Health Act rag bag delivers part of the real prize

Health Act Rag Bag

Almost unremarked in the rush of bills getting  the Royal Nod on Friday  the 13^th was the rag bag of measures collectively known as the Health Act 2009. Tucked away among new powers to strengthen tobacco control; to place a duty on all NHS bodies, private sector and third sector providers of NHS services to have regard to the NHS Constitution (more on that in a later blog); to deal with (whisper it) failing Foundation Trusts; to require (largely meaningless) “quality accounts” from NHS bodies and to reform pharmacy services is the provision to give money directly to certain patients so they can obtain their own health care.

It’s Getting Personal

But it isn’t as simple as it looks – the consultation on the regulations and guidance is pretty daunting.  The real problem is that this will deliver only half of the prize that should really be on offer:integrated health and social care individual budgets reflecting the real level of user and carer need.  This is going to be big in coming years given an ageing population and more people with long term conditions surviving for longer periods with better quality of life.  How many?  The think tank Demos At Your Service report estimates 1.5m people in five years will be controlling personal budgets for health and social care.    When this happens, public services will never be the same.

The progress in freeing up NHS money so it can flow direct to individuals for this purpose is welcome (NHS money can already be handed to third party organisations to spend on behalf of individuals) and it evens the scorecard with what is increasingly common practice in social care. In fact, the consultation on the health care budget regulations largely proposes to mirror existing good social care practice.  If this is a hint that the two channels of care services are converging then we welcome it.

If our public services could just get their acts together about this we might see some progress towards the real prize.  David Cameron had the right idea in his recent statement on health priorities earlier this month when he included as part of a reform of long term care that “budgets combining social care and health care funding for people with long-term conditions will be rolled out.”

People Powered Public Services

The latest report from NESTA*  The Human Factor provides the evidence about moving to “people powered public services”  which could save billions. It should be required reading in PCT and Local Authority boardrooms as well as by political party strategists. The word is that Andrew Lansley likes this approach.   Both parties are making noises that the boundaries between health and social care services are going to be intentionally blurred in the near future.  In that light, keeping separate budgets for healthcare and for social care is simply perverse and discriminatory against the very groups who are meant to benefit.  It perpetuates an impediment to integrated services which goes back to 1948.  It really is time to come into the 21^st century with how we commission and provide public health and social care services for our increasingly complex and diverse population.  That’s the challenge MAC would like to see all parties grasp as the election temperature starts to rise.

*NESTA is the National Endowment for Science, Technology and the Arts

The November Newsletter

Dread Moment, Dead Time – the Roots of Laughter and the Prompt to Action

I was in the queue at the Post Office – two positions open for business; 12 people in the queue; having to pay £5 for special delivery because of strike. The message on the QTV? ‘The only real laughter comes from despair’ attributed to Groucho Marx. Nothing could have better fitted the mood of existential gloom at the prospect of 20 minutes queuing while South London people sort out their complicated lives clutching half-filled-in forms and expired passports. None were laughing. It was the most apposite message I have ever seen on that medium but the best was yet to come two seconds later with the name and location of a photocopying shop new to me and just up the road. The ad worked – 20 minutes later I was in there and their sales figures leapt up by 0.72p.

Partners’ Prose

Schools

Of course had I been connected to the internet. the time in the queue would pass in a flash because I could read the Partners’ blog entries in October and November. Caroline Millar sends politicians to stand in the corner for wilfully getting the important Cambridge Review wrong.

It seems to be open season on schools and the question of how they should be run and who should run them. Caroline documents the candidates in some detail in the following terms:

“whether it be local authorities, faith groups, used car salesmen or aspirational lasagna-eating anxiety-monkeys who are running the schools of the future, it should be a requirement for all of them to demonstrate that they know what their pupils, parents and local communities think of them and to show that they are responsive to their needs.”

Read the full post to see where they all come from.

