National initiatives, local engagement and the latest NHS guidance on the duty to involve

The long-anticipated additional guidance for NHS organisations on section 242(1B) of the NHS Act 2006, the duty to involve and good involvement practice, appeared at the end of October – Real Involvement: working with people to improve health services. At 143 pages it is the most comprehensive statement yet about this legal duty.

If I read it rightly, this guidance puts a rather different interpretation on the local procurement of a nationally planned initiative from that which I thought applied. I now think I was wrong in believing the local NHS did not have to have public involvement in the local procurement process of developments that were not part of its own plans.

My assumption was that if developments were centrally directed and that all the local NHS did was implement something it had not planned for itself, then it could just get on with doing that without going through any formal engagement process locally. This key paragraph on page 51 suggests otherwise:

“If new services are planned and procured centrally by the Department of Health, for example intermediate treatment centres, and an NHS organisation is not responsible for those health services, it will not have to involve users or consult the OSC. However, where services are planned centrally and procured locally, the NHS organisation responsible for procuring the service must involve users and consult the OSC where necessary. In addition, it should be noted that an NHS body may have a duty to involve in relation to proposals or decisions which it has not itself generated: the issue is whether the proposal affects the services for which the NHS body is responsible. So a local NHS body may need to involve users if a national decision to procure a treatment centre has an impact on other services for which the body is responsible (see the judgment in R (on the application of Fudge ) v. South West Strategic Health Authority and others (2007)). “

PCTs are responsible for locally procured services and any new service is bound to have an impact on what exists already. If that is the “test” for the section 242 duty according to Real Involvement, then I think the requirement for engagement applies to the local procurement process, even if the initiative is a national one. The first thing that comes to mind in this context is the GP Led Health Centres (GPLHCs) being procured across London in each borough as I write this.

The whole procurement issue is fraught enough without this additional twist to complicate the public’s understanding. Also we have long argued against consulting or engaging with people if the deal is largely done and the important decision made. Consultation isn’t window dressing or rubber stamping.
The first thing to consult on is to get a better name for the procurement process itself. I’ve tried out “procurement” informally a few times recently in meetings and social situations to see what it meant to people. Nobody had a clue except the occasional person who has a particular type of commercial experience.
When “procurement” suggests anything at all, it has an association especially for older people with sleaze and prostitution. This is not the best understanding to be starting with when PCTs are trying to change services in London.

Trying out “tendering” wasn’t much better. Invariably it got a response that was about “privatisation” in one way or another. No one I’ve spoken to appreciated that tendering could be done by GPs or social enterprises (“social what”? people asked): “tendering” meant involving private companies.

That’s the level of incomprehension I fear we are up against. With legal and reputational risks existing around procurement already, let’s hope this gap in understanding doesn’t kindle into real problems. We are now seeing the moment when a vocabulary designed for those in the know to facilitate the internal debate needs to be recast for the purposes of public debate. This is not easy to do and cannot be done retrospectively.

One of the elements in getting the LINks off the ground where we under-estimated the amount of work required, is the need to explain and define so much about the vocabulary of the new health and social care services and the organisms that deliver them. People cannot conceive of the future if they do not understand the present.

Users cling to the words they know and the experiences they have had. Sometimes we have to wonder if resistance to change is generated by simple incomprehension of the terms of public discourse. People cannot agree with what they cannot understand even if there are benefits for them in the changes suggested.
Procurement of GPLHCs in London may well produce an example of that which will be tricky to handle, given the Government’s concurrent emphasis on involving patients and the public in decision making and service developments.

Best Practice in End of Life Care – MND Association case history

This week the MND YOC (the Year of Care commissioning tool) got prominent exposure as a featured example of condition-specific good practice in the National Audit Office’s End of Life Care report.  The Public Accounts Committee (PAC) will now conduct hearings on the NAO report on 17 December – open to the public - and then prepare its own report with recommendations for Government (to which the Government must make a published response).

