New Health Bill moves towards individual commissioning budgets

The Health Bill 2009  introduced into Parliament on 15 January boosts the personalisation and choice agendas by enabling direct payments for healthcare to people in England.  There are already 60,000 people receiving direct payments for social care.  This is a big step towards the objective of individualised commissioning which joins up health and social care.  MAC strongly advocates this for people with long term conditions who wish to take greater degrees of control over planning and delivering their own comprehensive services.  It also points towards the achievement by 2010 of individually agreed care plans. That is a key reason why we worked with the Motor Neurone Disease (MND) Association to create the MND Year of Care commissioning tool, which will be invaluable in creating and costing individual care plans for people with this condition. 

All of this was trailed in the Darzi Next Stage Review report High Quality Care for All along with the suggestion that individual budgets might be most advantageous to people with complex and generally deteriorating conditions such as MND or multiple sclerosis or Parkinson’s disease.  We agree, provided that assessment processes linked to budget setting do not become burdensome in the face of what can be a rapid pace of deterioration in these neurological conditions.  Using the MND year of care tool to predict needs should reduce the need for reassessments.

The Health Bill coincides with an NHS Confederation report claiming that direct payments could “revolutionise” patient care.    Personal Health Budgets: the shape of things to come? argues that giving patients control over healthcare funding could provide enhanced outcomes and change the nature of the patient-professional relationship.  We hope personalised budgets and individualised commissioning for those who want to use it with support and help available from expert 3rd sector organisations will be the shape of things to come. 

As Secretary of State Alan Johnson said launching the Bill, “People rightly have high expectations of the care the NHS offers, and they want more control over their own health – which is why the bill will give more power to patients and drive up the quality of care.”  Conservatives and Liberal Democrats also welcomed this, so the chances of making progress are even better. 

Of course there are the inevitable nay-sayers amongst some of the self-interested professional groups.  Unison  warned of  a “real danger of creating a situation where patients use their personal budget ineffectively and then, like Oliver Twist, go back for more. Or, patients will be persuaded to top up their budgets from their own savings, undermining the founding principle of free healthcare for all.”  Unlikely we think, especially if there is s strong link between users and 3rd sector bodies to advise them about making good choices, or even holding the budget for them and spending it with their agreement. 

The BMA made the rather eeyorish observation that it was “currently very unclear how such a system would work in practice – for example, what would happen when a patient’s budget ran out? Moreover, this policy seems further to establish the idea of healthcare as a commodity, which the BMA does not believe is in patients’ best interests.”   Those presently in control would say that sort of thing, wouldn’t they?  

In rebuttal, we can think of no one better than Jon Glasby,  professor of health and social care at Birmingham University,  who said, “personal budgets have allowed people in social care to be much more imaginative and use funds more carefully than the system did. There is no reason why this should not happen in health.  However, it will need to be carefully introduced.” 

An agreed individual care plan is the essential first step to identifying a personalised budget.   Real choice, as the MND Association said in their response to the Health Bill’s publication, also means the choice to opt out of personal health budgets and still receive high quality and timely care and support.   Expert organisations like the MND Association which are close to their members and understand in great detail what it is like for individuals, carers and families to live with a devastating disease feel that even with the risks, individual budgets are worth exploring.  

Helping patients and carers raise their expectations about what should be acceptable is part of this.  As Heidi Macleod, Director of Care Development at the Motor Neurone Disease (MND) Association said,  “we support and promote the principal of increased patient choice. This initiative has the potential to improve control and flexibility in care.  A further benefit is raising the expectations of patients about what should be acceptable in terms of quality care and shared decision making so that they can make better choices, including end of life decisions, for themselves.”  MAC believes that with the right kind of support, that is a prize worth striving for.

The 2009 future for consultation – better organised for action and value

I am sure I am not the only person working in the field of public involvement who has been wondering what the impact of our current financial crisis will be on the work which organisations have been doing to engage with public and with public service users.  So it was interesting to attend a round table session held by The Consultation Institute for consultants involved in public consultation.

A lot of it about

No-one has yet carried out a proper market analysis of the public engagement sector although the Institute’s Rhion Jones reckons it is worth millions.  The problem is that although everybody is at it, many organisations have difficulty recognising it when they see it and have never thought to add up the cost of it all. Try asking your average Primary Care Trust how much money they spend each year on engaging with their users and I bet your bottom euro few if any will be able to tell you.  You can be sure there will be high level surveys on which thousands of pounds are spent, well-intentioned tiny questionnaires in the foot health department, public meetings (with lots of sandwiches and lots of staff in an empty room) and enough leaflets to repaper every GP surgery in the Trust.  But no-one will have added up the cost, let alone identified what all this expenditure is designed to achieve or whether it has made any difference to anything or anyone.  The same is probably true in most local authorities.

Horizontal activity and why we like it

The problem is that Public/User Involvement/Engagement, or whatever you want to call it, is the ultimate “horizontal activity”.  It is hard to find boards or senior managers who are willing to shake out the silos and build user involvement into their plans and their activities in a strategic way across their organisation.  Their were nods of recognition when consultants described working with organisations which run numerous consultations, each one run by a different manager, supported by a different team, with different contact lists and making the same mistakes.  Too often the lessons learnt in Department A never even make it to the room next door, let alone to Departments B to Z.  To make matters worse, much of this work is outsourced to an army of different consultants, researchers, PR people and others who sit frustratedly in their allocated silos wondering how they can write their final report in a way which might actually influence the organisation’s future strategy and behaviour.  Perhaps this will be the year when the silos get emptied out and the wheat is separated from the chaff.

