This blog is about the way Public Health England commissioned Well North
To be clear – I am not criticising Aidan Halligan – I am criticising Public Health England – but that will be obvious.
In February 2015 Aidan Halligan a charismatic, passionate and visionary public health champion announced at a conference in Chester that:
“Duncan Selbie has sent me to the North of England to make the invisible visible”
Aidan was announcing the establishment of a programme called ‘Well North’ that was going to support local authorities in the North of England tackle health inequalities. The scheme was to be funded by £9m of Public Health England money over 3 years with the intention of 9 participating local authorities matching this.
Well North (A full description of Well North is available here) with Duncan Selbie as the Board Chair was launched in July 2014
The ideas around Well North built on Aidan’s work on the Homeless Pathway in London, Hot Spot Analysis at Aintree Hospital and high performing teams informed in part by military training methods, the last of which informs some of the ethos of the NHS Staff College where Aidan was the principal.
From Briefing to Oldham Health and Wellbeing Board Alan Higgins Director of Public Health
Like many I was surprised that this initiative had appeared – it had not been publicly requested or tendered for – The Due North Report report (published Sept 2014 and commented on by me here) had been produced by the ‘North coming together’. It makes no mention of ‘Well North’ even though both were in preparation at around the same time and both funded by Public Health England. Yet Duncan Selbie in his Friday Message from 18th of July 2014 which had been endorsed by Felicity Harvey (Department of Health Director General for Public Health) was able to say:
“There is a need to address the causes of ill health as well as seeking to cure the consequences. This has inspired the North to come together in a programme, led by the Academic Health Sciences Centre in Manchester, they are calling Well North, a strategically collaborative programme which seeks to tackle the wider determinant complexity of the whole problem, making visible the previously invisible (predominantly inner city) at risk people and attempting to solve rather than only manage their illnesses and anxieties.”
PHE Management Cttee Paper – Michael Brodie April 2015
A number of people in the Voluntary Sector were irritated – they had been lobbying Public Health England with little success for funding support and suddenly saw £9m go to an initiative that no one seemed to have requested!
A couple of FOI requests later and I was none the wiser.
The report they eventually sent me says that the original idea and approach came from Professor Ian Jacobs, the then Dean of University of Manchester and Director of the Manchester Academic Health Science Centre.
When tragically, Aidan died suddenly and unexpectedly Well North seemed to grind to a halt. It felt as though the whole programme was built around his energy, presence and ideas.
On November 6th 2015 Duncan Selbie in his Friday message told us that:
“Aidan had been the Founder of Well North, he was also the inspiration for its ambitious vision to radically change the life chances of thousands of our citizens who face some of the worst health inequalities in the country.“
The Review does identify a number of positives – not least the energy and commitment of some of the pilot local authorities. What will be galling to people like Judy Robinson (ex Chief Executive of the sadly missed Involve Yorkshire and Humber – victim of the cuts two months ago) is the emphasis that the review places on shifting resources from the public to voluntary sector, which is a message she and others have consistently championed with PHE.
There are criticisms – if you want an example of how to deliver these diplomatically just read the executive summary – here are some of the key points with my translation.
In order to ensure sustainability and impact of any project it is best if:
- Key Stakeholders from the communities concerned are directly involved in identifying what the problem is and have had a role in co-producing the solution
- There is an explicit and public procurement process – not a reliance on ‘who you know’
- The commissioned service is not built around individuals but organisations
- Its always good to make sure that your left hand knows what the right hand is doing
What do you think?
NHS England has invested millions of pounds in its NHS Citizen programme to strengthen its dialogue with the public. Unfortunately, where it really matters – when its decisions affects whole communities – there is no dialogue.
Here’s the story
Darnall Wellbeing is a small community organisation in Sheffield working alongside citizens in this poor, multi-racial, vibrant part of our city to help them improve their wellbeing. Darnall has a community that includes white British, South Asian, Somali, Roma, Eastern European and more.
Darnall Wellbeing works hard to integrate its services with other voluntary organisations and also the local General Practice – who are all salaried employees of Sheffield Health and Social Care Trust – they are called the Clover Group and provide a General Practice service in 3 other parts of the city as well.