Governance

Val Moore updates us with tales of a Norwegian state pension fund seeking to persuade large American concerns of the advisability of separating the post of chief executive from that of chairman – a central tenet as it happens of Policy Governance®. Val had recently attended one of a series of workshops being run by Caroline Oliver and the UK Policy Governance Association and this separation of function and titles still seems to be causing problems for many organisations.

Val wrote

“Many of these organisations are struggling to see the unique role of the Chairman and Board and want to avoid that well known situation where the Board usurp the role of the Executives and the Executives second guess the Board.  Policy Governance separates the two roles and maintains that the Chairman and the Board are ‘owners one step down’ and not ‘management one step up’.  This thinking frees the Board to concentrate on the ‘ends’ or goals of the organisation and to allow the CEO and executive team to work out the ‘means’.”

Politicians’ promises and social care

Ends and means were very much part of Andrew Craig’s piece musing on how strange it was

“that with little over a month to go for people to have their say about the government’s social care proposals for England, the Prime Minister pulled a monster rabbit out of his capacious hat which made roadkill of the consultation process.  Mr Brown pre-empted discussion by giving a personal care pledge to adults under 65 -  later clarified as also extending to younger disabled people aged 18-64 needing personal care at home.  That’s a lot of people and a awful lot of bawbees, Gordon, even if the Government is still around after 2010.”

If the consultation is to have any useful effect, it should provide some insights into what Andrew identified as the three main issues around social care:-

• First and foremost, we need one, integrated system of health and social care not two
• Second, the social care debate must be widened to include younger adults with disabilities and chronic conditions and people who care for them
• Third, while raising the universal standard of social care we must reclaim the Beveridge principle of individual initiative to make extra provision.

Complaints – Opening Up on Complainant Satisfaction

Back to where we started with a moment of existential despair in a Post Office queue – the mood seems right when comtemplating the Kafka-esque world of a complaint about service at our bank. We take a look  at the experience of having a problem with banks, specs and teeth – and no the NHS does not feature in any of them. The world of the banking back office and that modern contradiction in terms ‘the customer service team’ – neither a team or much to do with service -  and how best intentions and efforts can still go wrong even when all are trying harder than Avis.

But we finish on a good note – if you have a complaint about your private dentist’s service, find your way to the Dental Complaints Service and your complaint stands a good chance of getting sorted according to some new data. Well done Derek.

Broon’s Care Bunny – Trick or Treat?

Broon’s Bunny makes roadkill of consultation?

Was it a conjuring trick to thwart the consultation or just a soundbite one has to wonder?  We find it strange that with little over a month to go for people to have their say about the government’s social care proposals for England, the Prime Minister pulled a monster rabbit out of his capacious hat which made roadkill of the consultation process.  Mr Brown pre-empted discussion by giving a personal care pledge to adults under 65 -  later clarified as also extending to younger disabled people aged 18-64 needing personal care at home.  That’s a lot of people and a awful lot of bawbees, Gordon, even if the Government is still around after 2010.

Bunny Distraction

After the Brighton rabbit trick, is there anything still to consult about?  The King’s Fund was bemused but thinks the devil will all be in the detail.  No doubt it will, but the bigger problem is that rabbits out of hats don’t make good policy. ”Bunny distraction” is a disincentive to engage with the consultation.

How to fund social care costs as our population ages and more of us survive for longer could hardly be more important to all of us, yet most people outside the usual interested parties are only dimly aware this debate is even happening.

National Care Service and funding proposals

At the heart of the proposals is the establishment of a “National Care Service” providing all people with needs above a single England-wide threshold with access to some public funding for their care in older age: a minimum of a quarter to a third of the cost, rising to full support for those on the lowest incomes.

Three options are proposed for how people might fund care costs not met by the state:

1. A partnership model under which individuals are left to meet their care liability themselves. The Green Paper says that while average costs for people over 65 would be around £20,000 to £22,000 per year, those with the highest needs, such as people with dementia, could still face significant costs of £100,000 or above.

