“Voice” starting to rule the roost over “choice”

An excellent paragraph or two in a paper from the NHS Confederation, “Alive and clicking: information that benefits all“:

“In the lexicon of public policy there are two ways to improve public services: exit and voice. Exit enables people to choose a provider so they can leave services they do not like. In NHS terms, it is about choice, markets and the Any Qualified Provider policy. By contrast, voice is about getting involved and trying to change and improve services for yourself and your family. For NHS users, voice is about taking action such as complaining or becoming a member of a foundation trust or patient group, writing to the chief executive or even suing the organisation.

“Over the last 30 years, exit, markets and choice have largely ruled the roost while voice has been a whisper at the policy table. However, the costs of structuring markets are static or rising. Meanwhile, the costs of having a voice are falling like a stone.

“Successful providers will get much better at motivating and engaging their local populations, albeit through more people commenting about them, getting angry with them, making suggestions, and thanking their staff. Some of this will be on generic platforms like Facebook and blogs, and some will be on platforms dedicated to making feedback easy to use for busy staff like Patient Opinion and NHS Choices. These conversations will very likely play back into choice and the market because what consumers learn from their friends and other users of similar services is a powerful predictor of behaviour.”

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Pre-payment cards in personalised public services

In a personalised public service the individual has choice and control over the services they receive. If the public agency in this policy area enables individuals to take the cash equivalent of a service instead of having it paid for by the commissioner – such as local authorities in the case of Personal Budgets in adult social care, or PCTs (as is) as Personal Budgets are being trialed in the health service – then one of the questions becomes how the individual can make payments to buy services they want.

In our day-to-day lives we hardly question this. Most of us have a bank account which holds our money and we use a debit card over which we have control to make payment from our bank account to a service provider whose service we want to buy, e.g. Waterstone’s, Kwik Fit, Tesco.

Some services offer a form of loyalty card, in which you can pre-pay money onto a card and use that card instead of cash at that service. A good example of this is Starbucks (as my bank account will attest).

Over the last two or three years, public agencies have looked at pre-payment cards as a means by which to support and implement personalised public services. Some recent research by DWP (pdf) into “smartcard” schemes (which actually go slightly wider than just pre-payments cards, since they don’t necessarily entail money) has some interesting findings around the use of such cards, which I thought it would be useful to share.

The first area of interest is whether smart cards are available generally for all members of the public or for a specific subset of the local population. The key issue here is one of cost and scale. General schemes cover areas such as travel, leisure and library services, whereas more specific schemes can be found, for example, for only adult social care users.

The second area of interest is the benefits to service users, captured as follows:

• A smartcard allows a user to complete an application form for services “only once”. Having done so for the card, they can then access all of the services that card is designed to cover
• Smartcard schemes can offer individuals greater access to local and potentially national services
• Smartcards can potentially offer financial benefits in the form of service discounts for users.

There are, of course, benefits to public agencies too:

• Though smartcard schemes have a high set-up value, the ability to add on further services under the scheme is much lower than a standalone scheme at a later date
• Administrative costs for public agencies associated with making payments to service users and providers should decrease because of automation of the paying process and record collecting
• A central smartcard system can help with better data collection
• Smartcards can in theory (and sometimes in practice) drive joined-up working across public agencies or departments within one single organisation.

A very good example of pre-payments cards is Cheshire East Council’s Empower Card (pdf). According to the Council, this has resulted in efficiency savings of 49% concerning the users engaged in the scheme – a saving of some £236,000 on the previous account management process.

There are undoubtedly some issues regarding smartcards, not least of which is whether the costs of investing up front in a scheme provides realisable savings later on (I suspect it can, though I suspect the potential for significant costs is also a reasonable risk).

Even so, smartcards are a useful innovation that can enable service users to have more choice and control over the services they receive whilst saving money for public agencies.

Some more research on smartcards will be published next year by the National Centre for Social Research, which I’ll hopefully blog about then.

Reflecting on HealthWatch in the Health White Paper melee (updated)

Whilst the pandemonium about various changes proposed by the Health White Paper continue (rightly so, by the way), the issue of patient and user voice remains as high up the agenda as it usually does.

That is, not at all.

I’ve focused on this area in two previous posts – one on patient voice in the White Paper and another on the question of democratic accountability.

I have to confess I’ve not had chance to read the government’s response to the White Paper consultation (“Next Steps“) and what it says or updates about HealthWatch (HW). As far as I can tell, it’s strengthened issues around advocacy (particularly by saying advocacy services can still be contracted for directly by LAs, rather than sitting within HWs), strengthened HW representation on Public Health and Wellbeing Boards, and generally reduced the need for overview and scrutiny.

Of course, I’ll blog on what Next Steps actually says about HW when I’ve read it.

But in the meantime, today saw an event in the area I work on the establishment of a local HW. Here are some quick and dirty observations of the day:

• The level of understanding of what the Health White Paper is seeking to achieve is low
• The level of understanding of what HW England and the local HW will do is low
• The level of understanding of the relationship between HW England and the local HW is low
• There is a significant divorce between health and social care in the views of service user “representatives”
• “Entrenched interests” doesn’t come anywhere near explaining the problems facing commissioners of local HW over the next few months
• If today was anything to go by, the profile of people directly engaged as “representatives” and volunteers in LINks at the moment can be summed up in two words: (1) old; and (2) white
• Partnership working between organisations who are or will be relevant to the local HW feels a long way off
• For areas where there are unitary and county councils close together, the question of whether there is a joint Health and Wellbeing Board across all of them or a separate one for each is a very, very thorny one
• This said, the question of whether there is one local HW per council or a local HW operating across several is a bit easier – it’s only a very thorny question and not a very, very thorny one
• No one knows what money will be available to commission the local HW, or whether it will be ring-fenced. I’m guessing not, since it will sit in LA budgets. (As a comparison, in 2009/10, the DH awarded £24.3m across all 150 LINks.)

This may all sound like doom and gloom, and at least in that regard it’s similar to most other proposals in the Health White Paper.

But it’s not.

All the government needs to do is create some clarity soon on the topic of HW England and local HW in order to allow commissioners to demonstrate the local leadership they are hugely capable of.

Next week’s Health and Social Care Bill may give us this, so amid the tumult of discussion about the big ticket items, remember to keep an eye out for what the Bill says on HealthWatch.

Update: Of course, I forgot to mention whether social media was mentioned as a means of engagement for HW. Apart from the most cursory of mentions – a gesture towards Facebook – it wasn’t. A few of the kool kids at the back of the room whispered about it away from the more vocal participants in the day, but it was a useful reminder of how little wider awareness social media there is amongst parts of the population and as part of the debate/solution to engagement.

It would be great to have the opportunity to change that.

More positively, there seems to be some excellent LINks work at the moment on Twitter – see this list from LINk East Sussex and this nicely chirpy stream from Somerset LINk.