The way in which we frame our relationships determines the outcomes we will achieve.
If we invite people to answer a question they will (because they want to be helpful) attempt to help us answer it. So, consultations on services usually come up with ways in which a service might be improved rather than question whether or not the service should exist in the first place, its relative importance or its relationship with others.
The NHS has a long tradition of framing its relationship with the public in a particular way and although the language may have changed along with government policy (patients, consumers, users etc) the focus has remained the same:
“we would like to talk to you about the health services we provide”
This framing usually leads to a rather distorted view of how NHS Patient and Public Involvement perceives us – citizens.
I think there are three ways of thinking about people:
- We live – work, play, have families, learn. pay taxes and so on
- We give – we contribute to civil society – we volunteer formally and informally
- We receive – we are recipients of services – in this case health services.
I think that the NHS tends to see us like this:
This perception pushes us into being less of a person – we are instead ‘a consumer’ or ‘a patient’ and both of these roles carry with them assumptions of passivity. We receive healthcare and when our opinions are sought they are only understood to be valid within the context of our role as patients or consumers.
I think we are actually more like this:
Of course, when we become unwell the relative proportions of who we are may change – so we may be more of a patient (receiving) for a period of time.
Despite good intentions I think it is very hard for the NHS to break away from thinking in this sort of way. This leads to discussions which have increasingly diminishing returns as we try to use patient experience to help us improve services and efficiencies. This is because the discussion happens acontextually – not recognising the wider factors that impact on our lives, that have a greater effect on our health and wellbeing – employment, education, housing etc and our view of ourselves as more than a consumer or patient – a citizen.
We need to develop an ease in speaking about wellbeing if we are to move away from procuring services in silos. This means giving a greater focus to mental health and talking more about the social determinants of health.
I think that the continued survival of NHS survives increasingly relies on us moving to a dialogue which is about us as citizens and our wellbeing, the alternative is a narrow consumer dialogue – promoted by this government in particular – which drives us more quickly to increased marketisation and privatisation.
What do you think?
This is a story about some work I have been doing for the last year or so to improve the way the expertise of grass roots organisations is heard by local commissioners.
There’s nothing inherently wrong with the Joint Strategic Needs Assessment (JSNA) and the Joint Health and Wellbeing Strategy (JHWS) but the way they have been developed means that they are:
- read by few,
- provide a very high level view of need that is largely based on a set of standard national measures
- struggle to bend system priorities to complex, small and pressing issues that too often slip below the radar.
It is often the case that it is these small, complex ‘wicked’ issues that grass roots organisations are tackling on a day to day basis – and they feel frustrated that the problems they are addressing do not seem to be understood at a JSNA or JHWS level. This of course is one of the reasons why commissioning continues to favour big statutory and private organisations.
I think that one of the reasons this happens is because we fall into the trap of thinking that the JSNA process is primarily a linear one – gather up all the data, put it all in one place – a web site or a report and then analyse it.
I am not arguing against this process – its good to have a population level view - but it is not sufficient if we want a genuinely responsive, inclusive and integrated approach to local commissioning, specifically one that is able to bring issues forward that:
- Affect small populations
- Are complex – multi-causal
- Have poor incomplete data sets
- Are about power, exclusion and inequality
Many of the organisations that work in this area are voluntary and community sector ones. If you work in areas that are easily ignored with people who are unpopular with policy makers then you are likely to struggle to be heard too. Witness the Trussell Trusts exclusion by Ian Duncan Smith.
So, we need a more asset based approach. One that gives voice to these organisations, playing to their strengths and allowing them to share their analysis of the issues they are tackling. This means providing opportunities for the expertise of these organisations to play in and for the voice of the people they serve to be heard.
It also means making it worthwhile for these very pressured organisations to contribute to the process.
Rapid Intelligence Review
About a year ago I started a project to try to come up with a rapid way of trying to address this problem – this is not rocket science. Working in partnership with Involve Yorkshire and Humber and funded by what was then the Yorkshire and Humber Public Health Observatory (now Public Health England Knowledge and Intelligence Team) we devised a model based on the following principles:
- It had to make little demand on the voluntary and community sector in terms of time or resource
- It needed to be led by a VCS view of what issues we should focus on
- It had to capture a more complete story – so a mixture of qualitative and quantitative data
- It had to be cheap
- It needed to make some recommendations
The VCS in two areas (NOVA in Wakefield and Voluntary Action Sheffield) with their respective local authorities worked through the process with us. In Sheffield they identified food banks and specifically the people who use them as the priority area and in Wakefield they identified Pressured Parents.
