Results tagged “engagement”

This was posted as a guest blog on the always insightful , run by the always amusing (in a good way) @HPIAndyCowper, who has kindly allowed me to re-post it here.

Criticisms of the reforms of the health system have focused primarily on shifting £80bn of public expenditure to GP commissioning consortia.

Much less attention has been paid to the issue of patient/user voice and representation in the reformed system, something this post aims to address (building on two posts at the time of the White Paper, here and here and one just before the Health & Social Care Bill was published).

The White Paper contained proposals for the creation of both HealthWatch England and local HealthWatch - building on the work of existing Local Involvement Networks (LINks) - in each upper-tier local authority area.

Local HealthWatch will essentially be the local "consumer champion" for health and social care users, promoting choice and control, influencing the shape of services, and highlighting issues in service delivery, including through advocacy.

HealthWatch England will provide support to local HealthWatch and synthesise the issues they highlight at the national level, working with the NHS Commissioning Board and the Care Quality Commission.

In principle, the introduction of HealthWatch based on the work of LINks is a good idea (though there is a question over how effective LINks have been); what's more, there is "extra" money being made available for both local HealthWatch and HealthWatch England to carry out their roles.

In practice, however, there are 3 significant areas of worry about HealthWatch arising from the Next Steps consultation response and the Health & Social Care Bill and its associated Impact Assessment.

The first is money. Though there will be "extra" money for local HealthWatch, this is being taken from existing services.

In 2009/10, £27m was allocated for LINks. For local HW, the funding that was used to fund the Independent Complaints Advocacy Service (£11.7m) and PALS (£19.3m) is being handed to local authorities to commission local HW, meaning there will be £59.1m in 2010/11.

HW England will also have £3.5m of its own funding (figures from Impact Assessment, para D42).

But the major issue - and the number one risk identified by the DH itself - is that this money won't be ringfenced. Instead, since the money will be allocated to local authorities under normal LA funding arrangements, Councils can choose how to spend it.

In 2009/10, although £27m was allocated for LINks, Councils only spent £24.3m of it on LINks - they effectively creamskimmed 9% off the budget. There is no guarantee they won't do the same for local HW.

The second issue is independence. Local HW will be "contracted by and accountable to Local Authorities" (Impact Assessment, para D34). This does not make them independent in principle; nor, potentially, in practice.

More worrying is that HW England will only be a statutory committee of the CQC. Despite the Next Steps consultation response suggesting this means HW England would be "independent" (para 2.59), the Impact Assessment formally recognises (para D24) that

setting up HealthWatch as a statutory committee of CQC [means] it would not be formally independent of the NHS and social care system.

Furthermore, HW England's funding will need to "maximise synergies" with roles within CQC (para D28) to ensure its funding of £3.5m goes as far as possible. No "independent" committee should have to rely to this extent on staff within its host body.

Even more significantly, the Chair of the Committee will be appointed by the Secretary of State (Next Steps, para 2.59). The Health & Social Bill also stipulates that some members of the Committee will be appointed and others elected (Impact Assessment, para D27), but with no details about the blend of appointed and elected members or the process for elections (D26) - this is to follow in further regulations.

None of this sounds particularly independent, and there have to be worries about how this will operate in practice. Anyone who knows how the statutory disability committee within the EHRC has operated in practice - a very similar set up to that proposed for HW England within CQC - will rightly be concerned.

The final issue is advocacy, particularly complaints advocacy, in which confusion reigns. Next Steps suggests (para 2.43) that local HW should have a role in NHS complaints advocacy, but that Local Authorities will now be responsible for commissioning it and that this may or may not be through local HW.

Conversely, the policy summary signed by Andrew Lansley as part of the Impact Assessment says that HW will bring together patient voice and complaints advocacy. It won't - especially since advocacy in social care is not mentioned a single time anywhere in documents relating to the Health & Social Care Bill.

Unlike much of the rest of the proposed health reforms, the suggestions for HealthWatch were actually quite good in principle.

In practice, significant questions about money, independence and advocacy as one of the new, key functions of HW means the end position for HealthWatch is much the same as everything else associated with Lansley's reforms.

