Taking user-driven commissioning to the NHS: why we need a shift from patient voice to genuine power-sharing
From this year 2013-14, Disability Rights UK is in a new consortium with Shaping Our Lives and CHANGE. As a user-led strategic partner, we jointly report to three new national bodies which are (as before) the Department of Health in addition to NHS England (new name for NHS Commissioning Board) and Public Health England. We have used this opportunity to reconsider how we can promote investment in and use of the lived experience of disabled people and of user-led organisations (ULOs) not only in terms of social care but also the NHS. We believe the answers to many challenges in social care and health lie in strong partnerships with individual disabled people and communities.
The latest (combined) involvement guidance will be a key document which the new Clinical Commissioning Groups will use when it comes to involve people and co-produce outcomes with ULOs. Key points from our response to the latest draft include:
We welcome the decision to issue comprehensive guidance across individual and collective involvement duties. This latest version of the guidance is strong and clear on the background (eg Mid Staffordshire), mission and vision and on some principles and measures outlining ‘why’ involvement is necessary. However, with the case studies very much reduced in substance (and shifted to Annex E) an opportunity has been missed to convince clinical commissioning groups (CCGs) of engaging and investing in genuine co-production throughout and as an integral part of the commissioning cycle...
1. Demonstrating the business case
Thus, the guidance lacks a clearly illustrated public sector business case and a comprehensive manual on how to go about embedding individual and collective involvement. Such a manual (taking the form of exemplary change pathways or maps) would help commissioners, other public services and community initiatives such as user-led and voluntary community social enterprise organisations (VCSE) to approach involvement for mutual benefit... After all, CCGS do not and cannot operate any longer in isolation. Better health outcomes and productivity gains (eg through reduction of unnecessary A&E attendances and harmful clinical procedures) can both evolve from stronger patient participation and public partnerships. Patients, friends and families can be safeguards against false incentives under Payment by Results as they generally opt for the least invasive treatments as long as they are supported to make informed choices, eg through a ‘right to peer support’ established throughout the NHS...
As a previous draft of the guidance pointed out, “people (can be) inclined to be more radical in their thinking about options than managers and professionals”. In fact, the introduction of personal health budgets into the NHS can scale up such healthy influences in the NHS. Personal budget holders can potentially (especially with others through pooling resources) micro-commission care, treatment and complementary support in a range of care areas beyond NHS Continuing Care. Associated costs would then be completely transparent. These individual choices on personal budgets could be incorporated (once tried and tested) into the services made available to everyone in NHS-managed care. On the back of such (anticipated) achievements in partnership-working, transparency and productivity gains, a new consensus on things like ‘minimum staffing levels’ can be reached and also financed. This is the case that the guidance can and must make.
2. Empowering and increasing people’s capacity to act as change agents
The underlying partnership approach requires people not only to have voice but to have power and to exercise that power – as contained in the NHS Mandate. The current version of the guidance mentions the need for staff training to manage the cultural shift but we think there should be parallel investment in training for patients and the public as co-change agents, experts by experience and peer supporters / navigators, etc. . Ultimately, the NHS would hugely benefit from a support infrastructure that is more akin to that in social care where such capacity building, individual support planning and representation are commissioned out to independent (user-led) organisations. This would remove the gradient between staff and patients and create an organic platform for a genuine shift from enabling voice to genuine sharing of power.
See full response to the latest (combined) involvement guidance here http://disabilityrightsuk.org/policy-campaigns/briefings-and-submissions An example of an attempt of beginning to address this power shift is included towards the end of the document. This example has been taken from our programme in user-driven commissioning which we recommend as a model for both individual and collective involvement in the NHS – see full report here http://disabilityrightsuk.org/policy-campaigns/health-and-social-care-reforms/user-driven-commissioning-building-%E2%80%98lived-experience . Having paved the way for user-driven commissioning, we now hope to align our learning with approaches such as experience-led commissioning, test parity between medical and non-medical aspects of NHS care and pilot payment profiles or at least incentives that are linked to Patient-Reported Outcome Measures (PROMs) in the shift from voice to power.
LINks to Good Practice - Disability Rights UK helping to strengthen the transition from LINks to local Healthwatch
Disability Rights UK have just finalised a partnership project after 1 1/2 years which culminated in the production of some resources to the benefit of local Healthwatch organisations but also of other relevant community organisations such as Disabled People's User-Led Organisations. We are specifically responsible for the 'engagement' resource, and the main sections in this resource may be of great value to Disability Rights UK members as well; they focus on: Place-shaping through building up chains of opportunities; Quick wins through local partnerships – the art of the possible; Systematic approach to gathering, capturing and using data.