Approximately 3 years ago Darnall Wellbeing made a decision to move into the same premises as the GPs in order to provide a more integrated service. This move is in line with the ambition set out in the NHSE 5 Year Forward View for ‘Multi-Speciality Community Providers’.
This is about providing a better service with citizens from the local community bringing their skills and creativity to create solutions to Health and Wellbeing on their terms.
Darnall Wellbeing has
- 4 Health Trainers (including one recently recruited from the Roma Community)
- Over 40 Volunteer Practice Champions – who work with the General Practice
- Over 40 Community Health Champions
People in Darnall have created:
- Cycle Training
- Dance groups
- Conversation Groups……and more
In addition Darnall Wellbeing is part of the Enhanced Primary and Community Care Project with the General Practice. This identifies those who are most likely to to be at risk of premature hospitalisation and then tailors targeted health and community support to them. The Practice Champions and Heath Trainers are the bridge; building relationships and community support for these priority people.
Then along comes NHS England
NHSE are tendering for the Clover Group service – the outcome will directly affect Darnall Wellbeing and the citizens of Darnall have helped to create this integrated service.
So the chair Dr Jack Czauderna wrote to NHSE on the 9th of October. his letter is available here, one of his key concerns was:
“we are minded about the degree of consultation which NHS England are required to carry out when making commissioning decisions in Primary Care. This particularly applies to the involvement of patients in these decisions. The community organisations, particularly related to Darnall include many Clover patients among their staff and users. DWB has at least 40 Practice Champions who volunteer around health issues but remain patients of the Clover Practice.
We are formally asking you:
- What consultation have you undertaken so far with the communities who rely on these services?
- If asked would you be prepared to come to a public meeting to explain your tender specification and how this will improve the services, assets and health needs of these communities?”
On the 6th of November Darnall Wellbeing received a reply from NHS England NHS England reply (I have taken out names) which can be read here, there is an excerpt below:
“In terms of the consultation process, advice received is that as the services to be recommissioned by NHS England (core, additional and essential GMS services) remain the same. Therefore there is no service change for the element NHS England is responsible for and patients should experience no adverse change to the services they currently receive.
NHS England will be employing a communications strategy to keep patients and the current provider informed of any developments.”
Not good enough
- The ambitions set out in the NHS England five year forward view don’t seem to be understood by staff who are managing procurement. The letter says that services “are the same” as they were before the Five Year View was written. I cannot see how the contract for these services “stays the same” when NHS England has in the interim produced a report that explicitly calls for different service models!
- As I explain above the Darnall service has not “stayed the same’ there are now rich co-produced relationships involving almost 100 local citizen volunteers who are directly involved in delivering a sophisticated holistic service in partnership with the practice.
It feels as though there is a no interest in engaging and talking directly to the communities and organisations who are actively involved in seeking to improve their own wellbeing and are at the front line of creating a the new health service that the five year forward view calls for.
As I said in an earlier blog – I support the 5 year view – its analysis is good and its call for greater integration and strengthening the role of the voluntary sector is spot on its just that NHS England don’t appear to be working to it!
I don’t see how NHS England can run a procurement process without bothering to understand what the Darnall model might be and the implications of this for any tendering process.
What do you think?
Declarations of Interest
I am a trustee of Darnall Wellbeing and a Lay Member on Sheffield Clinical Commissioning Group – the views above do not represent those of either organisation.
Here are 3 small stories about voice and digital. A lot of organisations use digital as a tool to connect with the public. Much of it is ‘broadcasting’ sending messages out, but some also try to to use it enable dialogue and voice.
The first story – can I eat that lettuce?
This story is really just a bit of fun. I was walking past Leeds City Hall and saw that they had turned their flower beds over to vegetables – they looked great! Two people were looking at them and one of them picked a radish to eat and said to me “do you think I am allowed to do this?” I had no idea and tweeted the council with a picture – this is what happened:
I think the response from the council was great – whoever was managing their account responded quickly, answered the question AND used the request to point me in the direction of their allotment service – clever!
