How can the public hold Clinical Commissioning Groups to account

I think that 'holding to account' means that the public must be confident that the Clinical Commissioning Groups (CCGs) are answerable to the public and patients for the decisions they make on our behalf.

The sorts of decisions they will be making (maybe they have already made them) are:

• What healthcare do we need.
• How much.
• The quality of the care
• Where the care will be delivered and by whom.
• How long will it take to get treated.

There will be over 200 CCGs.  Our is a small one with only 190,00 people and a budget of about £200M.  Others will be much bigger and responsible for very large sums of public money. So it is crucial that they use this money for the benefit of their local population and get value for money.

So how can we hold these organisations to account.  It will not be easy as individuals to do so.  Organisations of this sort can hide behind a number of barriers. They use the Freedom of Information Act to delay answering questions.  They can also use the idea of 'Commercial Confidentiality' to avoid giving answers about the value of contracts, especially with private healthcare providers.  They also use jargon to confuse us.  Lastly one of the ways to ask them questions is at board meetings held in public and that isn't easy for many people. It isn't much fun standing up in from the board and holding them to account.

However there are a number of ways that the public can make sure they spend our money wisely and on healthcare that will benefit us.

Ask questions at meetings

CCG boards will have to hold their meetings in public and publish the board papers online.  Go to meetings and ask questions. CCGs will also hold other so called 'engagement' meetings so please go along and ask awkward question. 

Join your Practice Participation Group (Patient Reference Group)

Each GP surgery should have a group of patients, perhaps as an virtual group, who support the practice in many ways. They can ask questions of the GPs who in turn can ask questions of the CCG.  Our CCG intends to have a Patients Forum with one person from each practice participation group on it. Exact details are current unknown. The patients will need to set the agenda not the CCG.

Service User Groups

If you have a long term condition join the service user group/support group or set one up.  They may be able to ask questions about specific services as they are often considered as 'experts'.  These groups are often used when services are being redesigned or changed. 

Local Healthwatch

These groups will be taking over the role of the Local Involvement Networks on April 1st. They will act as the patients champion  and should be seeking the views of patients and the public about the health and social care services. They will be monitoring the quality of services and holding the CCGs to account if the services are not benefiting patients. These groups will be as new as the CCGs and will take time to become effective. Anyone can join a Local Healthwatch and support their activities.

GPs

Our CCG intends to have an 'accountability forum'.  Each practice will have a GP on the forum and their role is to hold the CCG to account on behalf of the GPs and the practices. Even more reason to get involved in your practice participation group so you can influence the GPs.

Local Health and Wellbeing Boards

This is a joint Council & CCG body that is responsible for strategic thinking and priority setting for health and social care. A lay person from the Local Healthwatch will be a member. CCGs should be answerable to the board to show it is matching commissioning to the health needs of the population. How it will hold the CCGs to account remains to be seen but it could be quite powerful.  

Health Overview and Scrutiny Committees

This is a Council committee that monitors the commissioning and delivery of services and can hold the CCG to account.  The meetings are in public and you can go along and ask questions.

CCG Governance procedures

CCG are required to hold meetings in public, publish their papers online and to publish the methods they use to make decisions.  We should make sure that they actually do use those methods when making decisions about our healthcare. There will be much talk of the use of 'evidence' and we need to make sure they use all the evidence and analyse it in a consistent manner. 

Lay people on the CCG board

Each CCG is required to have two lay people on the board and one of those must act as 'the patient and public involvement' champion.  Find out who it is and make sure they act on our behalf.

NHS Commissioning Board

The new NHS reform act makes sure that the CCGs will be accountable for their performance to this national organisation.  But there is nothing in the act to make the CCGs accountable to us.

Monitor

The CCGs will be accountable to this national organisation for their financial performance.

Conclusion

Those of you who have read my previous blogs about patient involvement might notice some similarity to this one. I feel this is inevitable since the two processes of involvement and accountability are two sides of the same coin.  Both rely on good communication and trust. The same limited number of organisations are going to be active in the involvement process as well as the accountability process. 

Meaningful and effective involvement of patients, at an early stage of decision making, and in a sustained manner throughout the process will enhance the trust that the public have in the CCGs.  The accountability process will follow naturally from the involvement of patients and the public in decision making. 

There seem to be very few ways in which individuals can hold their local CCG to account. So it looks like you will need to join one or more of the organisations mentioned above if you want to make sure the CCG does what it is meant to do and 'make no decision about me, without me'.

