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Private Sector Health Providers and local accountability – Quality Accounts and local Healthwatch

July 12, 2016

quality account blog

In an earlier blog I mentioned some of the good practice being developed by local Healthwatch with regard to engaging with and influencing Quality Accounts.

The NHS Choices website states that there is a statutory responsibility for all healthcare providers over a certain size to produce a Quality Account and to seek the views of local Healthwatch who if they wish may send a written response. This is affirmed in the Healthwatch England Guidance.

The logic is clear – a bit of local voice based on the experience of the public can provide a reality check, foster engagement and bring a bit of informed challenge to this annual statement.

This mechanism could become more important as we move to more devolution, integrated care and co-production with the public as local health and care systems respond to the ambitions set out in the Five Year Forward View.

Whats the problem?

When we compare the approach taken by NHS Trusts to the private sector in particular there is a striking contrast.  While the private sector does produce Quality Accounts their quality is more variable and they often do not appear to seek the views of local Healthwatch or the local Overview and Scrutiny Committee.

A quick scan of a couple of private hospitals in Sheffield shows that only one mentions engagement with their local Healthwatch.

The problem gets worse when you look at some of the big players in this field who operate across the country.

For example Partnerships in Care have around 60 sites across the country and specialise in providing services to some of the most vulnerable people (people with a learning disability, people with a head injury and people with a mental health problem). They produce one Quality Account for the whole service and it has no comment from a Healthwatch – although it does have a comment from one ex service user who now works for Rethink  he also commented in the previous Quality Account.

Service user comments are very important – and a number of private sector Quality Accounts have these – however, I think the views of an organisation such as a local Healthwatch are qualitatively different – they have a duty to consider a Quality Account when asked and are accountable for the views they express in a way that individuals are not, in the case above  I don’t think that the comment reflects the views of Rethink.

I could not find many examples of where a private sector provider has sought the views of a local Healthwatch and that Healthwatch has responded – but there are some.

Care UK in their 2014/15 Quality Account include comments from Healthwatch in South Gloucestershire and in Bristol. Also since writing the blog Sian Balsom from Healthwatch York has said that the Ramsay Clifton Park Hospital in York have asked them to comment on their Quality Account for the last two years. However, Ramsay have a network of 22 acute hospitals and their practice does vary – for example there is no mention of Healthwatch in the Ramsay Berkshire Independent Hospital Quality Account.

I could find no mention of local Healthwatch in the Quality Accounts that I looked at from:

Circle Group – for example see Bath and Nottingham
BMI General Healthcare – see for example the Priory Hospital Birmingham and Clementine Hospital
Spire Healthcare produce a national Quality Account – again no mention of Healthwatch in their Quality Accounts
Priory Group who are an acute mental health provider – who also produce one Quality Account

This national issue does not just apply to private sector providers – have a look at the one produced by Marie Stopes – again no mention of local Healthwatch.

Where this leaves us

Advice from NHS Choices is as follows

Screen Shot 2016-07-12 at 12.32.21

There is considerable variation with regard to how independent providers use Quality Accounts and what they expect from them. It does seem as though many independent providers are working in a parallel world where they have a much narrower view of the purpose of Quality Accounts and their relationship with local Healthwatch than NHS Trusts.

  • Some big national independents produce one Quality Account for all their sites.
  • Others produce a quality account for each site.
  • A minority seek the views of local Healthwatch – most don’t appear to.
  • There is a wide variation in the quality and accessibility of the Quality Accounts produced.

What should be done?

  • Local Healthwatch with the support of Healthwatch England should develop an explicit strategy for engaging with the Quality Accounts of the big national providers.
  • Clinical Commissioning Groups should take a more robust approach to challenging private sector providers on the content and quality of their Quality Accounts – some of the ones I looked at above are inaccessible and uninspired.
  • Finally, I think that NHS Improvement need to produce some clear guidance for non NHS providers stating clearly why producing accessible and engaging Quality Accounts is important and why local Healthwatch must be involved in commenting on them.

What do you think?