Story two – the Mental Health Champion
Those of you who read this blog regularly will know that I have been involved for years as a trustee of a Citizen Advice Bureau and have a particular interest in improving access to welfare rights for people with mental health problems. I am concerned that there is not consistent provision across the country for this small but vulnerable group of people who are 4 times more likely to be in problematic debt than the general population.
So when Kevin Fenton (National Director for Health and Wellbeing for Public Health England) wrote on his blog saying that he was going to be the organisations champion for mental health I left a comment calling for more action on welfare rights for people with severe mental illness and pointed at the evidence this is what happened:
Again, I think the response from PHE was good and since then I have had a conversation with Gregor Henderson and I am hopeful that with the Centre for Mental Health and others we can make some progress on this issue.
Story three – NHS Citizen
One of the ways that twitter is used is to have a ‘tweet chat’ basically a conversation over twitter usually for an hour. So when I spotted that NHS Citizen the engagement arm of NHS England were having a tweet chat on mental health – I joined with the aim of lobbying with regard to the same issue – welfare rights and psychosis. This is what happened:
The response here was not so helpful. As you can see the person running the tweet chat referred me to the NHS Citizen portal. As I understand it this is a mechanism that allows members of the public to raise issues – champion them virtually, gather supporters in the hope that by so doing a particular issue will rise to the top and be considered by NHS England at its Assembly.
While in theory this sounds good in practice I am less convinced for a number of reasons:
- It assumes that issues have not already been debated and considered in the real world – so risks adding another layer of bureaucracy
- Surely we don’t need to take all issues through this process – some should be dealt by engaging with appropriate officers
- It makes debate less public taking it into a controlled and managed space – you have to go on to the portal to find out what is going on
- I think it aims to bring a co-produced democratic approach to this sorting – but its a bit of a delusion as it does not attract very many people (see the comment from Simon Landau above) issues are considered by a very small number of digitally literate individuals. Look at the global rank of the NHS Citizen Site (the national engagement website for the NHS) compared to that of a local Clinical Commissioning Group! – not good! Also, see this screenshot taken on the 24th of October 2015 – look at the number of people involved in each issue – the best I found was 70 odd – not in this screenshot.
What this experience made me think about.
NHS England has invested large amounts of money in an extensive ‘digital democracy architecture’, neither Public Health England nor Leeds City Council have – yet my experience with both of these was more productive.
If you are going to have a mechanism for dialogue with the public make sure that:
- the people running the engagement are well informed and using engagement as an opportunity to progress action rather than referring to another place where the member of the public has to start all over again
- the mechanism needs to be simple to use and easy to join
Most fundamentally – theoretically correct and apparently rational models of engagement can actually stifle dialogue and democracy – it should all be more fluid and less managed than this!
There is a broader issue, some private sector companies have a twitter feed that is a key tool for dialogue with the public – from rail companies to Waitrose etc. Public Sector organisations have by and large not gone down this route – there are exceptions like the Leeds City Council example above.
I wonder if NHS England were instead to invest in some empowered staff to manage their public twitter account whether they would actually have much stronger engagement than the complex architecture of NHS Citizen?
Rather than tidying up the dialogue, organisations need to change their behaviour and culture to be more inclusive of the diversity and complexity of conversations
What do you think?
Those of us who work locally commissioning and delivering health services can be certain of one thing – the next five years will bring more cuts and we will be involved in making decisions about what actions we should be taking in response to these.
This was brought into sharp focus for me recently when the CCG governing body that I am a member of held a meeting in public to discuss making changes to funding to some GPs in the City . The meeting was attended by some 80 people from these practices – with many coming from some of the poorer parts of the city.
What I learnt
Its crucial to allow people to express their concerns first. Many of the people attending had clearly given a great deal of thought to what they wanted to say and had genuine anxieties about their service that they wanted the governing body to hear. It was the case that people who were not used to speaking in public had spent time working out what to say – some writing it out in preparation.
It can lead to a much better meeting if people are given their opportunity to have their say at the beginning of the meeting – this way they help set the agenda – and they are not left sitting there waiting for their allotted slot and wondering if they are will be allowed to speak. Its about respect – we talk about our role being for the public good – when members of the public take time out of their busy lives to turn up we have an obligation to respect their contribution.