Jake Abbas (Interim Director, PHE Northern, Knowledge and Intelligence Team) and I have written an overview report on the process which has now been published by Public Health England. This is titled:
The experience of doing the two reviews has led me to the following conclusions:
- the JSNA process cannot just be about putting all the data into one place – it must also include a continuous process of small reviews that focus on “wicked issues” and the process for determining these should be jointly agreed with local civil society organisations.
- it is important to have actions and recommendations – but for a number of these issues just using the review to create a debate at a place level is a step forward.
- we need a more inclusive view of evidence – lack of population level data or RCT evidence is not a good reason for failing to investigate a topic – its actually an abrogation of responsibility.
What do you think?
Jake and I will be sharing this work at the Local Area Research and Intelligence Association Conference this year – and hopefully at other national events – if I can get the abstracts done!
The recent BMA survey of the public health profession provides a useful insight into the current concerns of public health professionals and into the general condition of public health as a profession.
The survey is worth reading. However, I think its message is quite different to the headline statements from the Faculty of Public Health and the BMA. They have chosen to focus on two areas of loss.
Loss of Independence and Loss of Medical Professionals.
“We are particularly concerned that over half of the people surveyed say they don’t have the freedom to speak out. That freedom has saved countless lives in the past when public heath leaders have spoken out, often going against the grain of popular opinion to do so.”
“This survey confirms what our members have been telling us for several years: public health specialists are very concerned that the new public health structures in England are a risk to people’s health. We know the system is working well in some places, but the number of professionals who are considering leaving the public health profession is one of many reasons for concern.”
John Ashton President of the Faculty of Public Health
John is supported here by Penelope Toff the BMA Public Health Committee Co-Chair
“Two thirds of doctors who responded are considering leaving the specialty and more than half of medical trainees are planning to move on.”
Lets have a look at these two questions in turn.
Q – “I have the professional independence I need to speak out on public health issues”
- Agree – 49.90%
- Neutral – 23.7%
- Disagree – 26.4%
Ok, it is possible from the above data to truthfully claim that less than 50% of public health professionals believe they have the professional independence to speak out, after all the figure is .1% below 50%.
But it is equally possible to say:
“Hooray! Twice as many public health professionals feel that they have the professional independence to speak out, compared to those who do not feel they can speak out”
Indeed if we were to put aside those who were neutral we could even claim that almost 2/3 of public health professionals who have an opinion about this feel that they do have the independence to speak out.
Q – Medics – have you considered leaving the profession in the past two years?
- Yes – frequently and or seriously – 25.7%
- Yes – it has crossed my mind – 34.7%
- No – 36.3%
So from these figures Melanie says 2/3 of medics have considered leaving the profession – presumably she has added together “frequently/seriously” and “its crossed my mind”.
Of course we don’t know how many people who said ‘yes’ have actually left the service and the single largest group are those who have never thought about leaving the service.
In the last 3 years it has ‘crossed my mind’ on a number of occasions that I might go and live on a canal boat, in a remote cottage, travel round the UK in a trawler etc – I have no intention of doing any of these things. (Yes, I know that some people reading this wish very sincerely that I had taken up one of these options.)
I think it is perfectly reasonable for people to indicate that leaving the profession has ‘crossed their mind’ and for them still to be generally happy and committed to their job.
More Survey Problems
Of course the survey has no base line either – so it is hard to know what public health professionals might have said when they were based in the NHS. I can still just about remember those happy days and there were plenty of public health professionals then who felt constrained by the bureaucratic and apolitical straightjacket of the NHS.
So we do not know what the variation is between present perceptions of independence and past perceptions when public health was in the NHS. That is of course what matters.