The annual reports of Local Involvement Networks (LINks) for 2009/10 makes for interesting reading. This is particularly in light of the fact LINks will become local HealthWatches under the proposed reforms of the government's White Paper, and will be the major vehicle through which patient/user representation will be secured.

LINks are membership organisations which empower people in the community to have their say or influence local health and social care services. In 2009/10 there were 150 of them, with a total spend of £24.3m.

The numbers in terms of people engaged aren't, I'll be honest, particularly good. Even then, the data collected probably represents a slightly rosy view: as the report highlights:

Many LINks were not able to provide details of their finances, membership, activities or their effects.

It doesn't inspire confidence, does it? Even so, we will plough on with what the annual reports tell us.

Across all LINks, the average number of members (both individuals and organisations) was 489. In total, around 192,000 people were engaged in their activities (of which 42% related to social care). Given the population of Essex alone, for example, is 1.4m, this doesn't strike me as a great number. Nor does the number of LINks that report engagement directly with people from a BME background or disabled people: less than 60 and just over 50 respectively.

If the engagement numbers don't grab you, then potentially of more interest is the headline finding that LINks provided a net return on investment of £4.10 for every £1 invested.

I'm afraid to say the data behind this is optimistic at best. On the basis of the average benefit for 4 - just four - case studies being of the order of £270k, someone has simply multiplied this benefit by the number of changes that were "inspired" in services by LINks in 2009/10 - some 463. This gets you to a figure of £126m gross annual benefit.

Whilst the veracity of the 4 case studies seems reasonable, it's a leap of faith to suggest the same financial benefit applies on average across each of the service interventions LINks achieved, wouldn't you say?

My overall impression of the report is that there are undoubtedly some LINks making a positive difference through engaging their local communities in issues relating to health and social care services. However, the level of this engagement isn't particularly deep, isn't particularly innovative and is really quite limited. Nor can the level of financial benefit accrued from changes made by LINks be considered realistic.

At best, the report reads as if the most optimistic of civil servants has written it, looking for good as a whole where it only exists in patches.

Given this forms the foundation for patient and user enagement under the new health reforms, I draw the following implications for HealthWatch:

• Engagement is actually very low. LINks may have improved from 2008/09 to 2009/10, but the base was incredibly low in the first place. In particular, disabled people and people from a BME background were evidenced to be poorly engaged in LINks as a whole. HW will have to do much better than this.
• The report indicates that the money allocated by DH for LINks was not ringfenced within LAs: £27m was allocated by DH to LAs, £24.3m was allocated by LAs to LINks. Will the DH require money allocated for HW to be spent only on HW?
• The performance of LINks was patchy, but no enforcement mechanism seems to have been in place to address this. How will this be dealt with under HW?
• Data collection for LINks was quite poor. Given it underpins so much of the work HW do, will there be standards and requirements that are enforced in order to understand the work HW do?
• The annual report seems very keen to attribute financial benefits to the work of LINks in order to justify their works. Will a cost-benfit outcome be a key driver of HW, or is their value recognised as being one of engaging local communities in decision making on health and social care?

Whilst the pandemonium about various changes proposed by the Health White Paper continue (rightly so, by the way), the issue of patient and user voice remains as high up the agenda as it usually does.

That is, not at all.

I've focused on this area in two previous posts - one on patient voice in the White Paper and another on the question of democratic accountability.

I have to confess I've not had chance to read the government's response to the White Paper consultation ("Next Steps") and what it says or updates about HealthWatch (HW). As far as I can tell, it's strengthened issues around advocacy (particularly by saying advocacy services can still be contracted for directly by LAs, rather than sitting within HWs), strengthened HW representation on Public Health and Wellbeing Boards, and generally reduced the need for overview and scrutiny.

Of course, I'll blog on what Next Steps actually says about HW when I've read it.

