“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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HealthWatch: Good in principle, worrying in practice

This was posted as a guest blog on the always insightful Health Policy Insight, run by the always amusing (in a good way) @HPIAndyCowper, who has kindly allowed me to re-post it here.

Criticisms of the reforms of the health system have focused primarily on shifting £80bn of public expenditure to GP commissioning consortia.

Much less attention has been paid to the issue of patient/user voice and representation in the reformed system, something this post aims to address (building on two posts at the time of the White Paper, here and here and one just before the Health & Social Care Bill was published).

The White Paper contained proposals for the creation of both HealthWatch England and local HealthWatch – building on the work of existing Local Involvement Networks (LINks) – in each upper-tier local authority area.

Local HealthWatch will essentially be the local “consumer champion” for health and social care users, promoting choice and control, influencing the shape of services, and highlighting issues in service delivery, including through advocacy.

HealthWatch England will provide support to local HealthWatch and synthesise the issues they highlight at the national level, working with the NHS Commissioning Board and the Care Quality Commission.

In principle, the introduction of HealthWatch based on the work of LINks is a good idea (though there is a question over how effective LINks have been); what’s more, there is “extra” money being made available for both local HealthWatch and HealthWatch England to carry out their roles.

In practice, however, there are 3 significant areas of worry about HealthWatch arising from the Next Steps consultation response and the Health & Social Care Bill and its associated Impact Assessment.

The first is money. Though there will be “extra” money for local HealthWatch, this is being taken from existing services.

In 2009/10, £27m was allocated for LINks. For local HW, the funding that was used to fund the Independent Complaints Advocacy Service (£11.7m) and PALS (£19.3m) is being handed to local authorities to commission local HW, meaning there will be £59.1m in 2010/11.

HW England will also have £3.5m of its own funding (figures from Impact Assessment, para D42).

But the major issue – and the number one risk identified by the DH itself – is that this money won’t be ringfenced. Instead, since the money will be allocated to local authorities under normal LA funding arrangements, Councils can choose how to spend it.

In 2009/10, although £27m was allocated for LINks, Councils only spent £24.3m of it on LINks – they effectively creamskimmed 9% off the budget. There is no guarantee they won’t do the same for local HW.

The second issue is independence. Local HW will be “contracted by and accountable to Local Authorities” (Impact Assessment, para D34). This does not make them independent in principle; nor, potentially, in practice.

More worrying is that HW England will only be a statutory committee of the CQC. Despite the Next Steps consultation response suggesting this means HW England would be “independent” (para 2.59), the Impact Assessment formally recognises (para D24) that

setting up HealthWatch as a statutory committee of CQC [means] it would not be formally independent of the NHS and social care system.

Furthermore, HW England’s funding will need to “maximise synergies” with roles within CQC (para D28) to ensure its funding of £3.5m goes as far as possible. No “independent” committee should have to rely to this extent on staff within its host body.

Even more significantly, the Chair of the Committee will be appointed by the Secretary of State (Next Steps, para 2.59). The Health & Social Bill also stipulates that some members of the Committee will be appointed and others elected (Impact Assessment, para D27), but with no details about the blend of appointed and elected members or the process for elections (D26) – this is to follow in further regulations.

None of this sounds particularly independent, and there have to be worries about how this will operate in practice. Anyone who knows how the statutory disability committee within the EHRC has operated in practice – a very similar set up to that proposed for HW England within CQC – will rightly be concerned.

The final issue is advocacy, particularly complaints advocacy, in which confusion reigns. Next Steps suggests (para 2.43) that local HW should have a role in NHS complaints advocacy, but that Local Authorities will now be responsible for commissioning it and that this may or may not be through local HW.

Conversely, the policy summary signed by Andrew Lansley as part of the Impact Assessment says that HW will bring together patient voice and complaints advocacy. It won’t – especially since advocacy in social care is not mentioned a single time anywhere in documents relating to the Health & Social Care Bill.

Unlike much of the rest of the proposed health reforms, the suggestions for HealthWatch were actually quite good in principle.

In practice, significant questions about money, independence and advocacy as one of the new, key functions of HW means the end position for HealthWatch is much the same as everything else associated with Lansley’s reforms.

LINks annual reports 2009/10

The annual reports of Local Involvement Networks (LINks) for 2009/10 makes for interesting reading. This is particularly in light of the fact LINks will become local HealthWatches under the proposed reforms of the government’s White Paper, and will be the major vehicle through which patient/user representation will be secured.

LINks are membership organisations which empower people in the community to have their say or influence local health and social care services. In 2009/10 there were 150 of them, with a total spend of £24.3m.

The numbers in terms of people engaged aren’t, I’ll be honest, particularly good. Even then, the data collected probably represents a slightly rosy view: as the report highlights:

Many LINks were not able to provide details of their finances, membership, activities or their effects.

It doesn’t inspire confidence, does it? Even so, we will plough on with what the annual reports tell us.

Across all LINks, the average number of members (both individuals and organisations) was 489. In total, around 192,000 people were engaged in their activities (of which 42% related to social care). Given the population of Essex alone, for example, is 1.4m, this doesn’t strike me as a great number. Nor does the number of LINks that report engagement directly with people from a BME background or disabled people: less than 60 and just over 50 respectively.

If the engagement numbers don’t grab you, then potentially of more interest is the headline finding that LINks provided a net return on investment of £4.10 for every £1 invested.

I’m afraid to say the data behind this is optimistic at best. On the basis of the average benefit for 4 – just four – case studies being of the order of £270k, someone has simply multiplied this benefit by the number of changes that were “inspired” in services by LINks in 2009/10 – some 463. This gets you to a figure of £126m gross annual benefit.

Whilst the veracity of the 4 case studies seems reasonable, it’s a leap of faith to suggest the same financial benefit applies on average across each of the service interventions LINks achieved, wouldn’t you say?

My overall impression of the report is that there are undoubtedly some LINks making a positive difference through engaging their local communities in issues relating to health and social care services. However, the level of this engagement isn’t particularly deep, isn’t particularly innovative and is really quite limited. Nor can the level of financial benefit accrued from changes made by LINks be considered realistic.

At best, the report reads as if the most optimistic of civil servants has written it, looking for good as a whole where it only exists in patches.

Given this forms the foundation for patient and user enagement under the new health reforms, I draw the following implications for HealthWatch:

• Engagement is actually very low. LINks may have improved from 2008/09 to 2009/10, but the base was incredibly low in the first place. In particular, disabled people and people from a BME background were evidenced to be poorly engaged in LINks as a whole. HW will have to do much better than this.
• The report indicates that the money allocated by DH for LINks was not ringfenced within LAs: £27m was allocated by DH to LAs, £24.3m was allocated by LAs to LINks. Will the DH require money allocated for HW to be spent only on HW?
• The performance of LINks was patchy, but no enforcement mechanism seems to have been in place to address this. How will this be dealt with under HW?
• Data collection for LINks was quite poor. Given it underpins so much of the work HW do, will there be standards and requirements that are enforced in order to understand the work HW do?
• The annual report seems very keen to attribute financial benefits to the work of LINks in order to justify their works. Will a cost-benfit outcome be a key driver of HW, or is their value recognised as being one of engaging local communities in decision making on health and social care?

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.