I am involved in 3 local Healthwatch and as they get going one of the first things to think about is the process of setting priorities.
At the moment there are two things I am thinking about.
The first is how to select the priorities of today?
I think that one of the biggest challenges is getting the balance right between the memberships views and other views of priorities. An approach that gives too much weight to building a workplan based purely on the views of its membership runs the risk of setting priorities that do not reflect some of the real underlying concerns that need to be addressed within a health and wellbeing system.
It also lets the Healthwatch organisation off the hook – allowing it to say ‘this is what our members said were concerns’ and therefore not taking sufficient responsibility for addressing important system level concerns that the membership did not raise.
I think that there are three key areas that a local Healthwatch needs to consider and it is the way in which it manages these that then help shape local Healthwatch Priorities.
These three areas are summarised in the diagram below:
The Official Line – What key public documents say
I think the first place to go are the reports produced by public organisations. I am still feeling my way here but would suggest that this should include:
- The Joint Strategic Needs Assessment and Joint Health and Wellbeing Strategy
- Quality Accounts
- Local Accounts
- Relevant CQC Reports
- What other documents would you add?
There is a limit to how many documents a small organisation can read but I think that the above list are probably the essential ones. The key issue is to consider these seperately from any official consultation process. Together these documents represent the official shared narrative of priorities and quality in a place. This is not of course the same as a true narrative!
The Unofficial Line – what the professionals say
Many managers and directors in key organisations will have a clear professional view of system level challenges and failures. A lot of them will be working hard to champion improvement and will be finding it slow or worse. Some will be keen to share their concerns informally – in the hope that some external pressure or interest will help them drive work forward. A gentle process of informal dialogue with a range of key managers will help test ideas about where to probe, investigate and test.
Voice – what the public say
This is clearly crucial. I think that one of the challenges is how to use this important democratic mandate to greatest effect. Listening to the views of the Healthwatch membership and special interest groups is not enough. This has to be about building a mandate through dialogue with these groups. I think this will mean taking a risk and presenting an analysis based on the official, unofficial and voice information and being willing to debate this and amend it with the membership – producing a set of priorities through this process.
The second issue I am concerned with is how to strengthen the democratic voice in the future?
In many cases Healthwatch has inherited quite weak processes from the outgoing LINK (I know not all!). I do think that now is the time to recognise this and it is reasonable to focus some energy in year one on working with key stakeholders to establish processes to improve public engagement processes for the future. It is in local Healthwatch’s interest to ensure that the system as a whole puts energy into raising its game with regard to public engagement as a priority in year one.
What might this look like?
In year one this might mean convening a cross sectoral group involving the PPI leads from the CCG(s), Local Authority, NHS Trusts and big care service player to consider how public voice plays in across their organisations and the local system.
What is the balance between:
- Consultation – individual and collective
- Representation – from membership/patient fora/governers and none exec directors
- Co-production – from focus groups to volunteering
- Feedback – how does this happen?
What support is available for the public (patients, people using care services, carers, the public as a whole, people who experience discrimination) to engage and participate for example:
- Information provision
- Community Development Support
A shared view about deficits and ambition would help lay the foundation for a system that places a greater emphasis on public involvement in priority setting in future years.
What do you think?
I am not sure if this comparative silence is because Directors of Public Health have little responsibility here (see the Department of Health guidance for local government on the role of Directors of Public - Best Practice Guidance - issued in December 2012), or whether the profession is just breathing a collective sigh of relief because it is not under the media spotlight.
I think that public health has a crucial role to play here. Reading the Francis report I am clear about two things
- First – there was a culture of disrespect and appalling treatment to vulnerable people who expected the health service to care for them at a time when they were in great need.
- Second – that because of this treatment it is the case that some people died because this lack of care. However, it is unclear how many people did actually die. The report which is full of caveats and doubts presents a debate which walks around a figure of something between 400 to 1200 people over a period of 12 years. In other words between 33 and 100 people a year from April 1996 to March 2008 (Mid Staffordshire NHS FT Inquiry Vol 1 Section G Mortality Statistics Page 350 onwards). I really hope that I have understood this correctly – please feel free to correct me.
I do not want to diminish the awful experiences of people who had the misfortune ot be ‘cared for’ at Mid Staffs Hospital – but I am concerned that this focus on a poorly performing hospital and the next five that are in the pipeline diverts us from much wider failures in care and public health.
What concerns me is that there are much more significant examples of system failure – with a much greater incidence of preventable death and yet we accept them – there is no Francis Report to challenge these.
At a recent LGA Public Health Conference the excellent Chris Bentley gave a presentation on “Health and Wellbeing Boards with teeth – Interventions that Bite” . One of the challenges for Health and Wellbeing Boards is having a proper grip on the balance between need and actions to address these.
In his presentation he shared information from a study conducted by the University of Birmingham in 2006. The slide is below. We can see that in the UK there were 5.7m people who had CHD of whom the health system (I read this as primary care) was aware of only half and of these only 50% were compliant with their treatment. So of the total population of people with CHD only 20% were actually receiving and taking the treatment they needed! This is system failure on a massive scale – not in hospitals but in primary care in particular.
Of course it is worse than this – because there is a strong inequalities gradient to this picture and as Chris would be the first to say there is an even wider issue to do with societal inequalities such as poor quality housing, low income and lack of power.
As local authorities start to develop their leadership role with regard to the Health and Wellbeing of their communities it will be crucial that they take a balanced response to the challenges presented by Francis. This will mean a measured and thoughtful view on where the real system deficits are in their area and which are the ones that it is important to focus on. This view will affect the focus they place on relationships with the provider trusts, what they hope Healthwatch will achieve and most importantly the level of scrutiny they give to primary care provision and to work to address the social determinants of health.
It will be crucial that local public health provides a thoughtful and confident analysis that allows local politicians to get this balance right – otherwise we will end up being led by high profile, government led, media fuelled reports about priorities and not address much greater injustices locally.