But in the meantime, today saw an event in the area I work on the establishment of a local HW. Here are some quick and dirty observations of the day:

• The level of understanding of what the Health White Paper is seeking to achieve is low
• The level of understanding of what HW England and the local HW will do is low
• The level of understanding of the relationship between HW England and the local HW is low
• There is a significant divorce between health and social care in the views of service user "representatives"
• "Entrenched interests" doesn't come anywhere near explaining the problems facing commissioners of local HW over the next few months
• If today was anything to go by, the profile of people directly engaged as "representatives" and volunteers in LINks at the moment can be summed up in two words: (1) old; and (2) white
• Partnership working between organisations who are or will be relevant to the local HW feels a long way off
• For areas where there are unitary and county councils close together, the question of whether there is a joint Health and Wellbeing Board across all of them or a separate one for each is a very, very thorny one
• This said, the question of whether there is one local HW per council or a local HW operating across several is a bit easier - it's only a very thorny question and not a very, very thorny one
• No one knows what money will be available to commission the local HW, or whether it will be ring-fenced. I'm guessing not, since it will sit in LA budgets. (As a comparison, in 2009/10, the DH awarded £24.3m across all 150 LINks.)

This may all sound like doom and gloom, and at least in that regard it's similar to most other proposals in the Health White Paper.

But it's not.

All the government needs to do is create some clarity soon on the topic of HW England and local HW in order to allow commissioners to demonstrate the local leadership they are hugely capable of.

Next week's Health and Social Care Bill may give us this, so amid the tumult of discussion about the big ticket items, remember to keep an eye out for what the Bill says on HealthWatch.

Update: Of course, I forgot to mention whether social media was mentioned as a means of engagement for HW. Apart from the most cursory of mentions - a gesture towards Facebook - it wasn't. A few of the kool kids at the back of the room whispered about it away from the more vocal participants in the day, but it was a useful reminder of how little wider awareness social media there is amongst parts of the population and as part of the debate/solution to engagement.

It would be great to have the opportunity to change that.

More positively, there seems to be some excellent LINks work at the moment on Twitter - see and .

The Department of Health has published a number of accompanying documents to the Health White Paper that was itself published last week. Having written a detailed analysis of patient voice in the Health White Paper, I was thus particularly interested in the "Local democratic legitimacy in health" follow-up paper.

Though the paper addresses nowhere near all of the questions I outlined in my previous post, there is some good stuff in this accompanying paper on the role of local HealthWatch (HW) organisations (paragraphs 14-19).

In particular, it should be noted that additional funding will follow additional functions being added to local HW responsibilities (para 16), which themselves build on the Local Involvement Networks (LINks) that already exist.

These additional functions will be as follows: 1) an NHS complaints advocacy service, and 2) supporting individuals to exercise choice (essentially advocacy in its traditional sense). These are laudable functions which should make choice more available to everyone. I still have concerns over the ugly bunfight that will take place as existing and substantial advocacy organisations bid (through tender processes run by the local authority) for the right to become local HWs, but that's something that the voluntary sector has become more used to over the few years.

A further welcome clarification is that one local HW representative will sit on the proposed statutory Health & Wellbeing Boards, representing patient voice and both influencing and contributing to the local decision-making process (para 40). This is supported by local authorities being responsible for supporting "local voice and the exercise of patient choice" (para 10) and should be welcomed.

The paper is strangely silent on what HealthWatch England will be, how it's arranged, what it will do etc. I suspect this is because the government thinks this will be straightforward; I don't think it will be, for reasons outlined in my previous post.

As ever, some confusion remains. This confusion is contained within two topic areas: 1) why the NHS and health encroaches so much on social care, and 2) the non-top down, top down approach.

Let's take (1) first. For a document that has "Liberating the NHS" and "legitimacy in health" in its title, this accompanying paper sure does make considerable claims on social care. The key to understanding this better is to understand the differences between health, public health and (social) care and how they relate to and overlap with each other. I hope the planned White Papers on public health and social care will be clear on this.

The non-top down, top down approach is far more interesting.

In paragraph 28, the White Paper is keen to say that requirements for Health & Wellbeing boards will be "minimal" and that Local Authorities will enjoy "freedom and flexibility" as to how such a board would work.

