January 20, 2013 by Protect Our NHS
‘Voices for Health’
Communication, Engagement and
Many thanks for your letter. I will respond to it as well as the above document in the light of the 10th January meeting on the role of the PRGs in commissioning. Forgive me if I look at more general issues, but I think that it is crucial that the broader context is considered.
The strategy document is long and complex but can be summarised as being a statement of intent that wishes to develop a commissioning system that takes into account the wishes and needs of the local population as well as using patient experiences as a way of improving the commissioning process. The integration of all levels of health services as well as with social and other services is seen as critical to success.
The Health and Social Care Act, on the other hand has deliberately created a market system in which services are provided by multiple, independent organisations that are meant to be acting in competition and a multi-layered commissioning system that has no duty to provide services. In order to create the checks and balances required to temper the possible excesses of a pure market a whole series of monitoring organisations have been set up making the system highly complex.
Locally there are only a few, very large secondary care providers so that the ability to “play the market” is very limited accept by either commissioning services from relatively far afield or breaking up the providers in some way neither of which would appear to enhance the integration agenda. The system is further complicated in that each large provider will be holding commissioning contracts with multiple small commissioning groups. How this will affect these groups ability to negotiate individually tailored terms is unknown.
Much of what is written about the Act talks about the patient being at the heart of the system. I would suggest that the contract is more likely to play the most important role. From my understanding, what care the population gets depends critically on what is in the contract. I would suggest, for instance, that all providers must commit to open quality and audit systems; all clinicians must be willing to publish results which would be analysed by an independent expert body; patient complaint be treated as critical learning events and so on. Once the contract is signed, the commissioners can only monitor activities that have been agreed. Whether Healthwatch may have a broader remit and be able to question the contract contents, I’m not certain.
“No decision about me without me” is an eye catching slogan that confuses more than it clarifies. On the level of personal health management it is clearly critical that all decisions are made through agreement and consensus between patient and clinician. When looking at commissioning and managing the situation is entirely different. Managing a health care system can be seen as juggling a whole series of conflicting interests while trying to fulfil the almost impossible aim of creating the best of health for the greatest number of people. Understanding and taking these conflicts into account is critical if a rational system is to be developed. The Health and Social Care Act has made the situation far more complex by adding a market system and the penetration of private sector provision into the mix. Below, in no particular order are a few of the interests and resulting conflicts that need to be taken into account. The patient voice is still important but how to get it heard is the question. The lack of any action plan or conclusion following the recent meeting on the role of the PPGs in commissioning supports this contention:
- Increasing health care costs against willingness to pay
- Responsibility to private shareholders vs value for money for the commissioners
- Demand for treatment by a pressure group vs best evidence
- Single issue campaigns vs broader health needs
- Short term political gain vs long term planning
- Intuitively good ideas vs best evidence
- Clinicians personal work life balance vs patients’ wishes
- Research needs vs clinical care requirements
- Academic wishes vs practical application
- Teaching vs service provision
- Patients’ convenience vs system efficiency
- Management vs clinicians in decision making
- Central government vs local priorities
- Preventative vs curative care
- Primary vs secondary care
- Medical injury compensation vs learning from mistakes
- Commercial confidentiality vs freedom of information
It is reasonable to say that there is a significant consensus amongst clinicians that the only way to develop a modern health service is to have highly integrated care in which primary, secondary and tertiary care see themselves as part of the same system. The system should be coordinated so that the patient has confidence that all the members of the extended clinical team are working together, communicate well and have his or her best interests at heart. The various conflicts of interest as outlined above need to be recognised and addressed openly. The system is based, critically on good information about performance and quality. The example of how cardiac surgery has improved performance since the Bristol heart scandal is exemplary and clinicians’ willingness to be involved in open self-assessment and audit was crucial in improving care.
Patient care pathways and communication between clinicians are critical areas in which patients will have a great interest. I assume that these will be included in contracts though how one large provider will deal with multiple different systems negotiated by the CCGs is an interesting thought. PPGs and practices could play an important role in developing pathways and communication systems though my experience suggests that they are not easy to get right in practice and require time and resources that may not be available.
Teaching and training should be a central part of all components of the system and should be based on the integrated model. No part of the organisation should have the luxury of avoiding this obligation. Private sector provision makes this aim potentially very challenging.
So what are the possible ways in which patients might be involved in health care planning?
- As you have said in the paper, patients can sit on the various committees to give a “patient voice” though an individual is only going to give personal views on commissioning decisions which could certainly be viewed as inappropriate if strongly held and partisan in some way. Given the complexity and inevitable bureaucracy of the committee process it is likely that the patients on these committees will not be representative of the population. Having lay reps is important but I do not see it as a way of gaining valid information to inform commissioning decisions. Lay people that take in managerial roles also have a tendency to become involved in the management process and lose sight of their status as lay representative.
- Single issue organisations are very likely to be vocal (Parkinson UK and Clevedon Hospital were topics that were prominent at the CCG governors meeting on the 15th Jan.). It is clear that the conflicts of interest raised by these groups will have to be very carefully managed though their opinions on commissioning will be very important.
- Feedback from patient complaints and comments about services should be an important source of information. The commissioner/provider split is likely to make getting information difficult in that providers, particularly private may not want to “wash their dirty linen in public”. It is however crucial that complaints are understood and used to improve services. Healthwatch may be critical in this. As far as I am aware, this area was not mentioned in the document. I may well be wrong.
- GP practices could have a role in surveying patients about specific issues such as outpatient experiences and this information might be very useful. Setting up such surveys is costly and it is unlikely that practice would foot the bill. PRGs may play a role but this would probably depend on the enthusiasm of a few individuals. I note that there is no budget for a PRG role.
- Social media and web based feedback systems could prove to be a very interesting way of monitoring quality of care though I suspect that analysing the validity of the information might prove challenging.
- HealthWatch would appear to be critical in giving the patients a voice in how the system is run. Commissioning group and Healthwatch must communicate effectively in order to know how the providers are doing seems to be critical. There does seem to be a potential for duplication if both organisations are monitoring services. The Health and Social Care Scrutiny panels and the Care Quality Commission also seem to be playing similar roles. I would be interested to know how these various bodies will communicate in order to get a coherent idea of provider performance. PRG will need to decide whether they wish to be involved in commissioning groups, Healthwatch or both.
The other important aspect of this issue is motivation. Why should PRG members spend time and energy involving themselves in health service commissioning and monitoring? I would guess that an altruistic desire to do something for the common good may be the reason for some, though not many. Allied to this may be self interest in that they are going to be recipients of health care sooner or later. Others will be involved because of a personal interest in a specific area of health care. The Health and Social Care act has motivated many people (including me) to be involved in order to monitor the adverse effects of a combination of severe public expenditure restriction and the opening up of care to the private market. These different motivations will determine how PRG members will want to interact with the system and further complicate planning.
The Winter Gardens meeting was useful in terms of informing the attendees about the NHS changes but failed to develop any sense of how PRGs might be involved. As a next step I would suggest that you contact all North Somerset PRG chairs asking them to give an indication as to whether their groups wish to be involved either in the CCG or Healthwatch and what aspects are of interest to them. Your team could then arrange a meeting, the agenda being based on the group’s ideas on what interests them.
The practice’s attitude will, of course be most important in all of this. After all, the Government’s big idea was that GPs should be driving the planning of health care provision. It would say a great deal about the concept if the doctors “on the ground” do not see that supporting patient groups in their involvement in this new world is a priority.
I hope that response is useful,
With best wishes