The trouble with joining an organisation is that you hope that the person representing you is able to stand up to the CCG board.  Will the CCG take more notice of that person than the opinion of an individual?

Lets hope that the evolving CCGs will be different from the old PCTs. and that they will act in an honest and transparent manner so we can be assured that they are working on our behalf. 

  

My small part in the history of Liver Transplantation. Every interaction has an impact.

I have been blogging for a few months now and I wonder if my thoughts have had any impact on anyone. However a twitter conversation with Michael Seres (@mjseres) made me think about how little things can influence the bigger picture.

He tweeted about the death of the American surgeon, Dr Joseph Murray, who with Dr David Hume carried out the first successful kidney transplant in 1954. What got my attention was that Michael added the name of Thomas Starzl to that of Murray's and said that they were his heroes - the doctors who had made his own transplant possible.

The name of Thomas Starzl made a connection for me because I did some technical work as part of his research on liver transplantation back in the distant past. I used to work at St Mary's Hospital Medical School in the Department of Experimental Pathology. It was my second job after leaving university with a simple zoology degree in 1970. Between 1971 and 1988 I was technician carrying out diagnostic work and research as part of a team.  It was an exciting time, lots of research going on, the buzz of student life, living in London - you know the sort of thing.

There were lots of researchers who passed through the labs, learning and sharing ideas, and we were involved in their work. One of those people was Tom Starzl.

He and my boss, Prof Ken Porter, had worked together for many years on kidney and liver transplants.  In fact they developed an understanding of how rejection of the transplant happened and that discovery in turn led to the development of the immunosuppressive drugs that prevent rejection. Starzl carried out the first successful liver transplant in 1967 in Denver, Colorado and later developed the use of cyclosporin, a crucial immunosupressive drug, in 1982. Their original work had taken place well before I arrived at the lab but their transatlantic collaboration had continued and they often shared ideas and carried out research together.

So there I was, a relatively new graduate technician, still learning and I suddenly found myself contributing to the work of these amazing scientists. We did diagnostic work on the transplants from Denver and also lots of research into improving the chances of survival for transplants. Prof. Starzl would come over to London every couple of years but there was a constant flow of samples to be processed, cut and stained. We did light and electron microscopy but the most exciting technique was the auto-radiography that I did to see how the liver cells were regenerating.

I am sure the two professors could have done all the technical work we did but we did it all the time and they did all the thinking! They always appreciated the work we did and occasionally added our names to their scientific papers describing the results of the experiments. It was a great honour to be associated with them in this way.  Tom Starzl was always very friendly, a charming man. I remember that he used to ride around London on a push bike.  He would bring it into the lab and store it in one of the offices.

My conversation with @mjseres made me think about that part of my life again. I did a little research (Thank you Google) and found how just how important the work of these men was to the success of transplantation.  I realised that I, in a small way, contributed to their work and to the effect it had on the thousands of people who have successful transplants.  I now realise how fortunate I was to be associated with these amazing people and the wonderful things that they achieved.

So, thank you Michael, for reminding me about how important teamwork is and how everything, no matter how small, insignificant or routine it appears, is important.

We all have influence, every interaction has an impact and can produce slight changes in the way that others think and act.

How Health and Wellbeing Boards can involve the public

It is difficult to get the public involved in decision making about the big, strategic issues in Health and Social Care.  We are much more interested in things that concern us at a personal level.  

The Health and Wellbeing Boards that exist in shadow form in all local authority area are intended to promote the health and wellbeing of all residents in their area. Through the production of a needs assessment they will set the priorities for health and social service commissioning so that the best possible outcomes are obtained for local people. 

Or something like that anyway. 

The members of the board come from the local councils, health and social service managers and one member from Local Healthwatch. They are expected to involve the public in their work 

So I thought I would give them a few of my ideas, a few basic principles on how to involve the public. 

1. The Health and Wellbeing Board must know what it means by 'involvement' AND the purpose of such involvement.
2. The board must inform the public about its ideas on involvement and the purpose of public involvement.
3. The board must inform the public about what it can and cannot do with the results of the involvement process.
4. The board should use lots of different methods to involve the public.
5. The board should involve the public at an early stage in the development of ideas and plans.
6. The board should involve the public all through the process of developing plans.
7. The board should try to ask specific questions rather than vague ones.
8. The board should think and act 'locally' (small scale).
9. It will be more productive to look at single issues, conditions, treatments or groups of patients.
10. Use existing networks, service user groups, charities & voluntary sector organisations.
11. Face to face, informal events tend to be more successful than formal ones.
12. Go out to people, go to the workplace, the schools, clinics  shops, clubs & wards.  Do not expect people to come to you.
13. Use language that people understand, no jargon, and ask short questions.
14. The board must feedback to the public what information in gets through involvement and how it uses it.
15. The board will need to inform people and educate them about how decisions are made and how evidence is used.
16. Read the literature and research on patient and public involvement.
17. Patients and the public are different and so they will need different approaches .
18. We, the public will NOT be 'representative'.. 