But in paragraph 25 the government specifies that its preferred approach for proposed joint working on health and wellbeing is to establish a statutory board for such work. Indeed:

• Paragraphs 29 to 33 specify the four functions of such boards
• Paragraphs 34 to 37 specify how the boards will operate
• Paragraphs 38 to 41 specify who will be members of the boards, including a statutory obligation for commissioners and local authority staff to attend
• Paragraphs 42 to 50 note that the government wants the statutory functions of existing Overview and Scrutiny Committees will transfer to the proposed boards.

In truth, I don't have any particular issue with specifying in statute the role and requirements of Health and Wellbeing Boards, especially if they are to receive presumably extra funding, transferred from the to-be-defunct PCTs, in the form of ringfenced health improvement budgets.

But it's whimsical to pretend that this doesn't represent a top-down approach from the centre.

It's also whimsical to suggest this approach will remove "ongoing political interference from the health service" (paragraph 6). If there's one thing involving elected Councillors at a local level will do, it's introduce political interference into the health service.

This additional paper is useful and gives some encouraging detail on local HealthWatch arrangements, which were missing in the White Paper itself. But there remain significant questions around HealthWatch at a national level and the tensions of the White Paper between patient-led and GP-led reforms do not feel to be sufficiently addressed by the introduction of statutory health and wellbeing boards under the control of Local Authorities. And the ongoing confusion as to how health, public health and social care relate to each other quickly needs to be addressed by the imminent White Papers so as to appropriately reflect and recognise the distinct difference in what each of those policy areas requires as policy solutions.

This post also appeared on Stable and Principled

The launch of the coalition government's Health White Paper has made for interesting reading this week. Probably the best reaction to the proposals came from :

The document's flaws are in two main areas: those of Emmentalesque holes; and of biscuit contraception (the bits that are fucking crackers).

For reactions and criticisms that capture the key issues of the plan, I would certainly recommend Civitas's analysis and the series of posts that Paul Corrigan is writing.

In this post, I'll cover one element of the White Paper that I haven't seen much coverage of elsewhere: patient voice.

As there are gaping holes and tensions in the proposed reorganisation to enable GP consortia commissioning, so there are for patient voice within the new set up.

The key tension throughout the White Paper is who is in charge of decisions about care: the patient or the health professional? In their introduction, Cameron, Clegg and Lansley say that "patients will be in charge of making decisions about their care". But the talk throughout the rest of the paper is of "empowering" health professionals. In principle, the interests of health professionals and patients are aligned, in the same way the interests of social workers and service users are aligned in social care. But in practice, the interests of professionals (and social workers) often override - and indeed undermine - those of patients (and service users).

Such professional interest leads to patients fitting around services rather than vice versa (as noted in para 1.9). Which begs the question as to why the whole narrative the coalition is pushing in these reforms is one of giving GPs more power and responsibility for commissioning local health services? It's an odd paradox that the patient involvement proposals (see below) won't sufficiently overcome.

One phrase in the White Paper slightly sticks in the throat: "Nothing about me without me" (also appearing as "No decision about me without me"). Those of us familiar with the disability movement will recognise the appropriation of that movement's clarion call: "Nothing about us without us". For disabled people that phrase represents freedom, choice, independent living and the desire to have the same opportunities as non-disabled people. For NHS patients and doctors, it represents something altogether more managerial and process focused.

There are, though, some good things in the White Paper. These include appropriate recognition that some people will need extra support to enable them to have effective choice, and an understanding of the potential of Personal Health Budgets and a commitment to their contuining piloting and evaluation.

On the surface of it the introduction of HealthWatch - a "powerful new consumer champion" - also seems like a good thing. At the national level, HealthWatch England will advise the national bodies associated with the White Paper reforms (the NHS Commissioning Board, Monitor, and the CQC) on a variety of topics. It will also provide support to local HealthWatch organisations who themselves will ensure the views and feedback of patients and carers are part of the commissioning of health and social care. Through HealthWatch both nationally and locally, advocacy services will be provided to support patients in exercising choice in the healthcare system.

