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Private Sector Health Providers and local accountability – Quality Accounts and local Healthwatch

July 12, 2016

quality account blog

In an earlier blog I mentioned some of the good practice being developed by local Healthwatch with regard to engaging with and influencing Quality Accounts.

The NHS Choices website states that there is a statutory responsibility for all healthcare providers over a certain size to produce a Quality Account and to seek the views of local Healthwatch who if they wish may send a written response. This is affirmed in the Healthwatch England Guidance.

The logic is clear – a bit of local voice based on the experience of the public can provide a reality check, foster engagement and bring a bit of informed challenge to this annual statement.

This mechanism could become more important as we move to more devolution, integrated care and co-production with the public as local health and care systems respond to the ambitions set out in the Five Year Forward View.

Whats the problem?

When we compare the approach taken by NHS Trusts to the private sector in particular there is a striking contrast.  While the private sector does produce Quality Accounts their quality is more variable and they often do not appear to seek the views of local Healthwatch or the local Overview and Scrutiny Committee.

A quick scan of a couple of private hospitals in Sheffield shows that only one mentions engagement with their local Healthwatch.

The problem gets worse when you look at some of the big players in this field who operate across the country.

For example Partnerships in Care have around 60 sites across the country and specialise in providing services to some of the most vulnerable people (people with a learning disability, people with a head injury and people with a mental health problem). They produce one Quality Account for the whole service and it has no comment from a Healthwatch – although it does have a comment from one ex service user who now works for Rethink  he also commented in the previous Quality Account.

Service user comments are very important – and a number of private sector Quality Accounts have these – however, I think the views of an organisation such as a local Healthwatch are qualitatively different – they have a duty to consider a Quality Account when asked and are accountable for the views they express in a way that individuals are not, in the case above  I don’t think that the comment reflects the views of Rethink.

I could not find many examples of where a private sector provider has sought the views of a local Healthwatch and that Healthwatch has responded – but there are some.

Care UK in their 2014/15 Quality Account include comments from Healthwatch in South Gloucestershire and in Bristol. Also since writing the blog Sian Balsom from Healthwatch York has said that the Ramsay Clifton Park Hospital in York have asked them to comment on their Quality Account for the last two years. However, Ramsay have a network of 22 acute hospitals and their practice does vary – for example there is no mention of Healthwatch in the Ramsay Berkshire Independent Hospital Quality Account.

I could find no mention of local Healthwatch in the Quality Accounts that I looked at from:

Circle Group – for example see Bath and Nottingham
BMI General Healthcare – see for example the Priory Hospital Birmingham and Clementine Hospital
Spire Healthcare produce a national Quality Account – again no mention of Healthwatch in their Quality Accounts
Priory Group who are an acute mental health provider – who also produce one Quality Account

This national issue does not just apply to private sector providers – have a look at the one produced by Marie Stopes – again no mention of local Healthwatch.

Where this leaves us

Advice from NHS Choices is as follows

Screen Shot 2016-07-12 at 12.32.21

There is considerable variation with regard to how independent providers use Quality Accounts and what they expect from them. It does seem as though many independent providers are working in a parallel world where they have a much narrower view of the purpose of Quality Accounts and their relationship with local Healthwatch than NHS Trusts.

  • Some big national independents produce one Quality Account for all their sites.
  • Others produce a quality account for each site.
  • A minority seek the views of local Healthwatch – most don’t appear to.
  • There is a wide variation in the quality and accessibility of the Quality Accounts produced.

What should be done?

  • Local Healthwatch with the support of Healthwatch England should develop an explicit strategy for engaging with the Quality Accounts of the big national providers.
  • Clinical Commissioning Groups should take a more robust approach to challenging private sector providers on the content and quality of their Quality Accounts – some of the ones I looked at above are inaccessible and uninspired.
  • Finally, I think that NHS Improvement need to produce some clear guidance for non NHS providers stating clearly why producing accessible and engaging Quality Accounts is important and why local Healthwatch must be involved in commenting on them.

What do you think?

26 Comments leave one →
  1. July 12, 2016 16:19

    Hi Mark,

    Just for information, we at Healthwatch York have been invited to comment on the quality accounts for Ramsay in York this year and last. Nuffield in York also invited us, have involved us in PLACE, and also sent one of their volunteers along to our Preparing for PLACE volunteer training. I think you are right though that it depends too much on local relationships being developed to highlight the value, rather than clear national guidance.

