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Understanding how we are doing – building solidarity and excellence for health and care locally

July 20, 2015


Increasingly we are on our own. As the government promises us further austerity targeted at the most disadvantaged, we are are also to get greater devolution (see Local Solutions for a Healthy Nation and The Local Health Service?). It is therefore our responsibility to ensure stronger collaborations between services and most importantly with citizens.

We know that we need to integrate services – not just across health and social care – but more widely in order to address the social determinants of health

One of the biggest challenges we face is that the organisational cultures and behaviours we have been trained to use work against co-production with citizens, integrated service delivery and shared responsibility.

A key part of this are the performance management systems that all statutory agencies work within and that define the relationship (through contracts) that statutory funders have with local voluntary organisations.

One of the most eloquent critiques of the deficit of current performance management approaches comes from Toby Lowe – who has worked for many years in the voluntary sector in Newcastle but is now an academic at the University of Newcastle.

Toby gave a presentation of his analysis at the recent ESRC funded Politics of Wellbeing Group conference in Sheffield.

In essence Toby argues that the performance management system we use starts from simplistic definitions of the outcome that is desired (which has to be measurable) and then works back to identify actions that will produce that measurable outcome.

He argues this can lead to actions that:

  • don’t address the real problem
  • gaming to achieve targets
  • reclassifying what counts as success (see recent government changes to Child Poverty measures)
  • Making up the figures

(You can listen to Toby run through a more detailed account of his work here)

I would go further and say that this approach also:

  • Pushes agencies to only worry about their targets rather than taking a shared responsibility for the wellbeing of communities. So, hospitals worry about their performance targets but don’t take responsibility for what happens to people once they are discharged back to the community.
  • Takes attention away from the strategic and pushes it towards the operational. So, in the health world we often spend time at the highest strategic level on performance measures that focus on tiny operational failings such as trolley waits or failures to hit 4 hour targets in A&E while at the same time we devote less time to real strategic issues such as the relevance or quality of whole services or the reduced life expectancy of whole communities.


In this new devolved world we have the responsibility, incentive and opportunity to develop a local performance management system that is better than the bean counting Westminster driven system.

The work that I have been doing recently as part of my work at Leeds Beckett University offers some solutions. We have been working with Health Watch England to develop a common approach to helping local Healthwatch and their stakeholders understand whether they are effective or not.

This has involved developing a set of Quality Statements which we have produced through working with over 40 local Healthwatch. The Quality Statements cover the range of local Healthwatch activities from the operational to the strategic.

The idea is to use them to create a platform where local stakeholders who have some responsibility for making Healthwatch work can have a shared dialogue about the effectiveness of their local Healthwatch.

The aim is to move away from trying to measure impact and instead trust the expert opinions of a range of stakeholders who work with and are affected by local Healthwatch.

We think that responsibility for local Healthwatch does not just rest with Healthwatch or with the local authority commissioners but with a range of other stakeholders (we are not prescriptive here because local circumstances vary) but they are likely to include:

  • The Healthwatch Board
  • A range of local authority officers – not just the contract managers
  • Members of the Health and Wellbeing Board
  • Healthwatch staff
  • Local Voluntary Organisations
  • Advocacy Agencies

The approach we have trialled involves using confidential questionnaires sent to individuals from the above groups followed by a facilitated discussion based on the survey.

Early trials have been positive. It provides for a collaborative discussion about effectiveness and impact and as importantly a recognition that there is a shared responsibility for the Healthwatch function – which is ultimately about using citizen experience and knowledge to improve health and wellbeing.

I think that this sort of approach has a much broader application. It could be used with other key services – for example General Practice or a Citizens Advice Bureau.

It helps to develop a more inclusive approach to understanding and improving how services work to meet need. Along the way it also builds capability and understanding about services and how they work – and can help unite service providers, commissioners and citizens in a shared view about what is important and what is possible in present circumstances.

What do you think?

(with thanks to Jennie Chapman, Toby Lowe and David Walmsley for collaboration and inspiration!)

4 Comments leave one →
  1. Jean Hardiman Smith permalink
    July 20, 2015 10:17

    Unfortunately Healthwatch is so bad in a number of areas that increasingly Peoples’ Healthwatches are being set up to shadow it/do the work it is meant to be doing + it has no statutory powers. This has been reported to me as a national lead from an organisation of over a million members likely to use the health service. Peoples Healthwatches are not the only bodies having to step in where Healthwatch is failing to protect the public. It is not all bad, but this is often down to HW having a lead with real commitment and people who are prepared to question and push – and that is not always welcomed by the official bodies, despite what they may be telling you. My own and national experience is that this is getting worse as austerity and cuts bite deeper, and the cracks are being papered over with warm words around collaboration and effectiveness. If you are in the system, you will see words just for what they are. People are suffering, staff are becoming increasingly unable to be supportive to the public as their own moral plummets , while committees trill about respect and shared decision making and understanding. Fragmentation leads to a system where it is almost impossible to get anyone to admit to responsibility. Healthwatches are often simply a cog with no real understanding of anything locally – a local one has said nothing at all about a privatised system which has no accountability under FOI, and the CCG simply directs any enquiries to them they direct back, so it is all circular with no answers at the end. That Healthwatch is saying nothing about the huge extra costs and patient failures. This is money going out of a system which admits it cannot give a decent quality of end of life. Yes we have “one chance to get it right”, but there are not the qualified staff to do this (or I suspect the funding). As an insider, the system is so broken, Healthwatch, or anyone else locally, couldn’t fix it even if they had superpowers. The very best of Healthwatches acknowledge they are not able to do what they need, and are increasingly coming up against “place people” – people who are supposed to represent the public but are either too naive to do so, and believe what they are told, or are really in pockets. These are often working in official bodies who used to be really open, but now feel they cannot be, so are a product of the current broken system not the cause.