My favourite question has to be:
Q “In my local authority, the public health grant is not seen as a resource to be raided”
This is beauty! What a loaded question! This implies that some local authorities are being run by Highwaymen or Vikings – excellent! For those of us long in tooth I remember a constant complaint in the NHS was that there was no specific public health budget allocation at all – with any funds having to be fought for and protected every year.
For a good objective account of the current state of play in public health funding read the article by Gareth Iacobucci in the BMJ. In this there is a thoughtful response by John Middleton (Vice President of the Faculty of Public Health) who notes that:
“My (council) is no different (transferring money from the public health budget), although we are taking the opportunity to remould services in a more evidence based and public health focused approach … Its not wrong to apply public health funding to other areas, but some councils have just done it very crudely”
In the same article Duncan Selbie Chief Executive of Public Health England notes that:
“I welcome local government reviewing where the money has been spent. Local government is pretty advanced in looking at outcome based commissioning and of course they will be looking for more value….. the duty is to improve the public’s health, not to provide a public health service”
What is the real issue?
I think focusing on loss of independence and funding distracts from addressing a much more important and serious issue which I would suggest is something like this:
“How to develop a strong fit for purpose public health profession that is seen as relevant and useful to local government.” Importantly it also distracts from building on some of the strengths and positives that also come through this survey.
What the survey tells us
This is a profession in transition and as the introduction to the report on the survey notes – a divided one. It seems to me that non medical public health professionals and trainees in particular are generally more positive about how they view the future.
It also seem to me that there are quite large numbers often around 30% who are undecided about the present and future prospects for public health. In some ways this is fair enough – we are only one year into this transition.
There do seem to be as many concerns about Public Health England as there are about working with Local Government.
- This is a profession in transition, the Faculty in particular has to come to terms with a changing membership that is increasingly non-medical and recognise and represent their interests more.
- Public Health is still bedding into the new structures.
- Its not just about local government – if anything there are more fundamental concerns about Public Health England
- Trainees are generally positive about their future.
- Non Medics are positive about the future
- The independence of Directors of Public Health (whatever that means) is not under threat
- It is tough in public health – but that is no different to the experience of the rest of local government and the voluntary sector – there are common causes to be made.
It is really important to be working closely with local authorities to design a profession that works for them and not to try to impose the existing model onto them. It is particularly important build on and support those in the profession who are successfully establishing credible relationship within local authorities.
What do you think?
I was pleased to see the recent blog by David Buck at the Kings Fund “Health Inequalities we need a national conversation” calling for more collaboration and clarity between Public Health England, NHS England and the Department of Health. I share his frustration at the continued lack of co-ordination and leadership shown by these big (and comparatively well funded – compared to local authorities) national institutions.
I do however, take a different line.
First, I am really tired of the way national agencies and government launch into these national ‘conversations’. So was concerned to see (thanks to David drawing attention to it) that Public Health England have started one of these.
Remember the “NHS Listening Exercise”? What about Tony Blair’s “Big Conversation”? Or David Nicholson’s Call to Action? None grabbed me, maybe some of you reading this thought they were tremendous and made a real difference – if so please leave a comment!
Thus far I have been unimpressed by these attempts to establish a national dialogue with citizens and local players. They too often feel like a half hearted attempt to engage with the public and front line who already have quite enough to do with getting on with local challenges.
Having said that Public Health England do seem to have a more considered process which involves focussed interviews with Directors of Public Health, Councillors and local voluntary organisations.
Of course it is important to bring local voice and experience powerfully to national agencies. I just think that dialogue should be built around substantial long term relationships which recognise independence of view rather than fixed term conversations.
As a trustee of Citizens Advice I am impressed by the model that this organisation uses – but they are not unique – There is a long list of NGOs who provide evidence based challenge to policy – they include MIND, CPAG, Barnado’s, Disability Rights UK etc. Some of those get funding from government and its agencies to the irritation of right wing think tanks like the Institute of Economic Affairs who pejoratively brand these organisations “Sock Puppets” in their recent publication “The Sock Doctrine”.
One of the important services provided by Citizens Advice is to capture the evidence of need that emerges through front line delivery by its 350 or so member Citizens Advice Bureau across the country and interpret this, using it to bring suggestions for policy improvement and sometimes direct policy challenge. Through doing this they directly contribute to making policy better, society fairer and democracy stronger.