Are trustees ‘on another planet’ – does the voluntary sector need more regulation?

July 5, 2016

vcs blog

I recently attended a discussion organised by the Galileo Group which considered the above question.

The title comes from a statement by Conservative peer Lord Hodgson, a member of the All-Party Parliamentary Group on Charities and Volunteering, who stated ‘what planet are these people on’? When he heard that one of the largest charities did not want to pay £15,000 to set up the new Fundraising Regulator.

Since this discussion the Charity Commission Report “Public Trust and Confidence in Charities” notes that the level of trust and confidence in charities has fallen to 5.7/10 compared to 6.7/10 in 2012 and 2014.

The temptation is for the Charity Sector to accept the analysis of Lord Hodgson and of the Charity Commission and focus inwards on improvement. I am not convinced that there is any evidence that the sector as a whole has witnessed a deterioration in standards of practice.

Instead I think we are experiencing a ‘moral panic’ driven by an unpleasant mixture of government, some think tanks and some elements of the press

The sector is being criticised in a number of ways:

  • its independence and legitimacy to campaign
  • the strategies they use to fundraise
  • the competence of its governance

There have been cases where some charities have not been as good as we have the right to expect. However, I see no evidence that the current performance of the charitable sector is any worse now than it has been in the past. In fact the growth of an executive function and the diminution of the role of trustees has ironically probably led to greater organisational competence.

It is therefore disappointing when organisations like the Charity Commission fail to provide wider evidence of the competence of the sector and instead produce reports which tell us that the public have lost confidence in the sector because the media and government tell them that the sector is behaving badly.

If you look at other sectors (Banking – various miselling scandals), Service Sector (G4S, SERCO, A4E), High Street Retail (BHS etc), NHS Trusts (Mid Staffs) and judge them on the above criteria there are much stronger grounds for being concerned about their legitimacy, fundraising strategies and governance rather than that of big national charities.

I think that the current highly critical environment exists (there is a good summary in the Morning Star here) – not because the sector is failing – rather the reverse – its actually rather successful despite government imposed austerity. I think this relative success exposes the national voluntary sector to attack because there is:

  • dislike of independent challenge to government
  • concern that the charity model of service delivery is a direct challenge to that offered by private sector corporates who are fishing in the same pond for government contracts.
  • belief that large charities are a redoubt of the left of centre professional class

Sympathy

I have some sympathy for national charities (I am on the board of one – Citizens Advice) they have responded to the marketisation of public sector funding and the move away from grant funding – in some cases quite successfully. This must be galling to private sector providers who are keen to get access to the lucrative public sector market.

Action

I think that the sector needs to develop a more strategic response here.

  • Evidence – there needs to be a clear evidence based view of the competence of the sector. If the Charity Commission cannot do this (and in my view it should) then other players like NCVO need to step up and do the work – we urgently need a robust and clear view of the sector which challenges this moral panic.
  • Governance – it is too easy to portray many charities as the mouthpiece of the professional ‘charitariat’, it may feel frustrating for some to to give some power over to members and trustees but strong accountability and roots into the communities we serve is essential to charities survival and is an important way of keeping true to founding values – avoiding a drift to social enterprise or business.
  • Challenge – national charities must see the gagging legislation as giving them a mandate for evidence based challenge rather than a restriction. Part of all charities business plans should be to raise funds to ensure that they can lobby appropriately to represent the interests of the people who rely on their services.
  • Government – finally the sector should have the confidence to challenge government. A number of the problems here rest with government behaviour. From the sweetheart deals that were done by ministers with Kids Company, through to the way in which lobbying from some charities and private sector companies is condoned while charities are attacked – we need a coherent challenge that places these issues in the wider context of policy influence and access to markets.

What do you think?

Softly and suddenly vanish away – Department of Health Responsibility Deal

June 12, 2016

 

Blog Responsibility Deal 1

Remember the Department of Health Responsibility Deal? It emerged in the early days of the Coalition Government, well, I think its gone. I cannot find any official announcements but articles in the Daily Mail and The Grocer around December 2015 signal its demise – although the word used is ‘pause’.