Most of us just cannot grasp the scale and complexity of the NHS and its funding. If we are going to move to genuine engagement we need to be really sharp when it comes to describing how the decision that is being discussed fits into the wider context.
We need to:
- set out the relationship between specific funding changes and the wider financial situation.
- explain how the changes that we are considering will practically affect the services that they are concerned about specifically and services as a whole
- explain the role and purpose of the organisations concerned – NHS England, the Clinical Commissioning Group and so on
Some local authorities have realised that they need to be much better at providing information to the public as they seek to manage the awful government cuts to their budgets. I think that the infographics and video produced by Sheffield City Council are good examples of this – others clearly agree – Leeds City Council have used the Sheffield model for their own budget information.
In the NHS – CCGs in particular we need to be doing the same.
People come to public meetings – giving their time – because they are concerned, anxious and committed to an issue. It is crucial that the meeting is managed in a way that not only gives them a chance to have their say but also gives a clear view about what will be done to respond to concerns that have been raised.
It is important that when people leave they go away not just feeling that they have had their say but are clear about what actions will be taken next.
I am not aware of any good practice guidance produced by NHS England on holding meetings in public. I rather liked his piece from the USA Journal of Extension on The Do’s and Don’ts of Working with Local Communities: Tips for Successful Community-Based Public Meetings.
I do not think that NHSE should produce guidance – I think they should fund an expert organisation with a track record of supporting powerful exchanges between citizens and public services to produce it.
What do you think?
InfoGraphic by Generation Rent and Piktochart
When it was first published I shared my views on Due North on my blog here and here There were elements that I liked and others that felt to be important points but it was hard to work out what practical actions might stem from some of the challenges.
So I was keen to have a look at the 30 page PHE response – which when laid out on my dining room floor looks like quite e a long read!
Fig 1 – ‘the full monty’ – PHE Response to Due North 30pp
Luckily, once I had got rid of the case studies and contents pages it became a more manageable 10 pages – and I realised I could boot out the introduction as well which reduced it to a swift read before breakfast while the coffee was percolating.
Fig 2 – ‘the easy read’ – the actual PHE response to Due North 10pp
The two reports are a real contrast. The Due North report represents a coherent attempt by local authorities, the voluntary sector and academics to present an evidence based case for a stronger focus on the social determinants of health.
The Public Health England report is not a response to these recommendations – instead it is a statement listing work that Public Health England is already doing in related areas. There is one line in the introduction that refers to issues that have emerged from Due North specifically – mental health, violence and smoking – none of these are mentioned as possible areas of action for the future in the main body of the document.
Of course I know that Public Health England is an executive agency of the Department of Health – but I have attended two conferences where the Public Health Minister has said that they expect Public Health England to bring challenge to government policy. While I understand that this sort of public statement does not translate so easily into practice the latest Department of Health remit priorities letter for Public Health England states:
“The Government expects PHE to be an authoritative voice speaking for the public’s health and acknowledges that this can include constructive mutual challenge between PHE and national Government”
So, we should expect at least some public ‘challenge of national government’ Yet the PHE response does not appear to engage with the anxieties and concerns that local government has – for example the impact of welfare reform including the recent scandal over ESA deaths, cuts to local authority budgets, poor quality housing and the the role of the voluntary sector.
It talks about fostering debate but if this report is anything to go by it shows little evidence of ability to generate it.
Its actions feel anodyne, safe and irrelevant – for example its great that they now have an MOU with 20 agencies in the statutory and voluntary sector around housing and health. However, given that some of the real concerns are the present government’s policy commitment to push right to buy onto Housing Associations and the iniquitous role of a some private landlords where is the MOU with organisations advocating for tenants rights such as Generation Rent, Shelter and Citizens Advice? Where is the ‘debate’ about the health impact of further right to buy – given that there is now good evidence that the biggest single beneficiary of this policy are private landlords?
Voluntary Sector – How about getting a bit of a debate going now?
While the report indicates that PHE are part of the DH review into the future of the voluntary sector it could do better than say that they will wait until the outcome of the review – surely PHE has some view of the current role of and issues facing the voluntary and community sector and what it thinks might be some of the areas that are worth exploring further?
What to do?