 Any more ideas would be welcome.  Feel free to contribute.

Measuring improvement in the quality of care after reconfiguration of NHS services

I asked a question at a public meeting of our local Health Overview and Scrutiny Committee. They have a slot for questions from the public.  I asked if the PCT and hospital would provide a baseline from which to measure the improvement in care promised as a result of the centralising of services on one hospital site.   

I have posted a couple of stories about the difficulty I have had in getting an answer to this relatively simple but important question:  "Like getting blood from a stone" & "What is a 'benefits realisation'?".  I finally arranged a meeting with the hospital managers who are delivering the data. It is really important to talk to the right people.

They were very helpful and, despite being busy implementing the changes, they spared an hour of their time to talk with me about how they are measuring the quality of care.  They reassured me that they have plenty of quantitative data, such as re-admission rates, length of stay, avoidable admissions and mortality rates from before the changes and they will be collecting similar data from the newly reconfigured services.   Now that is good news.

They will not be publishing the data until they have the first set of new data so that there can be a comparison made between the old and the new.   This data will be collected routinely and published regularly. More good news.

We had a discussion about how to present the results in a form that the patients and public can understand.  Not an easy problem to solve. 

We also talked about using qualitative data from the patient experience to complement the hard numbers.  Now I think that the patient experience is a really good test of quality.  The government thinks so too because the 'Friends and Family' test depends on patients feeling they had a 'good' experience in a hospital.  I am not sure that any time spent in hospital can be considered good though.  This sort of data is more difficult to get and use but we agreed that it is important as the patient can have a different perspective compared to a healthcare professional or a manager. 

The hospital has been collecting this sort of information for some years and they said that they will be using it in the baseline measure as well as in the future. 

So my question has been answered at last and I feel reasonably certain that they have the data, both quantitative and qualitative, to measure the quality of the services in some way. 

What will be more interesting is what will the patients and public make of it?  Do they care about tables and charts showing that the number of people re-admitted within 28 days has been reduced by 5%?  Will they care that 95% of patients in a recent survey said that they had a satisfactory experience in the hospital?  Will they use this data to compare the quality of different service providers? Will quality information from other providers be comparable? 

Only time will tell.

The Tipping Point?

Has General Practice in England reached a tipping point?

During the last eight years, since the negotiations that led to the new GP Contract of 2004, there has been an increase in the workload and an increase in the complexity of the work of GPs and their staff. Work as moved out of hospitals and is now done in the community and in the surgery.  Most doctors work long hours into the evening after seeing patients doing their paperwork. They are checking repeat prescriptions, writing referral letters, checking the results of investigations and consultant letters.  The quality of their lives and that of their families is suffering.  Many doctors already work only 4 days a week and other for less.  This is the only way they can survive.

More recently the NHS reforms and the Health and Social Care Act has further increased the workload by making them take on the task of commissioning healthcare as part of the Clinical Commissioning Groups.

The Government has changed the pension arrangements for many public sector workers including doctors and nurses.  This has meant increased contributions and reduced pensions.

Within the last few weeks the Government has proposed to change up to 30% of the GP contract by next April. If this proposal is not accepted they will impose it. They are offering1.5% extra to practice resources knowing that 61% of all gross income is currently used to pay expenses such as staff costs. They acknowledge that GPs are looking after an extra 3.7 million people for no extra funding. In addition they are asking for an extra 4% work for no extra funding. The GPs are not impressed!

A considerable number of current GPs are in their 50's and 60's and so near retirement age. It is possible that many of them will jump ship early due to the changes mentioned above.  Certainly their families hope they will.

This could mean that surgeries, already stretched to the limit by increasing demand, will not be able to continue to work safely.

Is this the tipping point?

Is General Practice sustainable in its current form?

Will anyone want to become  GP?

What is a 'Benefits Realisation'?

In the summer I asked some questions at our local council Health Overview and Scrutiny Committee about how would the public know that the planned reconfiguration of services at our two local hospitals would benefit patients and what were the baseline measures for the specific services being changed.