The Responsibility Deal (RD) was Andrew Lansleys attempt to establish a public-private partnership between industry, government, public bodies and voluntary organisations in England. Organisations involved made voluntary ‘pledges’ on various areas, including alcohol, which are designed to improve public health and hence avoid trying to drive health improvement through regulation. Initially it was aimed at traditional targets – principally the alcohol and food industries but it developed to pick up on other areas notably mental health and health in the workplace.

I have documented some of its struggles in earlier blogs:

Its not our fault guv’

Evidence that the deal is dead is scattered around the web – this includes

Of course the Government has to say that it was a tremendous success – just look at the evidence based (not!) statement below by Parliamentary Under Secretary of State for Public Health Jane Ellison MP this was given as part of her Responsibility Deal Presentation in March 2015.

Screen Shot 2016-06-07 at 22.40.58Who cares that it is gone?

I would imagine that some of the 776 organisations who have signed up to the pledges might be a tad upset that the Government has walked away from this.

Similarly some special interest groups might also be a bit irritated at the time lost by this diversion from real policy change and activity. In my view this applies particularly to mental health in the workplace – where there is precious little activity taking place anyway.

What can be learnt

We do need to learn from this. Most importantly – and I realise this will fall on deaf ears – the Government needs to learn from this process and share this learning. Here are some thoughts:

  • First – there has got to be a realistic view about when regulation is required. The main reasons for key interest groups in the public health world resigning or refusing to engage was because they were concerned that the Responsibility Deal was an inappropriate mechanism for influencing the behaviour of powerful lobby groups in the food and alcohol industries. In a number of cases (smoking, sugar) it turned out that legislation was the only mechanism that would work.
  • Second I do think that voluntary processes that seek to  validate the good and motivate the inadequate are a useful driver for change. Local Authorities in particular use this as way to drive improvement. However, the way the RD was set up – its crude infrastructure, vague pledges, cumbersome website, poor communications and failure to share learning meant that it was impossible to understand how meaningful a pledge was, how much traction it had in a sector and whether it was being adhered to or not. It was far too much about spin as Jane Ellison’s presentation shows.
  • Finally, it is worth listening a bit more to the professional bodies.  If they say that they cannot be involved because they have don’t have confidence in the model – they are probably worth listening to!

At the end of the day the level of its impact can best be measured by the deathly silence from all the organisations who signed up – that is the sufficient indication of its irrelevance.

What do you think?

Where are health Inequalities, Communities and the Voluntary Sector in the NHS England General Practice Forward View?

May 16, 2016

GP Forward View

The General Practice Forward View is an important document, it sets out how NHS England proposes to support the development of general practice through to 2020/21. It is therefore important for all of those working in primary care and communities to understand the opportunities it presents and how it to access them.

Health Inequalities and Communities

Screen Shot 2016-05-15 at 22.23.12
As the graph above shows it was disappointing to see that with the exception of social prescribing there appears to be little recognition given to the context within which General Practice works. So, there is little mention of inequalities and of deprivation and indeed of the voluntary sector.

This is concerning. In Sheffield we have started an exciting piece of work with practices who serve the poorest parts of the city. We recently invited Professor Graham Watt down from the Glasgow Deep End Group. Their work as is shown by the graph below (Scottish data) shows that practices serving the poorest communities are likely to receive less funding yet face much greater demands than practices serving wealthier areas.

Screen Shot 2016-05-15 at 22.24.42

Nonetheless the GP Forward View does present opportunities – not least because there are a range of commitments including one to revisit the GP funding formula to better reflect deprivation and rurality as well as a promise of more funding (£2.4bn more by 2020/1).

There are a number of levers for us to use – they include influencing the development of the Sustainability and Transformation Plans which will include £508m over the next five years to strengthen practice resilience (£56m), grow the medical and non medical workforce (£206m) and support practice redesign (£246m) and a development programme for practices (£30m). Similarly it will be important to ensure that CCG commissioning strategies for primary care include clear actions with regard to health inequalities and the role of the voluntary and community sector.