Its clear that PHE are constrained by Government policy, I think the approach taken by Paul Johnstone in the North – commissioning an independent external agency like CLES is the way forward. I am not convinced that commissioning more evidence and producing more guidance is going to help a great deal.
Those of us at the grass roots need credible voices rooted in practice telling our stories and offering challenge at both a local and national level. So, we need more funding from PHE to independent agencies and to the voluntary sector who can genuinely generate debate and external challenge.
What do you think?
Increasingly we are on our own. As the government promises us further austerity targeted at the most disadvantaged, we are are also to get greater devolution (see Local Solutions for a Healthy Nation and The Local Health Service?). It is therefore our responsibility to ensure stronger collaborations between services and most importantly with citizens.
We know that we need to integrate services – not just across health and social care – but more widely in order to address the social determinants of health
One of the biggest challenges we face is that the organisational cultures and behaviours we have been trained to use work against co-production with citizens, integrated service delivery and shared responsibility.
A key part of this are the performance management systems that all statutory agencies work within and that define the relationship (through contracts) that statutory funders have with local voluntary organisations.
One of the most eloquent critiques of the deficit of current performance management approaches comes from Toby Lowe – who has worked for many years in the voluntary sector in Newcastle but is now an academic at the University of Newcastle.
In essence Toby argues that the performance management system we use starts from simplistic definitions of the outcome that is desired (which has to be measurable) and then works back to identify actions that will produce that measurable outcome.
He argues this can lead to actions that:
- don’t address the real problem
- gaming to achieve targets
- reclassifying what counts as success (see recent government changes to Child Poverty measures)
- Making up the figures
(You can listen to Toby run through a more detailed account of his work here)
I would go further and say that this approach also:
- Pushes agencies to only worry about their targets rather than taking a shared responsibility for the wellbeing of communities. So, hospitals worry about their performance targets but don’t take responsibility for what happens to people once they are discharged back to the community.
- Takes attention away from the strategic and pushes it towards the operational. So, in the health world we often spend time at the highest strategic level on performance measures that focus on tiny operational failings such as trolley waits or failures to hit 4 hour targets in A&E while at the same time we devote less time to real strategic issues such as the relevance or quality of whole services or the reduced life expectancy of whole communities.
In this new devolved world we have the responsibility, incentive and opportunity to develop a local performance management system that is better than the bean counting Westminster driven system.
The work that I have been doing recently as part of my work at Leeds Beckett University offers some solutions. We have been working with Health Watch England to develop a common approach to helping local Healthwatch and their stakeholders understand whether they are effective or not.
This has involved developing a set of Quality Statements which we have produced through working with over 40 local Healthwatch. The Quality Statements cover the range of local Healthwatch activities from the operational to the strategic.
The idea is to use them to create a platform where local stakeholders who have some responsibility for making Healthwatch work can have a shared dialogue about the effectiveness of their local Healthwatch.
The aim is to move away from trying to measure impact and instead trust the expert opinions of a range of stakeholders who work with and are affected by local Healthwatch.
We think that responsibility for local Healthwatch does not just rest with Healthwatch or with the local authority commissioners but with a range of other stakeholders (we are not prescriptive here because local circumstances vary) but they are likely to include:
- The Healthwatch Board
- A range of local authority officers – not just the contract managers
- Members of the Health and Wellbeing Board
- Healthwatch staff
- Local Voluntary Organisations
- Advocacy Agencies
The approach we have trialled involves using confidential questionnaires sent to individuals from the above groups followed by a facilitated discussion based on the survey.
Early trials have been positive. It provides for a collaborative discussion about effectiveness and impact and as importantly a recognition that there is a shared responsibility for the Healthwatch function – which is ultimately about using citizen experience and knowledge to improve health and wellbeing.
I think that this sort of approach has a much broader application. It could be used with other key services – for example General Practice or a Citizens Advice Bureau.
It helps to develop a more inclusive approach to understanding and improving how services work to meet need. Along the way it also builds capability and understanding about services and how they work – and can help unite service providers, commissioners and citizens in a shared view about what is important and what is possible in present circumstances.
What do you think?
(with thanks to Jennie Chapman, Toby Lowe and David Walmsley for collaboration and inspiration!)