Citizen Engagement – everyones doing it – even NHS England!
As the great beast that is NHS England gets up and running it is already proving challenging to keep up to
speed as it churns out ideas, instructions, promises and commitments.
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?
When this came up at an event in Manchester organised by NHS England it was simply ‘dropped in’ the discussion as a given. It wasn’t well received and I think that a lot of people working on local engagement developments such as Healthwatch just though ‘Oh, here’s something else to help them tick their boxes’
As David Cameron is fond of saying: “They just don’t get it!”
I agree that an element of national co-ordination of ‘public feedback’ would complement the representative democracy of MPs. But yes, crucially, ‘active citizenry’ can’t be imposed from the top, and a reversal of the trend to undermine Local Authorities’ role would be one necessary step. LAs themselves don’t find it easy to foster public participation, however, and when they do, it’s too often limited to the traditional consultative exercises. That’s where a key profession comes in: Community Development has been an easy target for service cuts, but is the only way we are likely to get the public properly involved.
Good points. If the NHSE believes that the paternalistic, medical model of the NHS is not conducive, it would be preferable to see action to address this.
Some really good points here Mark. I’ve long been advocating the greater involvement of district councils in health commissioning, for two reasons: (1) districts are close to, and regularly engage with communities on a regular basis (2) districts are responsible for services which directly impact the social determinants of public health (sport, leisure, planning, housing, environmental health, etc. I’ll be challenging my local CCG on their district council engagement at their next patient consultation meeting!
Good point too about direct patient engagement. Our local Patient Participation Group has good representation from the active retired but none at all from new mums, teenagers, disabled people or people living in poorer neighbourhoods. Chances are these sections of the community never will be represented. So health professionals must seek other comms channels. There are plenty of existing structures that they can tap into…with a little help from district councils.
The proposal for an NHS Civil Society Forum is welcome, but its needs a direct relationship with Parliament, as part of the democratic oversight on health, as I propose in a blog written in response to the Francis Report (and before I was aware of this proposal) – see
http://www.democracymatters.org.uk/we-need-a-parliament-for-health/
and
http://www.democracymatters.org.uk/how-would-a-parliament-for-health-work/
There is so much wrong in this post that my response will be long, but I will make some concrete proposals that will make the NHS better, so bear with me.
Strategic Health Authorities and Primary Care Trusts were statutory bodies and as such had to have board meetings in public. Did the public attend? Hardly ever, but that is not the point, the point is that they were open and the public could attend. NHS England is a statutory body and has public board meetings, but this is an organisation that overlooks a budget of over £100bn so a public once a month meeting is pointless because it is far too high level. Instead we should have access to many more local meetings of NHS England. Do we? Well, the SHA clusters (regional arms) have public boards, but again, these overlook a huge amount of work (each one covers a quarter of England) so making these meetings public is pointless: there is no detail and as a member of the public you cannot influence the services in your area.
Clinical Commissioning Groups replace PCTs and like PCTs they are statutory and have public boards. However, they only do three quarters of the work of that PCTs did (secondary care, community care, urgent care). The other quarter (primary care: GPs, dentists, opticians), has gone to NHS England and the teams that do that work do not have public board meetings. Further, although the CCGs have public board meetings they do very little commissioning themselves. The commissioning is actually carried out by non-statutory semi-privatised companies called Commissioning Support Units. CSUs do not have public board meetings. These were not mentioned at all in the Health and Social Care Act, and were not mentioned in either Coalition party’s manifesto. They have no legitimacy, yet they are where the real power in the NHS now lies.
We now have organisations called Local Healthwatch. Many of these are run by charities and not-for-profit social enterprises, but there is no standard governance, or recomendations on how the public should be involved. Furthermore, some LHW are private companies! This desparately needs fixing. LHW are supposed to be the patient voice, yet there is no standard way that patients can get involved.
Reading what you have given here, it is quite clear you have not been involved in the public meetings of the new NHS organisations. I have, for many years I have been an elected Foundation Trust governor. I am also a patient representative at a CCG, and (as a member of the public) I attend FT and CCG boards and Health and Wellbeing Boards. Can I make a jot of difference? No. Yet if the public are to make any difference it would be at the local level not the national level. We have to make the public involvement at the local level wprk, but it is not clear to me that that is happening now.
This silly ‘Civil Society Assembly’ will merely be a talking shop, it will be to make people think that they are having some influence, but they won’t. (Incidentally, if you want an organisation to have some influence then the only way to do that is to give it a budget and make it accountable for that budget. Non-budget holding organisations are laways treated as second rate by those who hold the budgets.) What will happen with this silly idea is that they will either agree with everything NHS England tell them, or they will disagree and NHS England will (quite rightly) say “there is no budget for that”. So what is the point?
So, you are fawning over a rather silly idea, one that is designed to divert your attention from the real issues: local involvement. Before we create yet another national talking shop, we must make local involvement work. Heer’s how to do it.
1) Make CSU boards public and have patient representation on their boards, and a patient reference group to oversee what the CSU boards are doing.
2) Make primary care commissioning open and transparent, that is, make NHS England open their local area teams commissioning board meetings to the public, have a patient representative on the decision making board and have a patient reference group overseeing wwhat they are doing.
3) Fix local Healthwatch: make sure that LHW have to have a public membership: if they cannot get 1% of the public to join them, then close them down and replace them, because if they cannot get 1% of the population to be involved then clearly they are not talking to the people who matter: the public.
4) CCG patient involvement is in its infancy and there are some places where it is working well. But there are many places where the patient involvement is just decoration. Patient involvement should be a vital part of what a CCG does, so NHS England should treat it as more important than, say, financial governance. So best practice must be spread. Those CCGs in the bottom 10% of patient involvement should be paired with the top 10%, where the top 10% will be performance managed to make the bottom 10% improve their patient involvement.
5) NICE should be opened to patient involvement. There is some involvement now, but it should be wider, with local groups feeding into a national patient group. NICE will become very important as commissioners start to think about rationing and co-payments.
6) EVERY organisation that delivers NHS commissioned care must have a patient representative on the board and a patient reference group overseeing their work. EVERY organisation. It should be a principle that if you take NHS money for clinical care then you have to have a patient representative board member. Virgin, Serco, Circle, BMI, Care UK: if you take our money, you have to accept our governance model.
There you go, rather than fawning over a rather silly talking shop, I have now fixed citizen involvement in the NHS for you. Will you have the courage to push for the changes I have suggested?