The answer I got from the PCT was "in relation to the Better Healthcare in Buckinghamshire programme, a benefits realisation performance dashboard was being developed".

At the time this went straight over my head and all I could think about was that they had not answered my question on baseline measures.  I have described my effort to get the information in a previous blog (Like getting blood from a stone).

Recently there was a twitter discussion (#NHSchange) on measurement for improvement and someone used the phrase 'benefits realisation' in a tweet.  I complained about the use of jargon but was challenged to find some alternative wording.

I had to think a bit but did come up with some suggestions for a patient friendly version.

"Is my experience as a patient better now than it was before the change/redesign/reconfiguration?"

"Is my outcome (better health, less pain, ability to work, feel better) improved as a result of the change in service provision?"

I also did a bit of research and even went back to a PCT paper on benefits realisation.  In the document it said "Better Healthcare in Buckinghamshire will begin the development of a business case from which the benefits realisation plan can be further developed". However I could find no trace of such a plan in the public domain.

The paper also said that it was important to set current baseline against which to measure benefits.  This is, of course, what I was asking about in my question to the scrutiny committee. But it did not appear to have been done.  Luckily I have a meeting with the Trust to discuss this issue in a few days and I can use this information in my discussions with them.  I will report on what happens at the meeting.

As part of my research I googled 'benefits realisation' and first up was the NHS Institute for Innovation and Improvement's (NHSIII) website where they have a paper on the topic. It is interesting and worth a read. http://www.institute.nhs.uk/quality_and_service_improvement_tools/quality_and_service_improvement_tools/benefits_realisation.html

In their view a benefits realisation is

"a tool to make sure you actually get the intended benefits originally planned for your project". 

I like that! Clear and concise.

Further on it says

"A benefits realisation should be a fundamental part of any improvement project running from the projects beginning to the end and beyond".

Now that confirms my view that you need to know the baseline so you can measure the effects of the change you are implementing. It seems so obvious.

*****************

So if you are running an improvement programme and you want to know if it has worked I suggest you read the NHSIII paper and make sure you have a benefits realisation framework established at the beginning of the project.

What is happening to my hospital?

I guess lots of people around the UK are asking this question?

All around the country NHS managers and doctors are proposing to change the way services are provided in our local District General Hospitals. These much loved hospitals, with a loyal following of local people, are having the services they provide reduced or moved to another hospital.  Beds are being cut, wards being closed.

What is happening and why?

Reduction in beds and ward closures.

It is claimed modern medicine is done in different ways now compared to even 20 years ago and so there is no need for so many hospital beds. The time spent in hospital is shorter, more surgery is done as day cases and more patients are managed at home or in the community.  This means that the managers believe that hospitals mean fewer beds.

Closure of A& E Departments.

The experts from the medical  Royal Colleges tell us that A&E departments need more specialist doctors and nurses to provide a safe service 24/7.  Hospitals also have to meet the 4 hr target for waiting in A&E. So rather than employ more staff (There is a national shortage of A&E consultants anyway) the managers are merging A & E departments and closing some down.  This is happening all around the country.

Centralising services (reconfiguration and redesign).

The Royal Colleges tell us that to ensure high quality care is provided the doctors and nurses have to see enough patients to keep up their levels of skill and experience.  In many cases our local hospitals do not have enough patients so the departments are merged and moved to another hospital, perhaps in the next town. This process is called service reconfiguration or service redesign and is taking place in most hospitals across the country.

Hospital mergers.

An extreme situation is the closure of a whole hospital and merging it with a bigger hospital. This is happening in big cities.

What is happening in Buckinghamshire?

There are two district general hospital, managed as a single hospital, in Buckinghamshire, in the two big population centres, High Wycombe and Aylesbury.  Before they were merged the two hospital provided a full NHS service for inpatients and outpatients.  Since the merger there have been several proposals for change with all the associated consultations with the public. A number of services have already been moved to one site (stroke and Cardiology).  The performance of the stroke service for acute patients has improved as a result of the creation of a Hyper Acute Stroke Unit at Wycombe.

Now the mangers are implementing the next round of changes following a public consultation called 'Better Healthcare in Buckinghamshire'. http://www.buckspct.nhs.uk/bhib/

The following changes are now being implemented:
A&E consultant teams are being centralised at Stoke Mandeville Hospital (SMH), Aylesbury.
Reduce the Emergency Medical Centre at High Wycombe to a Minor Injuries and Illness Unit (The A&E was closed earlier).
Centralise specialist inpatient care for emergency medicine , respiratory, gastroenterology, medicine for older people and diabetes at SMH.
Centralise breast cancer services at Wycombe.
Transfer complex vascular surgery to Oxford but retain routine vascular surgery.