Here are three suggested actions.

  • Data – any local authority/CCG area needs to be able to describe the particular challenge faced by practices serving the most deprived populations. The Glasgow Deep End Group focusses on the practices working in the 100 most deprived populations in Scotland. We need a similar hard edged focus. It is surprising difficult to re-create the graph above in a CCG area – but we need data on funding, health inequality and activity if we are to produce a robust evidence base that underpins actions.
  • Service Models – It is the case that many GPs have developed hopeful productive working relationships with voluntary and community sector organisations. The current buzz word is Social Prescribing – but many of these relationships predate this. There is often a strong link to a neighbourhood organisation – or community anchor, many of these are members of Locality. This is important because service models and relationships will vary depending on the community. In Sheffield the recent neighbourhood based approach – People Keeping Well – based on populations of roughly 30,000 begins to recognise this level of organisation. Again, the CCG is currently undertaking a piece of work to capture different service models developed by 4 of these GP/Community Anchor partnerships. These service models should help us develop a more systematic approach to promoting ways of working that foster local partnerships with communities.
  • Alliances – I know that this appears obvious. But in this case it is crucial to get General Practice staff, Active Citizens, VCS organisations and other allied services such as Pharmacy and Optometry to come together to design local service models. This is not just about consultations. This has to be an ongoing process of shared enquiry and requires different skills to the ones that NHS Commissioners have traditionally relied on. Again, we can learn from the Deep End model here who use a process of ongoing dialogue which continually spins off briefing papers and reviews. These have the potential to influence local strategies. The methodology is a bit similar to the Rapid Review approach that I referenced in an earlier blog.

What do you think?

Local Healthwatch – Getting Strategic and punching above its weight

May 4, 2016

HW Punch

In our work with local Healthwatch it struck me is that one of the challenges that local Healthwatch face is operating at both an operational and strategic level.

The default for understandable reasons tends to be towards the operational – not least because I suspect this is what they are performance managed on by their commissioner. In other words there is a focus on the delivery of services. In Healthwatch terms this might be:

  • Providing information and advice
  • Undertaking a set of investigations in areas where there is concern – for example on provision of urgent care or dentistry or a programme of enter and view.

All of this is clearly important – a local Healthwatch has no credibility if it cannot demonstrate that it has a clear programme of practical actions developed in response to concerns raised by members of the public.

However, this is not enough – they need to be able to bring their influence to bear at a system level too.

In the Quality Statements that we developed for Healthwatch England last year local Healthwatch identified that one of the most important areas by which their effectiveness should be measured was that concerned with how they manage strategic relationships – their relationship to their local health and care system as a whole.

In order to do this effectively local Healthwatch need to go further than just using their positional power on the Health and Wellbeing Board. From our work I have seen examples of where local Healthwatch are doing this successfully. Here are some examples.

Making Quality Accounts Meaningful

Following a report we wrote on with Healthwatch Leeds on the relationship between Quality Accounts (and Local Accounts) and local Healthwatch – Healthwatch Leeds have continued to develop work in this area. This year they are holding two workshops – the first held earlier this year gave Quality Account leads from across the system (big hospital trusts, hospices, community NHS trusts, the local authority) the chance to share progress they had made to address some of the challenges they identified in the Quality Accounts last year. The second workshop will allow a joint discussion on their draft Quality Accounts for this year.

This friendly, collective discussion achieves the following:

  • Sharing of good practice – its interesting that some of the work that the two Hospices were doing was of particular interest to the much larger NHS trusts.
  • Breaking down silos – this is one of the few places in the local system that brings organisations together to look at how they connect and work together to meet the health and care needs of people in Leeds.

A shared approach to engagement

Healthwatch Leeds pulls together a “Public Voices Group” a regular bi-monthly meeting of engagement leads from across the health and care system – provider and commissioner. This forum provides an opportunity to:

  • Share information on emerging consultations
  • Discuss good practice
  • Jointly publicise activity
  • Undertake joint work – the group recently asked us to undertake a quick survey which looked at how different health and care organisations in the city used membership databases to connect with the public.