2. An insurance model under which people would be invited to enrol in a state-backed insurance scheme – either run by the state or private insurers – and then get all of their care costs covered. The Government estimated that people might need to pay £20,000 to £25,000 into the scheme, protecting those with higher needs against prohibitive costs.

3. A comprehensive model under which all people over 65 would be compulsorily enrolled in a state insurance scheme. This would reduce premiums from £17,000 to £20,000, because the risk pool would be maximised, but people would need to pay regardless of whether they needed care or not.

1 and 2 are nonstarters.  If it’s non-compulsory, those that are likely to need it most won’t bother.  Think about National Insurance contributions - no one would seriously suggest that should be optional.

Accommodation costs – the kicker jacking up the price

Accommodation costs in care homes would not be covered by these arrangements, but these costs would still be met for those with the least means, as now.  But there is a “fix” proposed for this – “care now and pay later”,  in effect  from beyond the grave.  Property owners could have their hotel costs for care met now, with cost recovery from their estates later on.  If this were nationally consistent and  transparent, it could work and should be seriously considered, we think.

Consistency please

Councils are notoriously inconsistent in setting and applying their eligibility criteria for social care.  Many people with needs judged to be low or moderate have been dropped off the eligibility list as resources are concentrated on “serious” need.  The Green Paper proposes a remedy in the form of a consistent care system with  a single national eligibility threshold, under which people who had difficulty with three or more activities of daily living would be covered. People would be able to move between areas and take their eligibility for care services with them, unless their needs also changed. The government would decide what proportion of someone’s care costs would be met by the state and what by the individual, rather than allowing councils to determine charges for non-residential services, as they do now.  Provided this was equitable, we think a move to national consistency would be welcomed.

There are things that could be done now

Are these proposals the future for adult social care in England?  They are one possible future, but not the only one.  According to the Joseph Rowntree Foundation’s ongoing research programme “paying for long term care” there are a number of successful current models of long term care arrangements for older people that could be rolled out more widely.  These should not be ignored in concentrating only on the Government’s options.

Get down to the basics about social care

Over and above commenting on the details, we think there are three things to be emphasised in this consultation:

First and foremost, we need one, integrated system of health and social care not two. A “National Care Service” that is insurance funded will always be problematic compared with a taxation funded National Health Service.  Why not combine the two into a universal service with a mixture of central taxation and insurance-based funding?  Service users don’t see the rationale for the division between health and social care anyway.  It is illogical in terms of how people with complex needs live their lives and need to access services.  Isn’t having a seamless service what we are supposed to be striving for?

Second, the social care debate must be widened to include younger adults with disabilities and chronic conditions and people who care for them. Adult social care is not just about elderly people.  Many thousands of younger adults 18-64 need better social care now  - generally at home – and will increasingly do so as they live longer.

Third, while raising the universal standard of social care we must reclaim the Beveridge principle of individual initiative to make extra provision.

We want to see these questions addressed in the responses to the consultation.  So we urge readers to ignore Mr Brown’s Brighton bunny and buckle down to thinking about the real issues around social care in England.  As someone from the government-in-waiting said recently, “We’re all in this together”.   How true.

England needs a Welsh lesson

The Conservatives created them in England and Wales without appreciating their full potential.  Labour neglected, belittled, callously fragmented their functions and then destroyed them in England as an afterthought in the NHS Plan, despite widespread agreement that they could and should have been reformed and refocused. But in Wales , Community Health Councils (CHCs) survived.  

It’s time England learned a lesson about this. As Carol Jones, Director of the Board of CHCs in Wales wrote recently in the Cardiff Western Mail, CHCs have never been more vital as that country embarks on a new approach to its heath services .  

A Welsh lesson would be timely with a new Government on the horizon.  MAC believes now is the time to recover our inheritance, dust off the organisational memory and move on.  In effect reinvent CHCs for England. This isn’t a homage for just doing things as before.  First and foremost, we must keep the expanded health and social care remit of LINks, which is the one good thing to come out of Labour’s chaotic “reforms” of patient and public involvement.  