    Thanks,
    Siân

    • July 12, 2016 16:29

      Thanks Sian – thats great news I will amend the blog to point this out.

  2. Emma RDS permalink
    July 12, 2016 22:25

    Hi, from my perspective, I’d just be delighted if people would be prepared to read and comment to any local Healthwatch about any provider’s QA. The documents can be weighty and dry, Trusts are forced to produce one, and very often the public just don’t want to read them. Honest presentations and ongoing discussions are really how meaningful influence happens! Plus surely the regulations need to say Healthwatchs can include private providers in their remit, as that’s certainly not the main focus for our commissioners! Just my humble opinion…

    • July 13, 2016 07:51

      Thanks for your thoughtful comment Emma. I agree completely, there is an obligation on the organisation who produces the Quality Account to make them as accessible and interesting as possible and to think about how they can be used to promote engagement and dialogue. I think a well produced Quality Account has to start from the premise that it is an aid to dialogue. This means that it has to get the balance between saying how great the organisation is AND setting out some of the challenges and problems the organisation makes. Its like being at a party – nothing more boring than being trapped in a corner with someone who only wants to tell you how great they are! Best wishes Mark

  3. Jane permalink
    July 14, 2016 10:42

    I support a health scrutiny committee and I think that many of the issues that you raise here also apply to health scrutiny committees in relation to Quality Accounts of private providers. I can’t comment on the work of Healthwatch but Circle Nottingham do engage with health scrutiny in relation to their Quality Account, including attending meetings with councillors to discuss progress against their quality improvement priorities and plans for future priorities. We usually offer Healthwatch the opportunity to take part in these discussions too (although we separately decide on our own comments to submit for inclusion in the Quality Account) and I think this approach works well.
    One of the challenges for health scrutiny (and I imagine for Healthwatch too) is the capacity to meaningfully engage with the Quality Accounts of all providers. They all need to be ‘dealt with’ over a short space of time and are often lengthy and complex documents; and in some cases there may be nothing that health scrutiny (and probably Healthwatch) can meaningfully say if it doesn’t already have any robust information or evidence in relation to that provider (which in my view is to a large extent due to ongoing capacity throughout the year and the need to prioritise work; and recognition by all concerned that these processes and organisations also apply to non-NHS providers).

    • July 14, 2016 10:49

      Good stuff Jane – if you have not had a chance have a look at the blog I wrote about the approach that HW Leeds take to managing Quality Accounts “Local Healthwatch – Getting Strategic and punching above its weight” basically they try to address the problem you describe (timescales etc) by getting ahead of the game – running a workshop for ALL local providers (having said that the private providers have not been involved – I don’t know if they were invited) to share their draft Quality Statements and then a further one where they present to each other on the final versions. This starts to bend the QS to a whole system view – which I think is helpful. Best wishes Mark

  4. July 18, 2016 10:45

    Some really good ideas and agree on how to approach requests for local HW inputs to Quality Accounts. Agree with Jane on the issue of capacity and like the HW Leeds idea of inviting ALL providers to get ahead of the game.
    This year HW Leics invited the local Trusts to present the draft QA and one provided a helpful slideshow that was well received and more accessible.

    At an East Midlands regional HW network the Ambulance provider gave a presentation on their draft QA and a co-ordinated response was then compiled – this was led by one Healthwatch with each local healthwatch contributing. A joint submission was then included highlighted shared and specific issues.

    • July 19, 2016 10:26

      Cheers Vandna – good to hear from you. One of the things I take from your comment is that it is perfectly possible for local Healthwatch to respond to organisations who cover a larger footprint than their local authority – of course I realise that all of these issues place further strain on the resources of local Healthwatch at a time when many face reductions in their budgets. I wonder whether NHS England have recognised that moving to Sustainability and Transformation Plans which are sub-regional will place further requirements on local Healthwatch which will need to be resourced?

  5. Vicky permalink
    July 19, 2016 10:07

    Hi there, just to clarify, Healthwatch Sheffield have been asked by Claremont Hospital for comments for the last three years and did comment on the last two. We didn’t comment this year. Thornbury have not (to my knowledge) made any contact with us in the last three years. The reason we didn’t comment on Claremont was that while we held some views on the service provided, it wasn’t enough to ‘assure’ the report. Guidance from Healthwatch England says that we should be assured that the ‘real’ experience we capture matches what is in the report. Where we aren’t able to do that, we choose not to comment.

