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?
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.
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?
At the moment we (Leeds Beckett University) are doing some work for Healthwatch England developing ways in which local Healthwatch and their stakeholders can understand how effective a local Healthwatch is.
It is challenging to come to a view about the effectiveness of a small organisation with a very big remit whose impacts are often long term and therefore hard to measure.
One of the tools we are testing is to gather views of a wide range of local stakeholder organisations through a 360º process using the Healthwatch England Quality Statements (we developed these earlier in the year in partnership with local Healthwatch) to produce an analysis which is then considered at a facilitated workshop.
Gathering and analysing a wider stakeholder view should help contract managers (who are usually middle managers) have a more effective relationship with local Healthwatch.
What is clear is that the opinions of all stakeholders are shaped by the context they work in. Here are some thoughts:
It depends on where you sit
Organisational stakeholder’s perceptions are to some degree influenced by the position and role that they occupy, for example:
- Managers of services may have experienced local Healthwatch through being subject to an investigation or having sight of a report that may relate to their service. So, they will have a good and detailed knowledge of that specific interaction but may not be aware of the broader range of services that local Healthwatch provide or the other roles they perform at a more strategic level. It is also the case that a service that has been investigated by local Healthwatch will have to account for any criticisms they may receive to senior figures in their own organisation – this may feel uncomfortable.
- Leaders such as Cabinet Members, Directors and members of Governing bodies generally have a different experience of local Healthwatch. They are more likely to be aware of the broader scope of Local Healthwatch activities and may have a more personal relationship with local Healthwatch senior officers and board members through formal and informal strategic meetings.
- Different sectors perspectives vary. For example it could be argued that health providers have a view that is focused on the services that they are funded to provide. Local Authorities and NHS providers are large organisations and it is unlikely that all staff will have a shared understanding of a small organisation like Local Healthwatch, while a CCG with fewer staff and a broad health scope may have a more rounded view of local Healthwatch – but within the context of NHS commissioning.
It depends how you talk
There is evidence that the way that large organisations such as local authorities and NHS bodies are organised means that there is an emphasis on understanding the world primarily through analysis of quantitative data (demographic and performance) and evidence from research.
This is not the way in which citizens and communities operate where much more emphasis is placed on personal experience and the stories that describe them. Local Healthwatch operates in between these two constituencies, part of its added value is reflected in its ability to bring the public ‘into the room’ in a way that is understood and accepted by these large organisations.
Remember the history
Local Authorities and many health providers can often trace a continuous history going back over 100 years. It is very easy in the highly pressured environment of health and care to forget that local Healthwatch are actually very small and new organisations. Their effectiveness relies heavily on relationships, with the public and with stakeholder organisations. Local Healthwatch have been in existence for less than three years, they are still developing their expertise and their relationships with citizens and communities.
So, any analysis of effectiveness cannot just rely on a totting up ratings and opinions – these are important – but there also has to be some account taken of the context that respondents are working within and it needs to be understood that the effectiveness of a local Healthwatch while ultimately its responsibility can be improved by bigger players in the system helping; actions could include:
- Including an explanation of the Healthwatch role in all induction for new staff
- Briefing middle managers on the role and current activities of their local Healthwatch
- Agreeing what good practice should be when working with local Healthwatch on an investigation
What do you think?
With thanks to Healthwatch Dorset and Leicester, the local authorities of Poole, Bournemouth and Dorset and of course, Jennie Chapman