Background
From April 2013 local Healthwatch replaced the Local Involvement Networks (LINks) as the "consumer voice" in health and social care. It is important that local Healthwatch learns from the experience of the LINks to ensure they become the best they can be, and to prevent "reinventing the wheel".The Department of Health commissioned a consortium of partners, including Regional Voices, the Race Equality Foundation, Disability Rights UK and NAVCA, to deliver training for LINk members in key skills around leadership and governance, engagement, representation and influencing decision making. Following from this work, the partners were asked to research good practice in the LINks, to share as a legacy for developing local Healthwatch. 90 people responded to the survey and 50 LINks were interviewed. These has led to resources being produced on four themes:* Leadership and Governance,
* Engagement
* Representation
* Influencing.
The 'About' section on http://www.linkstogoodpractice.org.uk/ contains further background, and there are is also a repository of further relevant resources. Thanks to all the LINks and ULOs who were involved in this project and took the time to share what they had developed!
Further details on health and social care reforms
We would like to remind Disability Rights UK members and our networks of the fundamental changes following the Health and Social Care Act 2012 which we have outlined in our document ‘health and social care reforms at a glance’ disabilityrightsuk.org/policy-campaigns/health-and-social-care-reforms/health-and-social-care-reforms-glance . This short and very basic document provides the context for many of the further updates discussed here. In the coming months we aim to bring to life the various opportunities arising from the reforms, eg empowering communities with disabled social care and health leaders. We will also focus on the pitfalls of the reforms in community development and partnership-working with voluntary and statutory social care and health organisations, building on our joint resources in LINks’ good practice www.linkstogoodpractice.org. If you are interested and wish to discuss or take part in any of these activities, please contact our Strategic Partnership Manager Bernd Sass bernd.sass@disabilityrightsuk.org . He is looking forward to your views and contributions.
The NHS is going through one of the biggest reorganisations since its creation. The new system is designed and intended to deliver better health, better care and better value for money. All changes are led by doctors, nurses and other health and care professionals, who are working with local authorities and local service providers, in response to the needs of patients and communities. This relationship between clinical leaders and patients who merely receive services we want to put on a more equal footing. It may help that the new system aims to focus more on preventing ill health and empowering local communities to plan services according to their local priorities. People will have more say in the care they receive, and doctors and nurses will have more freedom to shape services to meet people’s needs. A detailed overview of the new health and care system from April 2013 is available at www.healthandcare.dh.gov.uk/ . There are numerous short guides with similar or more extended information on the health and social care reforms. You may wish to take a look in particular at the BBC’s excellent summary www.bbc.co.uk/news/health-19674838 . Continuous updates on Healthwatch organisations you should find at www.healthwatch.co.uk , however do not forget to find out about your own local Healthwatch organisation who will have their own website.
As clinical commissioning groups, health and wellbeing boards and Healthwatch take centre stage at a local level, the voluntary and community sector faces a range of issues and challenges. Regional Voices has produced a briefing which summarises the main changes brought about by the Act and highlights key considerations for the voluntary and community sector- covering all relevant new structures from the local to the national: www.regionalvoices.org/changes
Government launches care comparison website
The new website delivers information to help people choose, compare and comment on residential care homes and home care services. It is now available on NHS Choices.
The new care profiles provide the most comprehensive source of information on care services. They help people to search and compare residential care homes and home care services and make confident choices about registered care for themselves or family members. See www.gov.uk/government/news/government-launches-care-comparison-website
Care and Support Minister Norman Lamb: “People will see health and social care fully joined-up by 2018”
Joined-up health and community care is not currently the norm, leaving people often getting disjointed care and support, not designed to suit their needs. In a recent study, 32 per cent of bereaved people said hospitals did not work well with GPs and other services. Coordination will see better care and support, fewer people falling through the cracks and a drop in patients needlessly stuck in hospitals. An end to people passed around the health and social care system thanks to uncoordinated services will follow plans unveiled by Care and Support Minister Norman Lamb.
www.gov.uk/government/news/people-will-see-health-and-social-care-fully-joined-up-by-2018
Personalisation & Equalities: linking two complementary agendas for mutual benefit – joint project with Race Equality Foundation and National LGB&T Partnership
Disability Rights UK has so far delivered one event with its partners. The workshops on the day with people from ULOs, social care and equality staff focused on barriers and brought up some very interesting (local) solutions which we want to follow up in due course. So watch this space. Depending on consensus with partners and delegates, we will be working on three related workstreams:
- How to make the case for addressing unmet need (social impact models)?
- Creating a coherent story on personalisation (including its pitfalls) to foster dialogues with commissioners
- To what extent should we take ownership of care and support, eg by pooling personal budgets, user ratings?
Interim CCG Assurance Framework published
CCGs are accountable to their local populations and to NHS England for planning and delivering comprehensive and high quality care that meets the needs of their local community. The Interim CCG Assurance Framework for 2013/14 published on 8 May will help NHS England, patients and the public identify how well Clinical Commissioning Groups are performing in their role as the commissioners of local health services.
This framework is intended to support CCGs to transform local services and improve outcomes for all patients.