    This raises a wider issue with Quality Accounts, which echoes some of the comments made earlier. The timescales are so tight and usually inflexible, and the danger is that we provide ‘kneejerk’ comments which give the public some false reassurance about the quality of a service. I used to try and comment on all accounts but I now take the view that if I don’t know enough, I don’t comment. As you say, there are some mechanisms which could be put in place to make this easier. Two of the trusts in Sheffield hold quarterly or even monthly meetings with us to discuss the progress made on their priorities. Although this might appear time consuming, it makes the end process of commenting so much easier and ultimately gives Healthwatch a better relationship with the organisation.

    The issue isn’t solely with private providers. This year, despite asking several times, one organisation covering Sheffield refused to provide me with a draft as they were ‘between drafts’ and then despite more chasing, went ahead and published a final version. Having taken the lead on Quality Accounts for the last three years, I agree that they are an important document and could become more so, but without meaningful engagement from the providers and clear guidance from your infrastructure organisation, they can be very difficult to meaningfully contribute to.

    • July 19, 2016 10:12

      Vicky – what a helpful and nuanced response! I think that you raise a really good challenge to some of the national agencies I mention at the end of the blog. It is quite clear to me from your comment and the ones that precede it that there are many local Healthwatch who have are committed to using the Quality Account lever – but they require active support and interest from national agencies and local commissioners. Best wishes – Mark

  6. July 20, 2016 16:27

    Hi Mark

    I was really interested to read your article on Quality Accounts. These are something we have tried to engage with but we’ve not found it very successful. Yes Trusts have included our comments, but they haven’t involved us in a timely way, everything is very last minute. So a better framework for engagement makes sense.

    I’d be really interested to know whether there are examples across the country of anything changing because of a Healthwatch commentary in Quality Accounts. We’d hoped they would be an opportunity to get local providers to focus on issues of importance to residents/ Healthwatch members, but it hasn’t worked out like that. Maybe I am being unrealistic, do you think they a direct tool for influence or is it more of a tool for relationship building? We’ve stopped prioritising feedback on these documents because we can’t see it making a difference locally, but if that’s not the case elsewhere I’d love to hear some success stories to motivate us to try again!

    Best wishes

    Emma

  7. July 20, 2016 23:03

    Hi Emma – great comment! I think your challenge gets to the heart of some of this, particularly with all the pressure that local Healthwatch are under – with many experiencing cuts to their budgets (along with everyone else). Increasingly local Healthwatch have to (and are expected to) make sharp decisions about where to spend their time for greatest impact. I tend to agree with your second option its more of a tool for relationship building and developing soft influence rather than a mechanism for challenging practice. All the best Mark

    • EmmaRDS permalink
      September 5, 2016 20:46

      Yes I agree with Mark and Emma here – LHWs need to see proof that its worth their while gathering vols together and making them read the documents and coordinating a response on the commentary…before they claim ‘whoop, we made a difference’. Definitely a long-game and relationship building thing… but unfortunately, we’re not really measured on long game stuff, due to how our contracts and monitoring tends to be set up. Take heart Emma W but just do it if time and motivation is allowing!

  8. Robert Dalziel permalink
    July 27, 2016 15:58

    Hi Mark

    Hope things are going well for you

    Private Sector Health Providers, Quality Accounts and Healthwatch

    At Healthwatch Dudley involvement in Quality Account work with private healthcare providers has been patchy. Examples of involvement are:

    1. Ramsay Healthcare UK and their West Midlands Hospital
    We have been involved in PLACE Assessment work at this facility and have commented on their Quality Account – they have moved from an account covering all hospital services provided in the UKto separate accounts. We have asked them in the interests of transparency to be clear in their Quality Account that after CQC inspection they were rated as Requiring Improvement – with details of criteria met or not (they seemed reticent about doing this) as well as providing information on plans for improvement.

    2. Brook (not private sector but a charity providing sexual health services). We were invited to comment on their Quality Account (it was for all of the services they provide in the UK – we commented that it would be useful to have a specific local account for services provided in the Dudley area).

