So as small local organisations like Healthwatch have their heads down establishing mechanisms for citizen engagement NHS England enters stage left with its own ideas…….
The Civil Society Assembly.
In a paper to the February 2013 NHS England Board (or NHS Commissioning Board as it was then) Tim Kelsey proposed that it establishes a “design group to explore the creation and development of a citizen and community assembly through enabling a civil society movement that brings transparent accountability and a powerful voice for patients and the public to NHS England”.
This is to:
“build citizen voice and influence throughout the NHS commissioning system, so that citizens hold the NHS to account, driving improvements in quality and outcomes.
I agree with this part of his analysis:
“People have a passive relationship with the NHS and their activation is generally low. The paternalistic medical model of health is not conducive to equitable person-centred approaches to involving people, their families and communities”
He then goes on to say:
“Co-designing and creating an independent ‘Civil Society Assembly’ could be the means through which NHS England can directly engage with citizen voice in a publicly accountable and transparent forum.”
The paper is clear that previous attempts at patient engagement have too often attracted the ‘professional patient’ and it has too often been white, middle class, aged/retired professionals.
The paper calls for NHS England to go beyond the ‘usual suspects’ or the ‘expert patient’ reps instead going into communities whose primary issues may not be ‘health’ but other social determinants that have a major impact such as housing and employment.
It also acknowledges the need to develop a complementary approach with Healthwatch England to ensure mutual benefit.
The paper sets out the following ambitions:
- Public Accountability – an independent and critical mirror for NHS England
- Co-design, advice and reflection – a forum that stimulates ideas, tests thinking and draws experience and evidence together
- Challenge – a critical and challenging friend
- Voice – of the hardest to hear, most marginalised and most vulberable
“It will be a catalyst for a social movement that engages and stimulates new, emerging and established groups and organisations to connect”
Its helpful because………..
We never heard of any attempt of trying to build citizen voice into the old Strategic Health Authority structures and certainly not into mechanisms established by the Department of Health.
Indeed when I once offered to organise a regional meeting to bring the Chief Executive of an SHA into dialogue with local community health champions their reply was “why would I want to do that?”
So national recognition that engaging with citizens is crucial. This will help cultural change in NHS England which might then drive local engagement and help improve service quality.
Its unhelpful because………
This issue is more important than this – the proposal lacks an analysis of context for example:
What happened to localism? If NHS England wanted to be truly radical it would thoughtfully consider whether it might be better served by strengthening its relationship with local democratic structures rather than going for a quick fix national forum. For example it could:
- invest in supporting the only form of local accountable governance – local government – helping it to become stronger and more effective in bringing local accountability to the NHS.
- In partnership with local government it could invest in supporting Clinical Commissioning Groups significantly improve their practice with regard to developing local accountability and engagement.
- It could thoughtfully consider whether a better understanding of and support to existing arrangements – Health and Wellbeing Boards, Healthwatch England, Local Government, CCG arrangements and VCS contributions could be strengthened and how it could support them in developing a coherent national voice.
Actions NHSE could consider
- Get the language right. These proposals reek of hubris ‘establish a social movement!’ I thought this nonsense had died with the NHS Innovation Institute. In my experience social movements do not emerge through dictat. Although it would be fun seeing Malcolm Grant championing the social movement model on a national platform.
- It might be better to build, invest in and foster engagement with the public around institutions that are appropriate and unlikely to disappear. Tactically this certainly means local authorities and the voluntary sector and probably NHS hospitals and GPs. We can be confident that any ‘social movement’ built around NHS England will have a life of no more than 5 years before NHS England is being re-organised – I know that I am being optimistic here!
- By all means foster national good practice – but the focus should be on supporting existing local democratic structures. NHSE needs to consider how it is held to account through Health and Wellbeing Boards (of which it is a member) and needs to put intellectual and material resources into ensuring this process works well – build up from the grassroots rather than impose a national structure.
- Finally – try to stick to the values! The original paper which was presented to the NHS Commissioning Board on the 28th of February 2013 recommends that the the Assembly must be independent of the board (para 10). One month later the NHS England business plan has already given the ‘independent’ civil society forum a target! In the key deliverables section opposite para 3.131 it states that “The Civil Society Assembly demonstrates over 80% satisfied with the involvement of patients and the public in the planning and commissioning of NHS services by NHS England. This is a target for an independent forum that has not even been set up yet! I suppose NHSE are to be congratulated here because they have managed to move in the space of 1 month to the third stage of social movement development – bureaucratise!
What do you think?