The publication of the Interim Assurance Framework kicks off an engagement process with CCG staff, patient groups and other key stakeholders which will inform a final Framework to be published in the autumn. So understanding the Framework might be an important vehicle to get in touch with your CCG http://www.england.nhs.uk/2013/05/07/interim-ccg-af/
Compassion in Practice implementation plans
NHS England Compassion in Practice is NHS England’s joint strategy and is thought to help transform the care provided “in all care and support settings, throughout England every day and for everyone”. The strategy reflects Disability Rights UK’s project on bringing about parity between medical and non-medical aspects of care – following the Mid Staffs failures.
The implementation plans are a living, breathing and integral part of the strategy. NHS England must ensure that they are responsive to the changing needs of the people they care for and support. During the next three years, they have made a commitment to review and refresh these plans on a quarterly basis, update the timescales and report on what has been achieved. www.england.nhs.uk/2013/04/15/cip-implementation/
Business Plan NHS England
NHS England has published its Business Plan for 2013/14 – 2015/16, called Putting Patients First, which explains how they will deliver their mandate from the Government and ensure the best possible outcomes for patients. A full set of organisation structure charts for NHS England has also been published. For more information, go to:
http://www.england.nhs.uk/about/structure/ and http://www.england.nhs.uk/2013/04/08/bus-plan/
Monitor and NHS England call for views on how the NHS payment system can do more for patients
Health sector regulator Monitor and NHS England are working together to reform the way NHS services are paid for.
Hospitals are currently paid through the Payment by Results (PbR) system, which has been in operation for nearly a decade and has delivered benefits. However feedback from the health sector is that the current system is not sufficiently patient focused, not always based on good quality information, and can act as a barrier to delivering integrated care.
Disability Rights UK has called for (and is mapping out) new payment profiles that are linked to quality as reported by people using the NHS. We currently envisage such new payment profiles could be linked to Patient-Reported Outcome Measures (PROMs) or Patient-Reported Experience Measures (PREMs). That is, NHS providers payment would in future not only depend on PbR but essentially on achieving minimum scores on these or similar measures which still have to be developed. All this is to put (patient-reported) quality on a more equal footing with price. See www.england.nhs.uk/2013/05/13/tariffs-consultation/
Monitor - Draft guidance published for commissioners procuring patient services
In some local areas there is confusion on how free local commissioners are to re-contract with existing small providers as opposed to re-tendering. Monitor is seeking views on proposed guidance to help commissioners comply with new procurement, patient choice and competition regulations so that their patients receive the best possible health services. Under the Health and Social Care Act 2012, commissioners have responsibility for deciding what services are best for patients. The regulations passed by Parliament under Section 75 of the Act are intended to give commissioners flexibility when they decide how to procure services from health care providers. The guidance will help them make sure the decisions they make are consistent with the new regulations.
Monitor's role will be limited to making sure that commissioners have operated within the legal framework established by the regulations and to investigating complaints about procurement decisions. Over the next two months Monitor will be formally consulting on the guidance to make sure that it is a clear reference point for commissioners as they go about their work.
Dr. David Bennett, Chief Executive at Monitor, said:
"The guidance makes it clear that the regulations do not force commissioners to go out to tender for every service, but equally commissioners should not simply roll-over existing contracts without first asking how good the service is, and whether it could be improved to give patients a better deal. If so, the next steps might be evaluating alternative providers if there are any and if not negotiating a better arrangement with the existing provider. These are matters for commissioners to consider in exercising their duties. As a sector regulator, Monitor will be able investigate any complaints about procurement decisions in England as an alternative to bringing cases before the courts." See www.monitor-nhsft.gov.uk/node/3352
Updated NHS Constitution published (DRUK involved)
The Department of Health has published an updated NHS Constitution following a consultation that sought views on a number of proposed changes – Disability Rights UK has fed into this latest version. This version also incorporates some changes based on the recommendations made by Robert Francis QC in his inquiry. Important areas improved in the NHS Constitution include:
• patient involvement, patient information
• feedback, complaints
• dignity, respect and compassion
• duty of candour
• end of life care
• integrated care
• staff rights, responsibilities and commitments
To download the NHS Constitution and revised Handbook to the NHS
Constitution go to www.gov.uk/government/publications/the-nhs-constitution-for-england
Public Health England priorities for 2013-2014
On 1 April 2013, Public Health England (PHE) went live, bringing together a wide range of organisations and functions into a single body. These include the Health Protection Agency, Public Health Observatories, National Treatment Agency, UK National Screening Committees, Cancer and Non-Cancer Screening Programmes and DH Public Health marketing.
PHE works with national and local government, industry and the NHS to protect and improve the nation's health and support healthier choices. PHE are addressing inequalities by focusing on removing barriers to good health. PHE have recently agreed our priorities for 2013-2014 now available at: https://www.gov.uk/government/publications/public-health-englands-priorities-for-2013-to-2014