  9. OXI-UK permalink
    September 3, 2016 16:20

    I had been a member of a small, knowledgable, analytical team responsible for working with NHS service providers w r t their Quality Accounts.
    ‘We’ were one of the very first of these groups, working as part of a LINk, to be set up and publish our findings. We worked very closely, and as co-operatively as possible ,with a few of the major providers in our area in this new project, and a possible source of conflicts of opinion.
    Thanks to the excellent leadership of a community activist who was retained by the LINk, some superb relationships were formed, mutual respect established, and most importantly all parties benefited from the insights gained into not only the actual QAs, but in their preparation, content, and style of presentation.
    Operating under strict Chatham House rules, we as a Group were able to cross fertilize aspects of what we considered to be ‘Best Practice’ in a few key areas.
    Our Reports were moderately phrased, but did offer critiques when published in the QAs. In general the ‘negatives’ were presented as growth points, and ‘we’ were able to act in a consultative mode with the QA coordinator to attain new levels of attainment [Free of Charge or payment.]
    However, elements on the Board of Trustees of the LINk ‘Host’ had strong high level interests in some of the service providers, and were not pleased by a sub-section of their fiefdom offering such factual analyses.
    On the turn over to HealthWatch, the ‘Host’ became the total controler.
    P&P ‘membership’ was purged overnight, in favour of non-voting, un-voiced helpers;
    Trained and experienced Enter and View members were summarily dismissed (One was even told that he was being sacked because he was suffering from the 1st stages of dementia – neither of that two person panel was a ‘clinical’ anything.);
    And on ‘financial’ grounds the QA team was disbanded by email.
    LINKs weren’t anywhere near perfect, but they had great possibilities if control and direction had remained in the hands, and hearts, of the P&Ps of their catchment areas.
    BUT
    This was yet another part of the rolling back of P&P meaningful involvement in our NHS at other than a ‘What colour bandage would you like today’, level
    A process which you seem to be supporting, Mr Gamsu, by your high profile presence at Ms Anu Singh’s Citizen-Gather execution meeting on 12/9/16?
    A ‘consultative’ meeting where P&Ps will be presented with a previously unseen document defining the Top Down regime which will be imposed on ALL P&P input to discussions of NHSE Policy forums, ny Ms Singh and her team of censors..

    • September 5, 2016 08:25

      Thanks for your comment. I do not usually accept anonymous comments- but given that you have taken to the time to comment I will respond. If you do decide to comment further please add your name.

      Three points

      First, I agree with you – there were LINKs that had an excellent track record, although of course there are now a good number of local Healthwatch that are at least as good. My personal feeling is that central governments inability to stay away from tinkering with local democratic structures – in this case CHC, CHiPPY, LINks etc has been damaging. Nonetheless we have to operate in the policy environment we find ourselves – and in this case its about trying to make local Healthwatch effective.

      Second, like you I am concerned about the relationship between local voluntary organisations and commissioners – I think that there are occasions when we fail to acknowledge or address the conflicts of interest that can arise in the complex web of local relationships, contracts, services etc. My personal opinion is that the best way of addressing this is through ensuring that there are strong and inclusive local democratic processes that encourage positive and informed discussion and challenge. I think that structures such as Health Overview and Scrutiny, Governors linked to NHS Trusts as well as more informal mechanisms all help here.

      Third, I have written about my concerns with regard to the way that NHS England engages with the public on a number of occasions – for example – https://localdemocracyandhealth.com/2015/10/25/can-i-eat-that-lettuce-voice-digital-public-health-england-and-nhs-citizen/. My personal view is that there are many people in NHS England – who have a strong personal commitment to a more co-produced and engaged NHS and who are working hard to achieve this. For a wide range of reasons (political, cultural, capability, complexity etc) we know that developing a coherent approach to involvement is difficult. I can confidently say that I struggle with this all the time – I feel that I am constantly learning and being challenged by hearing about good things that others are doing. So, I remain keen to respond positively to opportunities to engage, contribute and be challenged.