Doing the right things and doing them well

According to Rhionn Jones who has done the back-of-the-envelope calculations, public sector bodies and central government are spending many millions on engagement activities and with all the pressure of new legislation, we can hope that this work will remain a priority. Maybe a little budgetary tension will force organisations to look more closely at how they are spending their money.  Organisations will be looking for methods which produce a high return for their investment: more e consultation, fewer uneaten sandwiches; fewer (and better) questions asked, more listening to the answers.

The costs of getting it wrong

It is easy to imagine hard-pressed managers sidelining public engagement work in favour of things which are less troublesome but we do at least have one thing working in our favour.  It seems very likely that 2009 will be the year when at least some of the carrots are replaced by big sticks.  In health especially, as reconfiguration starts to bite, we are going to see more decisions going to judicial review.  Organisations might finally be forced to recognise the benefits of getting their consultation processes right, really right.  Is it time for nationally recognised standards to be set for consultation and other public engagement activity so that everyone including the judges and the lawyers can recognise when it is done well?  Managers will need support and practical help as they tackle big consultation processes before, during and (importantly) after the consultation process has been completed.  The Consultation Institute offers training and seminars for practitioners to help them with every aspect of this process and MAC looks forward to working with them and others to make investment in listening to users and the public a better managed undertaking offering both valuable insights and value for money.

The first priority?

It is always easier to improve processes which take place outside the organisation – think of the ease of organising a survey. Just get a budget, and squads of competent market researchers will throng to your door to do it for you. The difficult bit is getting anyone in the organisation to pay any heed to the result. For MAC’s money, we would like to experiment with consultations where the whole process of the gathering of information, compilation and analysis is supplemented by a new focus on what happens next. We are seeing some innovative work in Wandsworth with a pre-consultation phase which prepares people for what will come next in the form of more detailed questions and work with health-related issues. We want a new emphasis on the post-consultative period – who sees the analysis of responses? how will they use it? In our experience, the organisations that use information best are those with the clearest idea of why they gathered it in the first place and how they are going to use in the future. The idea of compulsion to carry out consultation may not be helpful (we have written before how rules about ‘it must last 12 weeks’ do little for consultation quality) and equally, it is hard to see a sensible way to compell people to use the information they gather. But for our money, the route to money better spent is better planning for use rather than spending for show.

On being chosen by Mr Bradshaw to have my say – more than once

There it was on the mat. Young Mr Ben Bradshaw’s letter saying I had been chosen to give my views on local NHS services as part of the GP Patient Survey. Actually it should have said my views on “primary care services”, since it is only about GP practices not the NHS in general, but let that pass.  How kind of the Minister of State for Health, I thought, to take the time to write to me and about 5.5m other registered patients in England as part of the £8m exercise to find out more about patient experiences.  We as taxpayers pay for for it after all, so it ought to treat us well and listen to our views.  I’m all for finding out what the patients as customers think, provided the results actually produce improvement.

Not wanting to fiddle with seven pages of paper questionnaire, I went straight to the online version as invited by Mr Bradshaw and dutifully logged in my unique username and password as provided on the document.  I noted too the stern warning ”only one response per patient can be accepted.” I shall return to that point later.

The 47 questions are reasonable: lots about privacy and dignity, length of time for consultations and listening skills and – the crucial one I think – “involving you in decisions about your care”. That question came up  about consultations with nurses too, so it will be interesting to see if there are any comparisons to be made between patient experiences with different kinds of primary care practitioners.

What was missing, I thought, was the classic consumer research question: “Would you recommend someone else to use this service based on the experiences you have had?”  That should appear next time if Government is serious about patients having more choices, especially as 150 new GP led health centres are opening across England to increase primary care capacity and access and hence users’ range of choices about where and when and from whom to obtain services.

Completing the online form and being nicely thanked for my troubles by the Peninsula Medical School and the National Primary Care Research and Development Centre at the University of Manchester who deveoped the questionnaire, I then pressed “send” and that was that.  And then I had a devious little thought.  Let’s see if the system really means what it says about only one response being accepted per patient.  Having waited a  decent interval, I then went through the process again.  To my surprise, I as again welcomed warmly and invited to enter by “unique” (or maybe not?) username and password which worked without a hitch.  Would I now be allowed to proceed to complete the document again?  Expecting a big red “STOP” to appear somewhere, I proceeded through the questions and got to the end without challenge.  And then I did it a third time after which the words of the old electoral gag ”vote early, vote often” came into my mind.  Not very confidence inspiring really.

I’m not saying that I expect my experience means the Department of Health will be inundated with multiple online submissions for the GP Patient Survey.  They will be fortunate to get a decent return even from the two prompts built into the system – at least if the National Patient Survey results in our PCT are anything to go by.  It will be interesting to see if I get these postal prompts even thought I have submitted online already.  But what I am saying is that a reasonable effort to collect patient experiences which we should have confidence in isn’t secure  – at least judging from today’s empirical experience.  It is thus open to distortion if others wanted to “vote often” as I found I could do.

Has anyone had this experience with the online GP Patient Survey?  Try it and see what happens and then let us have your thoughts about the exercise and surveying patient experiences generally, here.