Healthwatch set up to fail?

Two important documents have been published by the Department of Health which focus on the role of Healthwatch England.

The first is a ‘Healthwatch Narrative’ which explains the thinking behind the establishment of Healthwatch England and provides the context for the second which is a consultation on the composition of  the Healthwatch England Committee.

The Healthwatch narrative.

This starts with an assertive justification of Healthwatch England.

Note – 3 overhauls in the last 9 years. This is a service whose role relies on a strong relationship with citizens!

It goes on to say that LINKs have encountered a number of issues (I paraphrase):

• no national body to provide leadership
• they have tended to be unrepresentative
• there has been too much variation and insufficient peer support
• they lack a profile and have no consistent identity which has hindered success and reach

We don’t take citizen led improvement seriously enough

If the above analysis is correct then why have local commissioners and PCTs and their national bodies – LGA, Strategic Health Authorities and NHS Confederation consistently failed to address this deficit?

This is probably because local commissioners have seen the contribution of LINKs and its predecessor CPPIH as marginal to improving the quality of services and therefore not worth bothering about.

I think that the current paradigm for quality and improvement drivers probably looks a bit like this:

LOCAL DRIVERS FOR QUALITY AND IMPROVEMENT

More problems

The establishment of a national Healthwatch Committee is clearly an attempt to address this weakness. However there are further challenges. Here are three:

First – Remit

The summary list of Healthwatch pathfinders came out in October 2011. This lists the topics chosen by the 75 Healthwatch pilots – the diversity of interests and variation in focus is tremendous. This is despite the fact that leadership for most of the pilots rests with local authorities rather than with LINKs – so we might reasonably expect strong strategic direction.

While it could be argued that this diversity reflects local priorities and agendas it is as likely to be an indicator of:

• a lack of engagement at a strategic level in local government – leading to a lack of strategic focus for the HealthWatch pilot
• a mismatch between the scale of the Healthwatch role and the resources currently available – leading to a lack of clarity about mission
• a lack of connection with other approaches to engage citizens at a local level – leading to a siloed approach to an issue that is should be central to all of us – health and wellbeing.
• A reluctance to move from the improvement paradigm I have described above to one that places a greater emphasis on citizen led accountability.

Second – Everything and Nothing

The Healthwatch transition plan identifies Local Heathwatch as the ‘local consumer voice for health and social care’ and sets out its remit as:

• Influencing – help shape the planning of health and social care services
• Signposting – help people access and make choices about care
• Advisory – Advocacy for individuals making complaints about healthcare.

However elsewhere in the literature we also see reference to:

• (Inspection?) – ‘it will also have a remit for adult soial care services including rights to entry to premises where care services are provided’ (page 13 transition plan)
• Public Health ‘local Healthwatch has a role in promoting public health, health improvements and in tackling health inequalities (page 7 DH Narrative)
• Accountability – ‘through Healthwatch, people will be able to hold the new system to account’ (Healthwatch narrative – page 13)

There is a real risk of role confusion, being spread too thin, losing strategic focus etc. Healthwatch has to:

• Signpost people to health and social care services
• Come up with sensible challenge on the quality of health and social care services
• Be an advocate for public health, health improvement and public health.

The danger is that the wicked issues where we have made least progress – public health, health inequalities – will continue to be poorly served and the more traditional areas – right to entry etc will get more attention.

This challenge is not specific to Healthwatch – other advocacy organisations such as Citizens Advice know all about this struggle to get the balance right between responding to individual need and making an impact on policy at a local level – and Citizens Advice has a narrower remit than Healthwatch!

Third – Incorporation

Appropriately DH has chosen to keep the local authority scrutiny function separate from the remit of the Health and Wellbeing Board. This will lessen conflict of interest and the risk of incorporation.

Yet Healthwatch has a statutory place on the Health and Wellbeing Board. At one level this seems reasonable – an ambition by government for an inclusive and co-produced approach – it feels like a validating quick win for new local Healthwatch. However, membership of the Board brings formal and informal accountability to this group. It has real potential to limit the room for manouvre of local Healthwatch – making it harder to articulate in public  a view that is independent of the Health and Wellbeing Board.

This tension is described in more detail in a good piece by Professor Jonathan Davies on the NCIA Website (For Insurgency: The Case against Partnership : Independent Action)

So, legislators may feel that they have assurred a positive, welcoming and inclusive seat for Healthwatch on the Health and Wellbeing Board but their positive intentions could actually be seen instead as rather naive policy making – coming before sound design; constraining local authorities and risking weakening the impact of Healthwatch rather than strengthening it.

It would have been better for Healthwatch to have a clear remit to support and strengthen local authority overview and scrutiny arrangements which are generally poorly resourced.

What Local Authorities can do

The role of Local Authorities is key here – they will commission the new service. They face a very tough environment and urgently need resources that will help them engage with citizens to defend good local services, challenge services that are not performing  and in particular promote a community led – as opposed to clinician led health and wellbeing delivery model.

A good local authority will commission a Healthwatch service that is able to clearly articulate the view of citizens even if these may sometimes feel uncomfortable for local government.

Commissioning arrangements that bring Healthwatch closer to working with scrutiny committees would be strong.

Using some Healthwatch resources to build citizen led intelligence functions and capacity building would also help – as I set out in an an earlier blog on this subject.

There are strong lessons from a diverse range of sources such as:

Constructive Challenge – Citizens Advice, the Tenants Movement, DH National Support Teams about how to bring constructive challenge.

Building Capability of Citizens – LMU Institute for Health and Wellbeing, Altogether Better England, Workers Education Association

What DH and Healthwatch England can do

The creation of a dynamic, independent and challenging organisation is not going to be determined by deciding who sits in which deckchair.

There are a wide range of examples within the voluntary and community sector of how relationships between national and local bodies can bring innovation and energy as well as trouble and destruction.

The Department of Health and CQC should urgently hold some tight discussion groups with organisations who have long experience of managing the relationship between local organisations and a seperate national one. Organisations which operate a federated structure with a strong citizens base have a lot to offer such as:

• Citizens Advice
• NAVCA
• Locality
• there are plenty of other examples

What do you think?

A PDF of this blog is available here: healthwatch discussion paper