Advice and Information

This is an emerging area. In our work across the country it has been striking that the area where the work of local Healthwatch is least understood is that to do with Information, Advice and Signposting for individual members of the public. I don’t think this is surprising for two reasons:

  • First, local Healthwatch are very small – in most cases there contribution to information and advice provision when compared to a large hospital trust, a local authority or welfare rights service is very small. This does not mean that it is not important. A local Healthwatch may be the last port of call for people who have struggled to get advice and information anywhere else.
  • Second, in most local authorities areas no one has a handle of the level of advice and information provision in the health and care world and I have seen no evidence that anyone has an analysis of what good might look like.

I think that this could be an area where local Healthwatch has a role to advocate for a strategic review advice and information provision – who is being missed out and what good might look like.

What do you think?

Getting value from local voluntary organisations

April 5, 2016

blog contracts

You can’t buy long term relationships with short term contracts

The growing recognition of the importance of relationships, user experience and public voice highlights the urgent need for commissioners to look more closely at their culture and behaviour.

Although there are exceptions it too often feels as though the main mechanism for ensuring value with small voluntary sector organisations is through using 3 year contracts (sometimes with a roll over year) at the end of which commissioners go back to the market and tender again. I think this is often destructive and fails to capitalise on the opportunities presented by ‘local’.

Its not as if there were no other examples:

  • Its quite usual for an NHS hospital to have at last a 5 year contract to deliver a particular service agreed with a Clinical Commissioning Group
  • Most GPs have no fixed contract period
  • Academies are offered 125 year leases on local authority schools and land for a token amount
  • Commissioning organisations like Clinical Commissioning Groups work have no specific length to their existence or roles

All of the above are subject to a range of measures, performance systems, inspections, challenges etc that are used to ensure quality and value for money – the main mechanism is not market testing.

Short contract periods are often used because they are believed to be cost effective methods that can be used to assure the public that value has been achieved.

This is quite different from actually achieving value!

I worry that:

  • A reliance on market testing and 3 year contracts takes responsibility away from commissioners of services to engage and foster collaboration with providers to ensure value.
  • Is often used unthinkingly for local relational services – like Healthwatch – which rely on time to build relationships with members of the public and local organisations
  • It does not take account of the strategic role of key smaller services such as Healthwatch confusing size of investment with strategic relevance and therefore allow system leaders to pass responsibility for quality assurance to comparatively junior contract managers who lack the position and strategic position to adequately assess competence.

The balance is of course shifting once again with a greater emphasis on localism and on new structures such as Accountable Care Organisations that seek to build relationships across different providers and with communities. Nonetheless, there is a risk that the emphasis here will be on relationships between the big players – leaving smaller voluntary organisations at the mercy of cruder mechanisms like fixed term contracts and tendering to ensure value.

Solutions?

Evidence and Collaboration

The work we have been doing with Healthwatch England starts to go some of the way to trying to address – using a 360º stakeholder survey that the contract manager/commissioning lead can use (in partnership with local healthwatch) to capture the views of wider players at both an operational and strategic level and then get a system level discussion going that generates a shared view of actions that can be taken to increase effectiveness not just by the local local Healthwatch but by all health and care organisations in the local system.

This sort of model can be used to gather a more sophisticated view of similar small VCS organisations whose role is complex, multi-sectoral and relational. For example community anchor organisations whose contribution is often ‘chunked up’ and defined by separate contracts that fail to capture the relationships, processes and added value. Its important to note that the Scottish Government is moving ahead on making core grant aid infrastructure funding available directly to Community Anchors.

Contract and Grant Aid – theory and models

There remains a crying need for local government and Clinical Commissioning Groups in particular to develop a more sophisticated view to how to best to ensure performance and value. There needs to be an urgent review of funding and performance levers that considers the respective roles of:

  • Small and larger grants
  • When fixed term contracts work and what length they should be
  • What skills and capabilities local systems need to have in place to drive transformation and value

What do you think?