But there are a series of questions relating to HealthWatch England that need answering before we'll know whether it will be effective or not, as follows:

• HealthWatch will be "independent". If this is so, why does it need to be based in the Care Quality Commission? Why can't it be a separate entity in its own right?
• It's odd to suggest that the NHS Commissioning Board "will champion patient and carer involvement" in healthcare (para 2.4), will "promote patient and care involvement" (para 4.11) and "involve patients as a matter of course in its business" (para 4.11). Isn't this the role of HealthWatch?
• What are HW's governance arrangements? Will it be a separately constituted organisation (e.g. a charity)? Will it be an NDPB? Will it just be a separate entity with some form of Memorandum of Understanding between it and CQC?
• Related to the questions on governance are questions on who will provide HealthWatch's leadership? Will it have a Board that oversees the senior management team? If so, will that Board be patient/user-led? If not, why not?
• If HealthWatch is "new" what happens to existing national service user engagement organisations across health and social care? Will they be allowed to bid to become HealthWatch? Or will HealthWatch sit alongside them? If HealthWatch replaces them, what happens to those organisations?
• Why does HealthWatch England only provide "advice" to NHS Commissioning Board, Monitor, the CQC and the Secretary of State? Why is it not empowered to take part in joint decision making?
• Given the above entities are going to be or already are statutory bodies, will HealthWatch England be the mechanism through which they meet their Public Sector Duty and Duty to Involve obligations?

At the local level, the White Paper outlines that the current mechanisms for service user engagement - Local Involvement Networks (LINks) - will become local HealthWatches. This makes sense, but with some cautionary notes:

• The contracts for LINks are in the process of being renewed in time for April 2011. The White Paper's timeline says HealthWatch will be set up by April 2012 and LINks will work towards becoming local HealthWatches during 2011. What happens in terms of service user representation during that year? It is, after all, the year in which the Shadow NHS Commissioning Board is established, the NHS Outcomes Framework is published, GP Consortia are established in shadow form, and Patient Reported Outcome Measures are identified and embedded
• The level of funding available for LINks from April 2011 has yet to be determined. When will this be done? Given the importance of patient involvement in the NHS, will it benefit from the real-terms increase associated with these reforms? If not, why not?
• In the proposed partnership arrangements at a local level, will local HealthWatch representatives be formally involved in decisions or merely consulted?
• LINks are expected to both represent user views to local commissioners and also provide advocacy-based services. My experience of organisations operating on both the demand- and supply-side of the health/social care market is that it can happen, but very rarely does so effectively. Does the White Paper expect too much of LINks, given their current infrastructure and capacity to deliver? What will it do to support the building of effective HWs to undertake the role expected of them?
• The desire for advocacy services is welcome, but I'm concerned by the focus (highlighted in the Analytical Strategy paper associated with the White Paper) of these on particularly supporting people who lack capacity to make choices. Advocacy services actually benefit everyone and shouldn't just be thought of as being available to people subject to the Mental Capacity Act.
• Advocacy is quite a crowded market (especially in social care). The LINks contracts and the role of HealthWatches in future will create a massive bunfight between existing provides at the local and national level, which local politicians may not have the courage to address or let take its course when it inevitably happens.

As they stand, the reforms in the Health White Paper represent the culmination of six years of thinking in Opposition by the now Secretary of State for Health, Andrew Lansley. If the proposals had been laid out in a Green Paper for the intention of deliberation and consideration, I'd have more reason to be positive.

But as with nearly every other part of the Health White Paper, the ill-thought through tensions between patient-led and GP-led reforms and questions around HealthWatch at both a national and a local level mean that it's very difficult to have any confidence the reforms will do what the coalition government hope.

I was struck by this comment made by David Cameron during his Skype call with Mark Zuckerberg:

Normally if Government wants to engage with people we’d probably spend millions of pounds, even billions, on our own website, and with your help we’re basically getting this public engagement for free.

This is revealing in two ways:

1. Making Facebook the government's "primary" communications method for debating with the public is being driven by the fact it's free, not because it will actually result in anything useful.
2. Cameron seems to think it could cost the government "even billions" of pounds on a website to engage the public.