There are other service improvements planned such as a day assessment unit for elderly patients, a step down ward and admission avoidance services.

How do people feel about these changes?

Local residents in High Wycombe are concerned that they will no longer have an A&E department even though they are next to the M40 and the town has a population af about 100,000 people.
They feel that the hospital is being run down as services are centralised at Stoke Mandeville Hospital in Aylesbury (15 miles away along country roads). Following the latest consultation the PCT and the Hospital, together with the county Council, are looking at the transport infrastructure in the county, especially for those who live in the outlying villages. It seems amazing that this was done at the time the proposal was developed!  The NHS considered that transport was the responsibility of the Council and so did not address the issue at the time. The patients see things differently.

Local campaigner felt the changes were to save money and to reduce the size of the hospital. They see the changes as the thin end of the wedge leading to eventual closure.The PCT and hospital managers insisted that the changes were all about improving clinical quality.  The changes had nothing to do with reducing expenditure.

People do not believe them.

I have asked for information on how we will know that the quality of care has improved (see my earlier blog "Getting blood from a stone".  They have a 'Benefits Realisation Plan' but I think the public need something they can understand. I have a meeting soon with the hospital and I will update this blog after the meeting. 

The question that needs to be asked about all these proposals is:

Do people want a gold standard service and have to travel some distance to get it or do they want local access to a hospital and have care at a reduced quality?

A brief history of patient involvement in NHS

The new Health and Social care Act 2012 was sold to us as putting the patient at the centre of everything the NHS (in England) does.

I have spent many years collecting information on patient and public involvement and I would like to share some of the things I have filed in boxes and piles of paper.

Way back in 1974 the Community Health Councils (CHC) were created to give the patient a chance to have a say about the way the NHS was run.  Later other groups replaced the CHCs and as part of the HASCA Local Healthwatch will take over that role (in April 2013).

I started to collect quotes when I joined our local CHC in 1992.

Here are a few:

1991
"A consumer responsive NHS will treat its consumers with respect and will enable individuals and communities to influence the health service purchased and provided on their behalf"
A Regional Strategic Framework - Towards 2000.

1991
"The government recognises that...involving people more at both strategic and operational levels in discussions and decisions about options and priorities.... will help them achieve their objectives"
The Health of the Nation June 1991

1993
"Patients and the public must have a say in health service decision making"
Purchasing for Health July 1993

Zooming on a bit

1998
The NHS must be more open and truly accountable to the public.
- involving the public in decision making and monitoring process
- involving patients in service planning, development and implementation
A First Class Service. Quality in the new NHS 1998

2001
"Duty to involve and consult patients and the public in service planning and operation and in the development of proposals for change"
Health and Social Care Act 2001 Section 11.

Its all sounding a bit familiar isn't it?
So moving quickly on....

2012
Section 14U.
"Each Clinical  Commissioning Group (CCG)... promote the involvement of patients and their carers in decisions which relate to;
- prevention or diagnosis of illness in patients
- or their care and treatment."
Section 14Z2
"CCGs must make arrangement to secure that individuals.. are involved in
- the planning of the commissioning arrangements by the group
- the development and consideration of proposals by the group for change in the commissioning arrangements where the implementation of the proposals would have an impact on the manner in which services are delivered or the range of services available."
Health and Social Care Act 2012

So what, you say!

My point is that various governments over the last 20 years have said a lot about the need for patients and the public to be involved in decision making at various levels in the NHS.  The fact that they are still saying it suggest that it has not yet happened across the country in a meaningful way.

Will the embryonic CCGs really involve us patients in commissioning decisions?

Is it all rhetoric?

Do patients really want to be involved at a strategic level in decision making about health services?

What do we mean by 'involvement' and what do the CCGs mean?

Involvement, to me, is an active thing, it means that patients and the public participate in the development of new patient pathways and how services are changed. It is about involving the public in decisions about which services to commission and which services not to commission.  It is about asking us for our opinions on setting priorities. It is not just asking us for our opinions after the changes have been developed or priorities set.

The question remains though,  how many patients want to be involved in such difficult decisions?

Added in Sept 2017

The latest version of patient participation is Co-Production. This is an idea that originated in the States where whole communities got together with the authorities to develop facilities or services.