    There used to be a surplus in the NI chest, but it has been raided for other things, and to cover they are talking about a nice private insurance system – the one that currently works so well for paying out to customers, and is a disaster in the USA (leading to the highest spend of anywhere). It will probably start as a government initiative, and at some point be handed to the Yanks. The system used to pay for nail cutting for the frail elderly, then the charges started. The elderly are now turning up in A&E because of falls caused by long unkempt nails . Thinking is becoming less joined up, not more. There is talk of Hospital costs to be paid by patients, and at the highest levels – and they are not talking small amounts. Who will be able to afford that – and will it be one body expensively billing another for it, so we also pay for staff and time, which means in total a huge amount more coming out of the public purse, while everyone who can pay goes private? In the devolved world things cost more, and there is more duplication. That is the excuse for all the company takeovers that end in “efficient” monopolies. Integration will not work while one of the systems is there to make a profit. Is integration a saviour, or more likely a Trojan Horse to patients paying, and a route to people suffering behind their own front doors The NHS cannot insist that anyone builds nursing homes to take patients in need, and the plan is to buy up beds in care homes, beds which are increasingly rare, due to low LA funding of places, so more people in need longer term will be unable to access them. Care in the home is heavily rationed to funding, not need, with unsuitable staff and short visits/people being put in bed and got up at times to suit the agencies not people and so on.

    Devolution: Will Manchester get as good a deal on meds etc. as England? Will there be boundary fights? What if my centre of excellence is not in Manchester? What if Manchester fails and goes bankrupt? What if the service is so bad that people are dying? So many what if’s, and I am afraid that Las are simply not up to the job in anyone who is active in my organisations experience – they do not have a clue what patients want and need, and nor do they care, as long as they can get shot of it to the private sector – even if that costs them more – commissioning is preferred to that bothersome (and expensive?) partnership model. As I said, lots of warm words at meetings repeated ad nauseum, so that the people who are neither long term patients, active on their behalf, or activists for the NHS really know what is happening. At the coal face I am in agreement about management styles, but worried that so few people really know the reality of what is happening to the healthcare system. The increasingly fragmented system has almost managed to kill me, after years of feeling it was working on my behalf, and others are reporting the same. Relatives are reporting it HAS killed their loved ones. I, and nobody I know who is actually in the system, wants a new level of fragmentation and bureaucracy at the local level. Increasing the power of LAs and Chiefs with bean counting experience but little else, has meant some very poor decisions already as we patients know to our cost. This is retrogression dressed as modernisation – only if you are a medieval peasant – and the push is coming from the very top.


  2. NormaT permalink
    July 20, 2015 11:41

    Really appreciate the article, Mark, one of Third Sector Leeds building blocks in the ambition statement relates to measuring impact. I am concerned that TS agencies understand the difference between activity and outcomes, but many commissioners continue to measure the easily measurable, or a proxy measure, which leads to exactly what you say, competitive delivery of units of activity. I’m really interested in how we could collectively be asked to measure outcomes I a neighbourhood with the recognition that it is all contribution, not attribution. I was at an arts impact workshop run by Cartwheel last week and spoke to someone from the Arts Council who said some areas are experimenting with ‘open commissioning’ – do whatever you think necessary with this funding to create positive change. Feel a bit saddened that this was the Outcomes Framework approach I was using 7 years ago in Leeds with PH commissioned community health development, which was subsequently largely realigned to units of weight loss and smoking cessation (PCT targets!). It will be interesting to see if the LA can work with procurement guidance to raise the weight of social value vs activity in future commissioning; and if TS agencies are willing to adopt some measures, whether required or not, to evidence their wider impact and social value.

  3. July 21, 2015 23:17

    Thanks Norma – interesting term ‘Open Commissioning’ I would have called that grant aid a few years ago!

  4. Jennie Chapman permalink
    July 22, 2015 15:32

    Interesting article Mark and would agree with critique of performance management systems which certainly prevent proper shared responsibility for service delivery and improvement. I think the approach we’ve taken with the Healthwatch England work and the initial testing provides a much more sophisticated understanding of effectiveness than other systems. I start from the assumption that very rarely is any service effective or not effective, it is much more likely a bit of both. The quality statements enable a considered analysis of the extent to which things are working but also allow an exploration of WHY allowing constructive discussions about actions all responsible stakeholders can take to contribute to improvement.
    I was really encouraged by the discussions that have taken place to date, following the questionnaires and in particular commissioners highlighting how helpful the process was in developing their understanding of the Healthwatch function. Also their own recognition of the limitations placed on local Healthwatch by the local system.
    I’m sure this approach has a wider application and from my own experience can identify where this might have been useful both in commissioning roles and in provider roles across sectors.

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