That last point is demonstrably untrue.

Notwithstanding Cameron getting a bit carried away because he was talking to one of the kool kids, and therefore exaggerating in a playground-like manner, it does hint at Cameron's mindset when it comes to whether government should or shouldn't be leading debates with the public, or whether other providers (probably private ones) could be doing it for them.

As so often, a great post from Matthew Taylor with his key points about effective consultation, which I paraphrase as:

1. Public opinion is inconsistent and often contradictory
2. Debates are often dominated by special interest groups, which by definition focus on the area of public spending/cuts that affects them
3. Consultation is very different from engagement or deliberation with the public.

Taylor then rightly notes Participatory Budgeting as a good example of policy making, where people have been brought up to speed on the numbers and the policy issues involved in a given issue and then participate in making decisions. I've noted something similar here before, though doubt its widespread use in the upcoming spending decisions.

Also, it's worth noting the perspective of a senior local government type I was talking to about PB, as participatory budgeting is known:

It's all very well, but there won't be any Bs to P in.

The Kent Messenger reports:

Plans to reveal more details of how Kent County Council spends millions of pounds of taxpayers’ money by publishing monthly accounts have been backed by county councillors. The move is expected to result in the authority setting out much more comprehensive details about how it spends £1billion on goods and services each year...

Cllr John Simmonds, KCC cabinet member for finance, said he wanted KCC to take a lead in meeting the much greater expectations of the public for councils to be open and transparent...

Cllr Simmonds warned that there were practical problems given the size of KCC and its budget, as well as issues of confidentiality. "In one week, we have 6,200 transactions of £1,000 or more. What I do not want to do is put lots of information out there that nobody will make any use of. I am in favour of openness but the public will not thank us if we spend millions doing it. Whatever we end up with, we have to make it worthwhile."

I had some thoughts on this type of suggestion a few weeks ago. To summarise: monthly income and expenditure reports are fine, but is an operational detail that isn't particularly useful. However, involving the public in setting budgets for a one-year or three-year spending cycle - i.e. Participatory Budgeting - is much more powerful.

Through the excellent Joseph Rowntree Foundation, Age Concern London yesterday published an interesting paper on involving users in commissioning. (I've covered previous JRF publications in this area here and here.)

For anyone who is interested in user engagement or user-led work, Age Concern's report is well worth a read.

Partly to support the launch, I gave a talk about Community Care Live today on this topic, the text of which is below. The main point I wanted to make was that finding the solutions to some of the most challenging aspects of the personalisation of adult social care - for example, workforce development, registering Personal Assistants, or market development - can be found through involving users.

User Involvement in Commissioning

All feedback gratefully received.

On the back of an interesting Twitter exchange with @paul_clarke and @jackcabnory, I wanted to get some thoughts down about budgets, transparency and the public. I'm afraid it is likely to be a rambling, incoherent post; it is also written by someone who has a keen interest in finance issues but who has literally no professional qualifications in its practice. Please do keep these health warnings in mind when you wonder what the hell I'm on about below.

My starting point is @jackcabnory's suggestion that the government should publish a monthly balance sheet showing all income and expenditure. This way, the public would know what the government was doing on a month-by-month basis and the state of the finances in general.

Of course, nearly all organisations - in the public, private and voluntary sector - will have monthly income and expenditure (I&E) reports, which are sent to managers so they can see how their budget stands. The quality of these budgets will vary significantly from organisation to organisation, but you would hope that they detail I&E against what was planned at the year start, monitor against the profile (i.e. the fluctuations in income and expenditure anticipated throughout the year the manager), and give variances therein (i.e. "this budget line is +10% compared to what we thought it would be at this point in the year").

In principle, it would be absolutely fine to publish these monthly I&E sheets for every relevant 'unit' within each organisation so that they public can see them. By 'unit' I mean either the organisation as a whole, or perhaps by directorate, or perhaps by team within each directorate. They're all part of the same and will lead to the overall position of the organisation one way or another. You could even bring together I&E reports from organisations in the same sector (e.g. health) within a defined geographical region to get an idea of I&E across a region.