      Best wishes

      Mark

      • brettghartmann permalink
        September 6, 2016 16:29

        Mark – as you kno there were 3 000 of us registered with NHSE Citizen when it was suddenly shut down without notice or consultation.
        Since you’re listed as one of us i e ”Citizen” on the agenda, w/could you plz open up a thread here about these workshops on 12/9/16 so maybe some of we 3 000 can have a voice for you at least, to hear?
        Thanyou, Mark

  10. EmmaRDS permalink
    September 5, 2016 21:00

    Hmm interesting that there is still some frustration about the fact that LINks were required to change to Healthwatch – this was a Government agenda folks. Regardless of whether you liked it, it was decided on by our ‘elected representatives’ 4.5 years ago. Time to move on. Some of us even opposed the H&SC Act at party conferences, despite it safeguarding LINks jobs, because we knew it would stifle the more individualized approach of LINk, but in hindsight, the name change and the national organisation and therefore improved profile of Healthwatch, has on balance been a good thing for P&P involvement. It certainly improved our standing within Trusts, private providers and our impacts within Social Care which up until then in our area had been very minimal.
    How is it that Mark’s presence at a conference means he is supporting or otherwise any approach? Do you already know what hes going to say?! There you go Mark – someone’s written your speech already, how kind!

    • September 5, 2016 22:11

      Thanks for the comment Emma – I agree we have to work within the policy framework that is set by our government (whether we voted for it or not).

      Like you I feel that the current Healthwatch model with independent local services AND a national office has the potential to create a much stronger and more effective function, and like you I think that there is some evidence that this is beginning to happen.

      As I have said before somewhere on this blog the model is a bit similar to the relationship between Citizens Advice and the 300+ local Citizens Advice Bureaux. There are inevitable tensions with regard to this approach – and sometimes it can feel that the balance has gone too much the wrong way – e.g. too much central control/too weak support from the centre/poor quality at the grassroots etc. But, this tension can also be a helpful driver to improvement and collaboration.

      As for my input at the workshop – I am still working out what to say – another useful source of tension!

      Best wishes – Mark

    • brettghartmann permalink
      September 7, 2016 06:53

      @EmmaRDS September 5, 2016 21:00
      Hi
      The change from LINk to LHW wasn’t a name charge; it was a Piratisation of a P&P voice, managed by us.
      LHWs ar now even encouragd to make a profit which can be spent on what they decide.
      ————
      About Anu Singh’s 12/9/16 Workshops on the future of NHSE’s multi £million Citizen, PPI project:

      Just reed the imposed Agenda, an the draconian ”Terms of Engagemnt” (Inc a Dress Code), an you’ll see what we 3 000 are being dealt, and Mark seems to be supporting by agreeing to be the – ”Citizen” – on the three person panel.

      Brett

      • brettghartmann permalink
        September 8, 2016 11:47

        Hi. Lates from Anu Singh’s office- NO documents will be issued. ALL will be verbal from Ms Singh – atendees will have to take notes… WHAT? Equal ops/anti-disc/etc?? Out the window!
        Hearing an sight impaired?
        Will the presentations be jargon free an in Plain English?
        Did you know about this, Mark?
        What as THE Citizen on the panel are you going to do about it, please?
        Thank you in advance, Citizen Gamsu/Mark

        Brett

  11. brettghartmann permalink
    September 6, 2016 15:40

    ” poor quality at the grassroots ”
    I’m not shure what you mean by this, or what could be done to rectify what ever is pour in quality while the ordinary public and patients?

    Brett

    • September 6, 2016 16:08

      Hi Brett – ah! I’ve been caught out by being unclear when I put something into writing. I was really just trying to illustrate that national agencies and local agencies both have a role and both can have strengths and weaknesses. Just because an agency is national does not mean that it is always competent and similarly just because an organisation is local does not mean that its practice is always good. No more or less than that.

      Cheers

      Mark

  12. brettghartmann permalink
    September 6, 2016 16:19

    Thank goodness for tha Mark as I thort that you were saying that the ordinary grassroots P&P were not up to representing ourselfs at the policy making committees of NHSE.
    It seems that some peeps do as there is a growth in (self appointed/styled) Patient Leaders. Ppl who are doing excellent work in their own projects, but arent elected by or answerable to, P&P.when they are seen as rep-ing us on NHSE Committees.
    Some are setting up in business training others to be ”Patient Leaders” – it looks like a growth industry.
    Brett

    • September 6, 2016 16:34

      phew! well I’m glad I managed to clarify – especially if you thought that! Cheers Mark

      • brettghartmann permalink
        September 6, 2016 16:44

        Glad Ive made someone a bit happier, Mark.
        What about the growth industry in ”Patient Leaders” very hard workin peeps but slef designated – and some parts of NHSE and associates are setting up training schemes for more Patient Leaders.
        ” … sed quis custodiet ipsos custodes? ”
        if the watched are appointing and training the ppl who will watch them?

        Brett

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