There is something very satisfying about seeing work that MAC partners and associates have laboured long over for clients getting noticed in the right places.  So it is with the MND YOC.  Launched in the summer of 2008 after almost two years of work, it is now available electronically to all in the National Library of Health’s specialist neurological library, together with the “Learning from Leeds” report on how the views of people with MND, carers and staff made a real difference to the final version of the tool for commissioners.

The witnesses before the PAC will be the CEO of the NHS, David Nicholson, and the ”cancer czar”, Prof Mike Richards.  Given the long-standing interest MPs have in the inequitable provision of end of life services around the country and the well-deserved tenacious reputation of the PAC under its chairman Edward Leigh MP, the encounter on the 17th of December should be worth watching.   Expect to see a bit of squirming.

MAC is delighted to have helped the MND Association make a contribution to stirring up greater interest in this subject and we will be following the PAC’s work on end of life services closely.

November’s Newsletter: No downturn here – M-A-C blogging team’s creative outputs breaks all records

10 posts since 30th September represents an all-time record as M-A-C engages with the issues and causes dear to our collective and individual hearts.

Our first ever post back in 2003 was about our central interest – user involvement. A theme echoed in this month’s output with Andrew’s post Engagement isn’t enough. Two posts later, we were taking a look at Ann Abraham’s approach to her then quite new job as Health Ombudsman. Complaints and the way they are managed and treated and what they mean for the organisations trying to deal with them are another abiding interest – see the piece on 24th looking at how common themes can emerge from different surveys of the complainant/ customer experience.

It is not all about the familiar themes – since 2003 we have broadened our interests to embrace two new areas – Policy Governance and parental involvement in schools. In the case of the model developed by John and Miriam Carver, Policy Governance® has taken a while to get off the ground in the UK. Most of the work and case histories reflected US practice and we have not had a good UK example of how this approach to corporate governance can help organisations here. Now the Southend University Hospital NHS Foundation Trust have led the way for others to follow. Val Moore reported on this on 27th October.

Finally, Caroline Millar reports on how the new models of participation – involvement, engagement – are impacting schools, parents and teachers. Her piece focuses on the consultation on complaint handling in schools and how parental problems are handled (or not).

We call ourselves a consultancy that specialises in the user interest. What keeps us interested and involved and in business, is how that interest can manifest itself in so many different contexts while the principles underlying best practice can be so similar. Different diagnoses, different solutions but underpinning them all are the common questions – what do users think of this? Has anyone asked them? Has anyone listened? Has anyone done anything with what they have heard? What happens when people have a problem? Easy really.

The final question that comes up when looking back over 5 years – has anything changed?  Well Andrew inspired us all with a 2006 look at what the NHS will be like by 2015. We are almost halfway there and what has come true? Well the Department of Health seems to see things the Andrew Craig way. Allowing people to pay for their drugs was something Andrew took a look at in March this year when he pointed out that ‘topping up’ was something that Beveridge seemed to have explicitly anticipated when he wrote about the State leaving “room and encouragement for voluntary action by each individual”.  As far as the management ethos of the NHS as a whole is concerned, we will wait and see how PG will change all that.

In the meantime, it is still worth repeating a little Olympic-flavoured M-A-C joke from 28th November 2006 -

A parable of NHS reforms

(Elements are borrowed from several sources and sexed up a bit by us)

An NHS rowing team raced against a Japanese team. There were eight people in each team, of similar fitness, but the Japanese team won by a mile. How could this have happened asked John Reid? Top NHS management established a committee of analysts, which reported that the Japanese had seven rowers and one captain, whereas the NHS has seven captains and one rower. The experts called for restructuring of the NHS team. The new team comprised four captains, two service managers, and a director who also did the rowing. After a second lost race to the Japanese, the single rower was dismissed on the grounds of incompetence, and the management team received a bonus for strong leadership. A new NHS boat is currently being designed , but is reported to be running behind delivery schedule due to IT problems.

Let us see what has changed by the Olympic year of 2012 assuming we have not had to make a choice before then between funding bread and circuses or the NHS.