Exams - What are they good for?

I will be honest.  I hate exams.  I hated them when I was a student.  I hated them when I was a teacher.

There has been lots of discussion recently about what sort of exams we should have in the UK for children at 16. But there has been little talk about what are exams for? What is their purpose?

Most people would say they are there to test the student, to see if they know anything about the subject, even to see if they understand anything about the subject.

Others would say that exams can be used to provide a measure of the quality of the teaching.

Others may say they are there to measure the achievements of the school.

Maybe it is all three.

I do not think that exams are any good at finding out if a student can manage in the real world of work.

Exams are a one-off test.  They depend on the ability to remember stuff.

Do modern exams assess our ability to collect, assess and analyse information?

Are they important to employers? What do exams results tell employers about how someone will work and improve? I don't think that exams are much use for this but employers always ask for them and I guess, use them to short list candidates.

So I suppose we have to add to our list that exams are used by employers to assess candidates for jobs.

People say that continuous assessment is not a good way to measure the performance of students. They say that students get help from others students and their parents.  But isn't that what happens in the workplace. You use other people skills where appropriate, you bounce ideas off colleagues, you read lots of books and nick their ideas.

When we are working we don't work alone.  Yet we test students by forcing them to work alone.  We assess a two year course in 3 hours.   We use test that does not relate to how we normally work.

So we need to think about the purpose of exams first and then design a test that fits the purpose.

Great idea - shame about the implementation

There is this great idea.  There is a sum of money available.

Everything is set up, application form printed, lots of publicity. GP surgeries informed of the scheme by email.

The scheme went live - patients and carers informed.

All they had to do was get a signature from a GP.  Oh so simple!

There was lots of interest and so lots of visits to GPs.

Suddenly a problem emerged.  The GPs knew nothing about the scheme.

The first they knew about it was appointments being filled to get the signature. Now we all know how hard it is to get an appointment with a GP. So any appointments being used up in this way, just for a signature was not good news.

There was another problem. Carers were turning up asking for the signature on their own. There were confidentiality issues as the patient was not there to give consent.

All in all a most unsatisfactory situation and the GPs got a bit fed up with it.

So why did it come to this?

Sadly it was the result of not doing things properly.  The Primary Care Trust should have involved the GPs at an early stage in the design of this scheme. They did not!

Result: a good scheme that would benefit those hard pressed carers is delayed.  There are irritated GPs, carers and the other people involved in the scheme.

All the evidence shows that when designing a new patient pathway, a new service or a new scheme of some sort you should involve everyone in the design of the scheme at an early stage in the process.

You also need to develop the implementation of the scheme at the same time as designing the scheme itself.

Typically redesign happens, then they think about talking to the patients and other stakeholders. Its too late then.  Involve them early often and in a meaningful way!

So what is happening? Hopefully they will talk to the GPs, sort out the form, sort out issues of confidentiality and then maybe, carers can get the breaks they deserve.

Cock -up or conspiracy

Like getting blood from a stone

It started like this.....

Our local Hospital Trust and the Primary Care Trust (PCT) decided that they needed to reconfigure services across two of its three sites. I guess that there are many reasons why they should choose to consider such a redesign. There is the European working hours directive for doctors, medical training requirements &  Royal College recommendations etc etc., all of which suggest that some services needed to be centralised on one site and some on the  other site.

A few years ago they held a public consultation on the general principles of such a change and it passed without too much fuss. Obviously they then went away and developed proposals on how the reconfiguration might look, A number of options were identified, including leaving services as they were. This option appraisal then went out for another extensive round of public consultation.

The consultation agreed with the preferred option (surprise!) but once the implications of the proposals were known and discussed in the press the public began to express their concerns about the effects of the changes at a local level. 

These concerns were a) that it seemed that one of the two hospitals seemed to be reduced in size and in services, b) its A&E becoming an Emergency Medical Centre, and c) the issue of poor transport links between the two hospitals, especially for those living in the villages outside the major towns.

There was an extensive campaign by the local press and a 'Save our Hospital' group held meetings.  Managers from the hospital Trust and the PCT attended these meetings, made statements to the press and a useful debate took place. One of the interesting statements made was that the changes were designed to improve the quality of care and had nothing to do with money.  "Its all about quality".

This got me thinking about how we , as members of the public and patients, would know that the changes have achieved their desired outcome, that of improving the quality of care.  As a scientist and part time 'change manager' I realised that we needed a baseline measurement of the current quality of care provided by the existing services.  So I asked the question.