Is that all there is? – Five Year Forward View for Mental Health

March 7, 2016

5yFV MH Task Force

When a system is under pressure a natural tendency is to focus inward at precisely the time it needs to be looking outwards. So its not surprising that this report focusses almost exclusively on the NHS.

The Independent Mental Health Taskforce to the NHS in England report is a determined attempt to raise the profile of mental health services and in particular contribute to action that drives parity of esteem for mental health.

The foreword says:

“we have placed a particular focus on tackling inequalities. Mental health problems disproportionately affect people living in poverty, those who are unemployed and who already face discrimination. For too many, especially black, Asian and minority ethnic people, their first experience of mental health care comes when they are detained under the Mental Health Act, often with police involvement, followed by a long stay in hospital. To truly address this, we have to tackle inequalities at local and national level. ”

The problem is when I look through the report I cannot find this ‘particular focus’.

Inequality

The report does say that inequality is a major cause of poor mental health:

  • People with mental health problems are overrepresented in high turnover, low pay and often part time or temporary work.
  • Children from low income families are are 3 times more likely to be at risk.
  • Children living in poor housing have increased chances of experiencing stress, anxiety and depression
  • People in marginalised groups are at greater risk – especially people from black and minority ethnic communities
  • As many as nine out of ten people in prison have a mental health, drug or alcohol problem

System Failure

The report does make the case for system failure:

  • Three quarters of people with mental health problems receive no support at all
  • There is wide variation in access to services such as IAPT – with waits of 6 to 124 days
  • 20% of people on the Care Programme Approach have not had a formal review in the previous 12 months
  • Mental Health accounts for 23% of all NHS activity but spending on secondary mental health services is equivalent to just half of this.

An argument for funding for NHS providers

The recommendations largely miss out on the root causes of inequality and primary prevention and instead focus on the system at the end of the line – the NHS – social care is poorly represented in the report.

There are almost 60 recommendations. With the majority concerned with local operational matters – how services are delivered, yet the report speaks primarily to NHSE rather than local health and care systems.

I am not saying that this huge wodge of recommendations are bad – but I think the commission ended up not seeing the wood for the trees – it has produced a plan that is about operational change rather than system transformation.

Missing the point

Inequality – The report is unclear about inequality – there is no challenge to how government policy risks exacerbating inequality. Although many of the examples it gives in the introduction are about how societal inequality increases the likelihood of poor mental health. The few actions that explicitly reference inequalities focus on the unequal way in which people who have mental health problems are treated and how some groups of people with mental health problems such as some minority ethnic communities and people who have been in prison are not treated equally.

Community – Locally the role of community organisations, social prescribing etc is increasingly understood yet the VCS barely scrapes into the report – I spotted one explicit reference with regard to navigators.  It is unfortunate that the important contribution that local Healthwatch are increasingly making as positive disruptors in local systems is not affirmed. If there is one area of social policy that needs strong ongoing disruption it is mental health. The need for public and user experience is briefly recognised but needs to be much stronger if real and sustainable change is to occur.

Social Determinants – When the social determinants of health are mentioned it is only within the context of secondary prevention – supported housing and employment support. Of course this is important but we know that the NHS and Social Care are increasingly being used to pick up the fall out from wider government policy attacks on the vulnerable – particularly with regard to changes in the benefit system and housing provision. There is no mention of the prevalence of indebtedness among people with a psychosis despite the strong evidence base to support this.

Money – Others are more expert than me here – but I am not convinced that the £1bn asked for and apparently promised by the Government is close to being sufficient. Tactically the report should at least have called for more funding than it thought the government was likely to give!

What next

  • Local Health and Care systems must ensure that the recommendations and focus of this report are understood to be only a small part of the discussion they need to have locally. It is crucial that the role of Housing Providers, Citizens as advocates, Social Care, Employment Support, Access to Education and communities themselves is also included.
  • There remains an urgent need for a more holistic mental health strategy that recognises the crucial role of the social determinants of health

What do you think?

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