England needs unified geographical authorites to integrate local commissioning of health and social care.  We also need local statutory consumer bodies mirroring the health and social care commissioning spectrum.  Their job would be to co-produce, enable, articulate and advocate based on the views of the public, users, clients and carers.  To start fleshing out this role, we’ve identified the following chacteristics of “CHCs Mark 2″: 

• comprehensive strategic and collaborative remit with NHS and local authorities balanced with attention to quality and detail of service delivery which matters to patients, clients and carers
• professional staff to continuously engage with their communities, co-produce intelligence for action and support their members
• sufficient real budgets including recognition and reward for lay people’e time carrying out public duties
• access to all premises and services where publicly-funded patients and clients go
• one stop complaints and redress advice across health and social care
• visibility on the high street as well as the web
• national operational standards and an independent regulator and auditor to ensure probity and compliance
• independence in governance and funding from the services scrutinised
• democratic control and accountability to local people for their policies and actions
• access and rights of referral to overview and scrutiny bodies and ministers when issues cannot be resolved locally.

Rights and influence are the trade off for responsible and accountable behaviour.  We want new-style CHCs in England to be the informed and critical friends of the statutory services.  Too often in some places in the past they were allowed to become the neighbours from hell in confrontational relationships with local services.  A governance approach reflecting the suggestions above would go a long way to ensure that did not happen again.

MAC would like to see people elected to new-style English CHCs as independent members without party affiliation for the individual contribution they could make because of their knowledge, skills, local networking and other attributes. Public money should fund election hustings and “town meeting” type events where candidates would be voted on to CHCs and where on a regular basis reports would be made back to the public about the body’s activities.  It is good that the NHS in England now has a statutory duty  to listen and engage, but without a stronger voice the listening ear is just an appendage.  Let’s try some real localism for a change, because centralism doesn’t work when it comes to getting things down “down our way”.

As Carol Jones rightly observed, “If we want to avoid another Mid Staffordshire catastrophe, learning from the Welsh experience and building on it for the English NHS and social care system seems an obvious way to go.”  Let’s not quibble over names; it is roles that matter. Whether it is called “Healthwatch”   or something else, a new-look English CHC rose by any other name would smell as sweet, so long as it was up to the job.

Patient-centred Care – still top of the 2009 agenda

ΤThe Healthcare Commission came out its 5th and last report on the State of Healthcare in December. The report summarised the overall picture as “positive, with targets relating to the health of the population either met or on the way to being met with life expectancy increasing and rates of premature death due to cancer and circulatory disease are falling. However the report went on to make the general point that “we have seen little change in the scores that trusts get for the experience of patients.”

What has to happen for the dials to move in the year to come? A recent report from the Kings Fund saw the authors Joanne Goodrich and Jocelyn Cornwell worry about how hard it was to find good evidence about the impact of patient-centred initiatives. They assess the evidence as all too frequently “patchy, fragmented and tends to be descriptive”. What is the mechanism that connects the intervention and a positive outcome? National policies and strategies are often no help at all.

The MAC Partnership have long been sure of a key part in that mechanism is. It is the people delivering the care. And they are helped enormously by users who know what they want and say so in a way that does not come over as aggressive and abusive. If staff feel good about the service they give, then they will convey that feeling to the people they serve. The greatest early failure of customer care was the imprisonment of unempowered and under-resourced people in the call centre factories manufacturing (if you get through) a response but never service, never a human connection to the person on the other end of the phone.   One of the two heartening examples quoted in ‘Seeing the Person in the Patient’ shows how compassionate and empathic staff can deliver effective patient-centred care. The example comes from the Kenneth B. Schwartz Center a non-profit organisation based in the Massachusetts General Hospital and its biggest programme ‘The Schwartz Center Rounds®’.

