Results tagged “involvement”

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.

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.