthy of the name in most other public or private sector organisations.
A leap too far
It told you to complain to the Head, then complain to the Chair of Governors and then escalate your problem to the Secretary of State - definitely a leap too far. This long-winded, defensive document conveyed the clear message to parents that there was no real point in complaining but if they insisted on doing so then they could not expect anyone to make it easy for them. Behind it lay the depressing fact that beyond the governing body there really was nowhere to take their complaint and whatever they did, nothing much was likely to come of it.
No wonder few complain
Under current arrangements local authorities can get involved (if they want) but they don’t actually have any power to require action by the school and no express legal role in considering complaints. The Secretary of State’s hands are tied too and there are very few circumstances in which he or she can intervene. Small wonder few people complain. We know that many people believe that it would make no difference to anything if they complained about health and social care services. If parents of school children were to be asked the same question I suspect an even higher percentage would give the same answer.
Hip! Hip! Hooray! for DCSF
So it is pleasing to see that finally the Department for Children, Schools and Families has decided to address this issue and issue a consultation document seeking views on its proposals for what looks to be a much improved approach to complaints. It is also pleasing to see that the department explicitly refers to the need to learn lessons from other areas of government such as health and local authorities.
The Children’s Plan explains what the department is trying to achieve:
“Parents’ complaints will be managed in straightforward and open way and as many issues as possible will be resolved quickly. Parents, particularly those who may not be so readily engaged, will understand the route to follow when they have a complaint. We will review what more can be done to streamline and strengthen these arrangements” (paragraph 3.2).
The first main proposal in the consultation is that efforts should be made to ensure a quick and effective response to complaints within schools supported by an effective system of local mediation if complainants remain unhappy once the issue has gone to the governing body. This sounds like a good idea but the consultation document rather amusingly (and with a terse nod towards those scary teachers’ unions) suggests that this should be done without imposing “any additional burdens on school staff, leaders or governing bodies.” This seems fairly unrealistic.
At the moment schools may be recording complaints (although unlike other sectors they are not formally recorded, analysed or reported anywhere). Good schools will certainly give parents the time of day and have a chat about their concerns but knowing that the complaint is never likely to be escalated and that if it is, it will never get anywhere, means that there is no real incentive for schools to handle complaints properly or provide any effective redress. If they were to start doing it properly there would inevitably be implications in terms of data recording; reviewing and tightening up other areas of school administration; training staff and governors and taking time to talk to people. Not to mention the fact that they might even have to change the way they do things in response to complaints. Real and ongoing input will be required, so schools and governors should not be encouraged to bury their heads in the sand and think they can just get away with ticking a few boxes.
The second major proposal is for an independent complaints review service, probably hosted by the local government ombudsman. We will be taking a longer look at the implications of this - the LGO does not have the same powers as other Ombudsmen such as the Health or the Financial Services Ombudsman to force compliance and can only name and shame.
Unified Data available to all
One thing which is not mentioned in the consultation document is whether there should be processes for collecting and analysing complaint data at a local or national level. It happens in the health service; the police and utility companies have to do it. But it is a peculiar feature of English and Welsh state schools that they seem to be left to get on with it without taxpayers being given much meaningful information about what is really going on behind the school walls. As we are all perhaps all beginning to realise, SATs don’t tell us much. “Choice” may be the government’s current mantra for parents but how can parents make informed choices with so little meaningful information available to them? No wonder they end up relying on school gate gossip. Ofsted reports can be useful but are often so infrequent as to completely fail to notice when schools nosedive into chaos and there are really very few other measures of their effectiveness or user satisfaction. Other public services such as local government and the health service are inspected and judged year after year and required, as part of this process, to provide copious amounts of data including data about complaints. So maybe this is something that needs to be added in order to provide some real accountablity to parents and taxpayers.
Things may be about to change. It is time for schools to sit up straight and pay attention.
MAC will be drafting a full response to the consultation in time for the 21 November deadline. Meanwhile let us know what you think.
Have you noticed that PPI is being eased aside by many NHS bodies in favour of PPE? The “patient and public” (PP) part is unchanged, but in the new rubric “E is for engagement” and “I for involvement” is falling off the page. We should be concerned if the “I-word” has been waylaid in the corridors of Whitehall in favour of “engaging people and communities” . Engagement and Involvement aren’t interchangeable.
However it might be dressed up in the latest policy couture, “engagement” implies a process of enquiry initiated by the NHS when and how it chooses. “Involvement”, in contrast, implies a sustained, continuous and co-created process. Picture a gaggle of patients and members of the public hanging around until the NHS decides to engage with some of them for something specific in order to harvest their views for its own uses. That is a relationship based on dependency, status and power and it won’t do for a user-led NHS. It doesn’t encourage either health literacy or enthusiasm for doing it again. You may ask what’s in a word: in the case of ”engagement” vs “involvement” the answer is rather a lot. If PPE is now DH-approved will we see a rebranding for the NHS Centre for Involvement and the National Library of Health’s PPI specialist section and a host of other respected and established sources using the “I-word”? I sincerely hope not.
It isn’t that engagement is wrong, just that it is insufficient on its own for the purpose of influencing commissioning decisions. Sustained involvement is the key to this. PCTs needs to develop processes to ensure they listen to patients and the public as they shape ideas for new service delivery models. Can they be assured that service users, carers and the public are with them on the journey of service re-design as they develop service specifications, consider tenders, and monitor contracts? If not, they are at risk and cannot demonstrate their accountability to the moral owners of the NHS - that’s you and me.
Here is an excerpt from a PCT policy that does understand the linkeage between involvement, engagement and communications:
Throughout this document we refer to involvement, engagement and communications for patient and public empowerment. “Involvement for empowerment” is the overall objective; engagement is an aspect for specific purposes, including consultation on specific proposals; and communications is the range of techniques and tools used to interact with people, listen to their views, understand their feelings, communicate them appropriately and feed back to them what they said and what we are able to do with this intelligence. The result of this is helping people feel that they are continually involved in our business.
Whatever you call it, If “involvement” doesn’t positively influence commissioning then it is a sham. So why make it harder for ourselves by pretending that “engagement” will do it all? Achieving sustained involvement is difficult, skilled and resource-intensive work, but it is an investment we cannot do without. I am reminded of the comment attributed to ”Red” Adair the legendary oilfield firefighter: “If you think hiring an expert is expensive, just wait till you find out how expensive hiring an amateur is.”