The County Council Health Overview and Scrutiny Committee was being updated on the reconfiguration and so I asked a question about getting quality information into the public domain.

The important part of the question was:

"Given that the aims of the changes.....are all about improving the quality of care ...can the Hospital and PCT provide the current level of quality of those services in a form that the public can understand."

Their answer in full (names and details removed to protect the innocent) (from the PCT director of communication and engagement) was:

"Quality reports are routinely considered at meetings in public of the PCT cluster Board. These look at issues such as waiting times, levels of hospital acquired infections and delayed transfers of care. In relation to the changes proposed by the programme, a 'benefits realisation' performance dashboard is being developed. This will contain a number of indicators which will be monitored to ensure that any changes are producing a better experience and better outcomes for patients.  This will look at factors such as patient satisfaction, mortality rates, length of stay and admission and readmission rates of these services which have been changed."

Now I know I am just a member of the public but I did spend two years teaching science to GCSE students and I reckon that comes under the category of 'this student did not answer the question'.

Now in my role of 'a stone in the shoe' I had a email conversation with the Trust representative ('the messenger') which resulted in no improvement and so I was allowed to re-ask the question at the next Overview and Scrutiny meeting .

This is the next answer, given by a senior clinician from one of the two embryonic local Clinical Commissioning Groups:

"At the moment a large amount of data is collected the Trust.  This includes data on length of stay, readmission rates and mortality rates. However the way in which this data is currently analysed and reported reflects the current arrangement of services not the proposed new reconfiguration. The Hospital Trust is currently undertaking an exercise to analyse the data to reflect the changes and to determine benchmarks from which outcomes can be monitored. Once this is completed the key indicators will be published and monitored in the public domain".

Once again it seems to me that they have avoided answering the question. In fact they seem to have missed the point about establishing the quality of the current services, entirely. Yet at the same time they say that the way the data is analysed at the moment does reflect the current services!  If this is so they should be able to give some indication of the quality of the current services.

Each time I go over the answers I see more confusion and lack of information.

It seems to me common sense that the baseline for measuring quality improvements should be taken before the changes are implemented and are an essential piece of information that any organisation should use when managing change. 

The more I look at what has happened over the last few months the more concerned I am about the ability of the local health services to understand the quality of service that it provides for the local population. They do not seem to understand the process for monitoring the change process either!

We are being told to choose the health care provider that gives the best quality care but if they cannot give us the information on quality how can we choose?

Or is it that they do not want to tell the public what is happening?

Why?

Why have I called my blog "A stone in the shoe"?

You know what it feels like when you have a stone in your shoe? Every step you take it irritates, you can feel it, it niggles! You try to wriggle your foot and hope it moves to somewhere else in your shoe.  Then you try kicking your feet in an attempt to move it.

Finally you have to stop, take off the shoe and give it a good shake .

Even then once you put the shoe back on you find the bit of grit is stilll there.  Or is it another piece?

Off with the shoe
Off with the sock
shake it all about

Put them all on again and suddenly you are comfortable.  Walking is a pleasure again.

Well.

That is what I feel I am to the local health authorities. An irritant, a stone in the shoe that just will not go away.

I want them to remember that there are patients involved in the 'businesses' that they run.

I want them to remember that they need to provide evidence that the changes they implement will benefit patients (and staff).

I want them to remember to manage change properly.

I want them to design and redesign patients pathways involving patients (and staff) early and often in the process.

I want them to build the process of implementing the new designs into the design process, not tack it on afterwards.

I just want them to do things properly.

So I ask questions at board meetings and Council Health Overview and Scrutiny committee meeetings.

I persist until I get an answer that members of the public can understand AND that answers the question.

Its not easy.

So I try to be that stone.  Always there.  A reminder to do things properly, in an evidence based way, using language that people can understand.

How to improve healthcare in your area

How to Improve Healthcare in Your Area.

Patient and Public Involvement in Healthcare

I find that patients are, on the whole, only too happy to discuss their experiences of using the health service. In fact often it is hard to stop them talking and I cannot take notes fast enough!

Yet they find it hard, as individuals, to get their opinions listened to by Hospitals, PCTs and Social Care providers and commissioners.

Perhaps part of the problem is the bureaucracy and apparent inflexibility of these organisations. They like to do things in formal ways, by holding consultations and engagement meetings. Most patients prefer a face to face, informal conversation.

Patients also want quick feedback.

Then there is the language!