In an ideal world, such I&E sheets would be published with a commentary so that anyone reading the reports could understand the context behind the plain figures in front of them. Such commentary might include, for example, an indication that a significant invoice hasn't been paid, which is what leads to a given significant negative variance on a budget line. Such commentary would also help to negate some of the typical issues associated with the practicalities of budgeting in general: information will always be published in arrears (typically 10 working days or so after the end each month); there is inevitably a reconciliation process through which expenditure is moved from budget line to budget line to ensure it is captured in the right place; there will be typical limits within which an organisation is happy for there to be variances (often leading to 'reporting by exception' where only real problems are highlighted); and there is operational detail that a manager will be aware of which isn't necessarily captured by any sort of commentary.

The question then comes: so what? What can a member of the public do with this information? It could tell someone if an organisation is achieving value for money. But how does a member of the public - who probably uses 'common sense' as a measure - tell if an item of expenditure represents good value for money (especially if it's been through a procurement process)? The information could tell a member of the public is there is a massive overspend or underspend in expenditure. But what would a member of the public do with that information? Ask for their money back? Suggest a 'unit' spends no more money until it has its books back level?

And, more to the point, even if the publication of the figures enables a member of the public to ask a reasonable question of the manager or organisation involved, who is to say that the manager's manager or the overall management board isn't already addressing the issue? And what is the extra administrative burden not of publishing the information (which is straightforward) but of processing requests that come from it (cf significant Freedom of Information departments within government departments)?

If I sound skeptical on this specific issue of publishing I&E reports monthly (or even quarterly), it's because I am. I'm not sure about the added value publishing budgetary information on a monthly (or quarterly) basis would bring.

Where I am in support of transparency in budgets, though, is in the annual process of (a) reporting the budget, and (b) setting the budget.

In terms of (a), public, private and voluntary sector organisations are already pretty good at this. All public agencies publish their annual income and expenditure, and all voluntary sector organisations registered with either the Charities Commission or Companies House are required to publish their annual reports (for example, the organisation I work for has its results published here). In public meetings such as Annual General Meetings (AGM), members / shareholders of organisations, or the public at large, are entitled to question an organisation's management team or Board on the budget and interrogate it at any level of detail they wish. That this doesn't happen very often is a failure more of engagement than transparency, and I would absolutely welcome more interrogation of my budgets annually.

But perhaps the most exciting element is (b) - involving people in setting budgets. In this scenario, an organisation can set out its available resources and the way in which they need to be spent according to whether funding is 'reserved' (i.e. has to be spent on a specific project) or 'unreserved'. Other stipulations can be made (e.g. staff salaries, rent, stationery etc.) but then any discretionary budgets available can be put to members / the public and the question asked: "how should we spend this money?"

This type of work has a reasonable heritage, under the name "Participatory Budgeting". There's a PB Unit in Great Britain (see here), which defines PB and some of its benefits as follows:

Participatory budgeting (PB) allows the citizens of an area (neighbourhood, regeneration or local authority area) to participate in the allocation of part of the local Council’s or other statutory agency's (health services, police) available financial resources. PB aims to increase transparency, accountability, understanding and social inclusion in local government affairs. PB applies to a varying amount of the local Council’s budget and the actual process is developed to suit local circumstances.

In practice, PB provides citizens with information that enables them to be engaged in prioritising the needs of their neighbourhoods propose and debate new services and projects and set budgets in a democratic and transparent way. As the process becomes embedded it involves citizens being engaged in an annual budgetary cycle of setting priorities and budgets and monitoring the delivery of projects and services.

The beauty of PB is that it's about the vision for an area or a policy sector that the public might want to see. Seeing monthly I&E reports is fine, but it's an operational detail that is probably best left to staff of organisations to oversee, with appropriate scrutiny by their boards or equivalents and through the annual reporting processes. Setting budgets for a one-year or three-year cycle, however, is much more powerful, and enables local citizens to make real choices about where their priorities are.

Participatory Budgeting, alongside proportionate transparency in income and expenditure reporting, enables the public to put their money where their voice is.