HealthWatch – Rhetoric and Reality

I have 3 concerns about the Department of Health publication Local HealthWatch – the policy explained (LHWtPE) which came out earlier this month. These are: the critique of LINks; the absence of public health and the emerging remit for HealthWatch.

Concern 1 – The Critique of LINks

The document starts (1.3) with a hard nosed critique of LINks.

Stating among other things that:

• LINks found it “impossible to be truly representative of their local population.”

• LINks showed “unecessary variation in ways of working and effectiveness.”

• the public and health and care professionals were unaware of the work of LINks and they lacked a consistent identity

• there is no no national organisation to provide consistent identity

Some of these statements may be correct – but no source is given. It is not acceptable for this sort of unsubstantiated critique to appear in a Government policy document.

Further some of these statements feel like rather crude rhetorical flourishes – precisely what is meant by “truly representative of their population?” This phrase is used a number of times in the document. Are there examples of services that are consistently truly representative against which we can benchmark the performance of LINks? The NHS Commissioning Board perhaps? Maybe the boards of Hospital Trusts? Perhaps the Executive Team of the Department of Health?

I am not disparaging the ambition here – just pleading for a bit of sophistication and clarity.

Another example – “unecessary variation in ways of working and effectiveness”. Again what level of variation is unacceptable? How does the degree of variation of LINKs compare to variation in say  NHS services for children where there is a more than 3 fold variation in A&E attendance for the 0-4s? or quality of homecare?  The 2011 NHS Atlas of Variation notes that “it is common to see twofold or greater difference in PCT expenditure for each programme budget area” (page 19). How does the variation among LINks compare to this?

What is most disappointing is that there is no recognition in this or any other documents of the challenges that any agency that is charged with bringing challenge and criticism to local systems has to face. Anyone who has worked in the local statutory sector will have heard senior managers often talk defensively, disparagingly and critically about organisations like CSCI, CQC and the Audit Commission. This is the environment that LINks have operated in and that HealthWatch will enter. Policy documents such as LHWtPE need to show some awareness of this. LINk/HealthWatch managers will require very sophisticated influencing skills, a strong grip on principles, the pragmatic negotiating skills of ACAS and the skin of a Rhino.

You can see the point – the analysis as presented is a straw man – knocking down LINks in order to justify the establishment of HealthWatch and its relationship with CQC.

Concern two – the Department of Health forgets Public Health

In March 2011 the HealthWatch Transition Plan (HWTP 2.13) says that “Local HealthWatch needs to develop a good understanding of what good looks like in the public health arena” it goes on to state that “the Department of Health will continue to work with public health colleagues and with councils and LINKs (HealthWatch) to help determine what information and evidence HealthWatch will need and how they can best get it and use it.

It states (HWTP 2.16) that “one key element for realising the (Governments) visions for the NHS, public health and adult social care is the establishment of …. HealthWatch.

There are further references to public health with regard to bringing forward the views of the public (HWTP 2.31) and in relation to the analytical capacity that HealthWatch will need to have.

The HWTP (2.19) also makes clear reference to HealthWatch giving “local communities a bigger say in how health and social care services are planned, commissioned, delivered and monitored to meet the health and wellbeing needs of local people and groups and address health inequalities.

One year later all references to Public Health and health inequalities have gone. In LHWtPE The only reference that comes close is a reference to health improvement in the context of local authorities roles.

So, the remit of local HealthWatch has become narrower – it is now almost exclusively focussed on a service access and quality role – focussing on the provision of NHS and Social Care services.

This stands out even more when we look at the roles, responsibilities and functions of local HealthWatch (LHWtPE 4.1). Which are clearly focussed on health and social care services.

Any notion that local HealthWatch would have some room for manouvre with regard to bringing the citizen voice to the debate about the balance between downstream clinical and care provision and upstream work to address the social determinants of health seem to have gone.

So, the contribution that Healthwatch could have made to bring citizens in to help commissioners tackle one of their most difficult challenges – rebalancing expenditure to focus on prevention has been substantially weakened.

Final Question – so what is the purpose of HealthWatch?

When I look at what remains of the HealthWatch remit it feels as though it is increasingly boxed into a corner – it feels rather anodyne and has a slight taint of PALs.

This narrow role of local HealthWatch is summarised by David Behan in his “Dear Colleague” letter of the 2nd of March as:

“Giving citizens greater influence over local health and social care services and to support citizens access information about the increased choices available to them under the reforms.”

The future success of local HealthWatch rests with the way in which local authorities will choose to commission it.

A first step is to consider what the two functions that David Behan sets out actually mean in commissioning terms.

Support citizens access information about the increased choices available to them. 

This could be interpreted as signposting and advising people about services. I have seen no evidence produced by the Department of Health of exactly what the deficit is that needs addressing.  I am unclear about the added value that a small service can provide on top of the responsibility that local government and the NHS already have to ensure that their services are accessible and people get the advice they need about which ones to use.

Local Commissioners will need to consider:

• Precisely what is the added value that they need local HealthWatch to bring here?
• What is the relationship between this service and other local signposting and advice services?

Giving citizens greater influence over health and social care services.

The remit now feels much narrower – focussing on social care and health services not citizen engagement with wellbeing. In many cases it is not how we experience individual services – but how they interact or don’t that is the issue. For example – mental health, housing and utilities. There is a strong argument that sophisticated generic advice and advocacy services like Citizens Advice are best placed to respond here.

Local Commissioners will need to consider:

• Do they want to commission local HealthWatch to have a broader role that allows citizens to engage on wellbeing and social determinants issues rather than the narrow one described by DH?
• Do they want HealthWatch to challenge and develop how commissioners and providers engage citizens or do they want local HealthWatch to provide the engagement?
• What is the relationship between any processes that local HealthWatch might establish and other mechanisms (neighbourhood committees for example) that already exist?