I think DH, PHE and NHSE in particular should look across the communities and people they serve and check that they are providing sufficient resource to advocacy organisations ranging from local government to the voluntary sector to ensure that they are exposed to continuous evidence based policy challenge. If they were to do this consistently and in a co-ordinated way they would not need one off ‘Big Conversations” instead they would be continuously exposed to powerful debate and dialogue from organisations who are directly connected to citizens and front line services.
Second, a little comment on David Bucks three national agencies and his suggested actions.
- NHSE – fully support his call for a greater focus on what primary care can do to tackle health inequalities – as I pointed out in an earlier blog the NHSE inequalities strategy is to put it politely – weak. I do think it is unfortunate though that the two areas that David focusses on are both to do with physical health – the role of of primary care in addressing poor mental health is crucial here.
- Public Health England – I am not convinced that David is right in calling for PHE to do more on health impact assessments of other government departments – for the reasons I outline above I think it would be better that PHE funds local government and NGOs to do this work – this will give much more independence and transparency to the challenge.
- Department of Health – I struggle to have expectations of the Department of Health. While I take David’s point on the Social Value Act I think that local commissioners just need to get on with it and guidance would probably better come from the sectors concerned.
We need to push government not rely on government departments giving us permission.
What do you think?
I have been involved as a trustee or committee member of various voluntary organisations for a long time. Well actually – for a very time.
I have become increasingly concerned that it is us in the voluntary sector who are too often unclear about the role and contribution of trustees. This is ironic because the voluntary contributions of trustees is one key element that makes the voluntary sector different and brings so much added value.
The dead hand of governance
I know that as the conversation turns to governance its time to switch off…. don’t stop reading just yet! I am going to try to avoid getting sucked into a piece on the bone dry world of corporate governance here.
I know they are not elected but being a trustee of a voluntary organisation – local or national – is just as political (with a small ‘p’) as being a councillor, MP or non exec on an NHS trust board but I don’t think this similarity is sufficiently understood or utilised within the sector.
It is too often the case that executive teams see trustees on voluntary bodies as a necessary evil – who will go through and check their work at board meetings – provide some useful support to key internal processes such as HR and Finance and sometimes bring a bit of internal testing on user experience and that – more or less – is it.
This is frankly not good enough. If we are to play to the strengths of the voluntary sector we need to expect that trustees will bring with them much more than this – here are three examples:
Specialist Technical Knowledge – When I was a trustee of a specialist CAB working in the mental health sector we always had at least one specialist NHS mental health worker on the board and often a current or ex service user of mental health services.
Environmental Analysis – another voluntary organisation that I am currently a trustee of has clearly worked hard to ensure that they have a wide range of trustees who have powerful connections and current experience of the wider social policy environment in which the organisation operates. The board spends little time on long discussions on finance, HR and programme implementation – the CE clearly understands that they have to do the bulk of this work and report on it to the board. Instead the CE uses the board to understand the environment, test ideas and develop strategies for action.
External Relationships – Trustees can bring real added value to developing relationships at the top of organisations. In many cases voluntary sector managers – even at Chief Executive level are compromised. I think that some of the challenges they face can include:
- Status – executives in a voluntary organisation may be at the top of their organisation but large funders – for example a local authority funding a local voluntary organisation – will see them as effectively a middle manager at best. They will often allocate a fairly junior manager – usually responsible for contracts to manage the relationship. This immediately reduces what should be a strategic relationship to a contractual service provider one.
- Conflict of interest – discussions about funding – particularly at a time of cuts – can be particularly difficult when these are led by managers whose staff (and indeed the manager) may be materially affected by the outcome of negotiations. This is particularly true when local funders will know that the final decision about financial viability and strategies to address deficits rests legally with the trustees not the manager.
Trustees are actually the custodians of an organisations values and vision – they should be in the best position to articulate these to leaders of other organisations – elected members, MPs, trust governors. They bring with them an experiential authority that comes from their willingness to take on unpaid positions of leadership on voluntary organisations boards. In my experience politicians and non executives understand, respect and value this role and welcome the opportunity to have this sort of dialogue and relationship.
It is through building these strategic relationships that foundations are laid for long term practical joint action and sometimes even funding!
What do you think?