Another re-post from Mark Gamsu, Professor at Leeds Met, a keen specialist in tackling health inequality, this time about how participation can be embedded in Clinical Commissioning Groups’ work.
NHS England are currently coming to the end of a consultation on a guide titled Transforming Participation in Health and Care. Its always risky to have titles like this – because stakeholders then look to them with raised expectations. Sometimes I think it might be better to go for titles such as “Improving things little by little – participation in health care” or “Steady as she goes – some ideas about improving things a bit in participation in health care”!
I am not going to comment on the document directly. Here instead are five areas that I thought about when I read the document – some of these are mentioned in the draft guidance others are not or are not mentioned strongly enough.
Role of Clinical Commissioning Groups.
The old NHS paradigm sometimes felt like it was based purely on how each commissioning or service improvement process involves the public. While this is important if we are to genuinely transform participation in health care CCGs also need to provide place leadership in partnership with local authorities to shape how the local health and wellbeing system involves the public.
Unlike provider organisations CCGs have this system level responsibility.
So, this cannot just be about involving the public in individual commissioning processes that CCGs manage. It has to be about CCGs sharing responsibility for how an area (local authority level) provides ways for citizens to participate in the local health and wellbeing system.
Clinical Commissioning Groups therefore need to work with providers to ensure that they have powerful systematic actions for ongoing public involvement. In particular as a member of Health and Wellbeing Boards CCGs need to ensure that the participation of the public occurs across service AND organisational silos.
CCGs must also promote (with local authorities) a shared approach to driving forward good practice and building local capability. This should include explicit strategies to:
- Build local capability and capacity at a system level – to enable citizens (particularly from disadvantaged communities) to build on their interest in their health and wellbeing and that of their families and communities so that they can confidently get involved.
- bring joint investment to key local infrastructure organisations
- ensure explicit approaches to working across services and organisations to share practice and information and report on these to the health and wellbeing board.
- Championing dialogue and challenge across provider organisations
Effective Models of Participation by the Public in Commissioning.
Many of the models of Commissioning that are promoted by the NHS tend to be neat and tidy – for example the old World Class Commissioning Model – this graphic is taken from the Patient and Public Engagement Toolkit – South Central:
These flow charts reflect how commissioners imagine the world to be not how it actually works – they are led by how finances are organised; financial year reporting requirements; 3 year funding programmes; target delivery requirements and election cycles. They do not reflect how we live our lives as citizens and what we need in order to engage and influence.
We need models that start from how the public experience the world not how the system feels the world should be. For example I do not manage my personal relationships on the basis of some conceptual model of needs assessment, analysis, commissioning, review and recommissioning. Of course those of you who know me might argue that I would benefit from this!
So, CCGs will need to recognise that developing relationships with people in order to increase accountability and strengthen co-production actually requires approaches that foster stability, consistency and the long term. They need to provide flexible, long term points of entry built on trusted relationships – such as those developed by neighbourhood organisations like development trusts and healthy living centres.
So I think that a public centred model for participation might look a bit like this:
Active relationships with an empowered public
Powerful relationships with the public require commissioners to take a balanced approach to investing in support – this means taking a shared responsibility with local government in particular for the relationships that people have with sectors and institutions. It is crucial therefore to share responsibility for commissioning key local institutions such as Adult Education, Voluntary Sector Infrastructure Organisations – such as those that support volunteering and generic and specialist community development organisations – particularly those that operate at a neighbourhood level.
It also means recognising that it is important to foster mechanisms that promote dialogue and challenge. I am actually not convinced that we should have a core target that 80% of stakeholders should be feeling satisfied with regard to how CCGs have involved people. Dissatisfaction and disagreement are powerful drivers for positive change – promoting targets that call for high degrees of satisfaction feels really dangerous to me – not least because as Ibsen tells us “the majority is always wrong”!
Knowing what is going on
Clinical Commissioning Groups must work through Health and Wellbeing Boards to establish agreed ways of testing whether the level of public participation and involvement is adequate. I think that Health and Wellbeing Boards with active support of the CCGs should be commissioning intelligence reviews that capture the level and type of engagement that is happening within the health system so that providers and commissioners can be held to account for the degree involvement and participation.
Lets face it we could all benefit from a continuing evidence based dialogue to help us build on good practice and tackle areas of weakness. Frankly if Francis tells us anything at all it should be that we need to establish mechanisms locally that stop us deluding ourselves that we are ‘good’ at participation.
I do think that any guidance on participation has to recognise the key role of volunteers. These are people who are actively involved in co-production. Either through delivering services or helping to develop or manage them. I think that there is a strong relationship between the number and quality of volunteers and the effectiveness of work to increase participation.
What do you think?