If you want to understand more about these two virtues of compassion and empathy and how to apply them in a practical way in both your professional and personal life, in my experience you can do no better than to seek out UK practitioners and trainers of Nonviolent Communication® at this website.

A good point, I think, both to finish and to begin again. All the best in 2009 from all of us in the Partnership.

Engaging Health & Social Care Communities Online

Just published on the main Moore Adamson Craig site – a case history of building the website for the Wandsworth LINk:

Engaging Health & Social Care Communities Online – setting up a website for Local Involvement Networks (opens as Adobe PDF file).

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.

Complaint Data – common themes confirmed in different surveys

It gets a little dispiriting if you work with complaints and complainants to see the same old messages emerge in survey after survey as the years go by. If I was a complainant, I would be tempted to be very rude to the next person who wanted me to complete a survey about the experience I had with my complaint. The questionnaires or the questioner have a little spiel along the lines of “your experiences will help us greatly in improving the way we handle complaints”. Really? There seems to be little sign of that.

The National Audit Office has taken a look at complaint handling in both health and social care services in anticipation of the creation of a single complaints system in 2009. Our friends at the Customer Care Alliance and Surveylab have just published their annual look at the complainant experience across a variety of markets and providers based on a survey done during July, August and September 2008. 10,102 responses were received from a random sample of UK consumers and some 230 of them had their most serious problem with health care services.

The findings from the two surveys cannot be compared directly but some interesting common themes emerged – the same reason came top in the list of reasons why many did not bother to complain. Namely, the perception was that nothing would change as a result of voicing that complaint. The NAO survey which focussed exclusively on health and social care services asked more detailed questions about both the informal and formal processes. Young people were especially likely to drop the matter at the mention of a formal process. The people who persisted – this came through with the health care problems – were those who were looking after or complaining on behalf of someone else and there is an interesting suggestion with the social care data that readiness to voice dissatisfaction was linked to whether or not part at least of the service had been paid for. Class and age played their usual part in readiness to voice with ABC1s and 35-54 year olds the more likely to take the problem up.

Social care service problems are most often triggered by a social worker or home help and this personal flavour to the problem explains why people with a problem with for example the bad standard of treatment, worried about the effect of making a complaint, not wanting to damage a continuing relationship with the service provider.

What did complainants want? The CCA survey asked directly whether revenge would be nice. 7% of men said yes to that compared to only 1% of women. That same survey confirmed that what people wanted overwhelmingly was an apology (46%), an explanation (57%), and an assurance that the problem would not be repeated (40%). One of the most telling pieces of data in this study (the NAO did not ask the question) was that 54% of the people who were dissatisfied, shared that experience with friends/ colleagues.

Ministers despair that people do not believe what they are told about the health service. As we have said before, we listen to and more importantly believe our friends more when it comes to service experience. Service reputation lags well behind the public announcements – the speeches, the ads – because private user information (the wisdom of the crowd) discounts these official messages in favour of their word of mouth sources.

We will await the lessons from the early adopters programme for the new combined health and social care complaint handling arrangements and how well local providers put in place their own arrangements within the Making Experiences Count framework. The main pitfall to avoid when building new organisations is to push complaint handling to the back of the process building queue. This overlooks the fact that good complaint handling is an vital resource for users who have been dissatisfied by some aspect of the fledgling organisation’s service delivery. Bad first impression plus bad problem resolution equals poor reputation straight after launch – revisit our thoughts on who gets believed.

In the meantime,  service process designers and commissioners need to look out for the user who is ABC1, 35-54 years old, responsible for someone else’s care. Lives in London and the South East and has lots of friends. Your reputation rests in their hands. Sort them out quickly with an apology and an explanation and just as most of those users do not want revenge, avoid giving any impression that vulnerable users still in the system will suffer for being cheeky and complaining. Worth perhaps repeating that stunning bit of data from the UK Customer Care study showing the rewards of good complaint handling that satisfies your users.