Public and Patient Involvement (PPI) has its own jargon, like many of things that happen in the NHS.  There is ‘engagement’, ‘consultation’ and ‘involvement’. They seem to mean different things to different people. In fact to most patients they mean little. They are words that managers use and are found in all the strategy documents and reports published by hospitals and the government.

Patients just want someone to listen to them and then to take some action so that services are provided or improved. One of the things that patients feel is important is to have some feedback from the organisation about how it is using the information it receives from patients.

This is what the government has said (see bullet point 6) about giving patients a louder voice through the Health and Social Care Act 2012:http://www.dh.gov.uk/health/files/2012/06/B3.-Factsheet-Greater-voice-for-patients-300512.pdf

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Involving Individual Patients

Patients, at an individual level, have always been involved in managing their own health.  This took place, either through self-management of their illness or during the consultation with a health professional. Between them the patient and doctor or nurse will work out what is best for the patient.

There are times, however, when the patient would still say “What do you think, Doc?”  But in every consultation there should be some form of joint decision making about what should be done to improve the patient’s health and wellbeing.

There are other ways that patients, as individuals, can influence how healthcare services are delivered.

Choice.

We all, as patients, have the right to choose where we receive our hospital treatment. The hard part is finding out which hospital provides the best treatment for our condition and for us as a person. But by making a choice we are influencing those who make the bigger decisions for all patients. So ask your GP about the quality of the service you need.

Patient Advice and Liaison Service (PALS).

If a patient or carer has concerns about something then one way of letting the organisation know is through the PALs officer.  This service has been around for a while now and the PALs officers are there to provide information about services but also to sort out minor concerns and problems that patient’s experience.

The PALs officer is able to pass on the concerns to senior management who should sort it out or provide explanations.

Regular reports are made to the hospital board on the number and types of issues that come to the PALs department.  The idea is that this provides information on services that may need to be improved in some way.

Writing to MP and local press.

This is always a good way of getting the attention of the Chief Executive.

Ask questions at Hospital Board meetings.

This is not easy for some people and I suggest that you write down your question and ask the chairman to read it out.

Ask questions at your local Council Overview and Scrutiny Committee.

Again some people might find it easier to ask the chairman to read out your question.

Complaints.

People are often hesitant in making formal complaints. They are concerned that if they cause a fuss something might be written in their notes about being a ‘trouble maker’.

However every complaint has to be investigated and a report is seen by the Chief Executive. A sub-committee of the board will also see the investigation and should make sure that actions are put in place to ensure that no harm comes to future patients. Regular reports are made to the board in public on the causes of complaints and the actions taken to stop similar things happening again.

Sadly, sometimes the only way to make sure that services are improved is by making complaints. 

The NHS needs to make it easier for people to make complaints. There are organisations, such as ICAS (see below) that support patients, their carers and relatives, in making formal complaints about the care they have received.

The Independent Complaints Advocacy Service (ICAS). ICAS provides advocacy support to people who wish to make a complaint about the service - or lack of it - that they have received from the NHS.

Finally patients and carers can also influence the way their healthcare is provided by joining one of the many groups that exist in the community and becoming part of a network.  Networks of people tend to have a louder voice than an individual.

There are lots of organisations and groups in the community that can help patients and members of the public to influence the authorities. The hard part is to find them and then to find the time to be active.  Often local councils will have lists of such organisations.

Join your local GP surgery Patient Participation Group.

If you have a long term medical condition you could join the local user group (or set one up). These groups are often used by the authorities to provide ideas for improvements in specific services such as stroke, diabetes, mental health, disabilities and other conditions.

There are local & national charities and other voluntary sector groups who support patients and carers and who can start campaigns to improve care services.

Foundation hospitals will have members who elect a board of Governors who can influence the executive board of the hospital.

Hospitals and PCT (and hopefully the new Clinical commissioning Groups) have patient experience groups or forums.

Online groups.
There are plenty of online groups that can both provide support for people with long term conditions and others like Patients Opinion (https://www.patientopinion.org.uk/ ) who provide a way of raising your concersn in a user friendly way.  Hospitals do respond to these online comments so hopefully they also act on them.

There is the Local Involvement Network (LINk), an independent local volunteer led responsible for collecting the views of the patient and passing them onto the authorities.  They also have the right to inspect NHS and social care funded organisations providing care. The LINk will evolve into Local Healthwatch in April 2013.

Local Healthwatch will have a greater involvement in this sort of activity and will be recruiting members to undertake some of the work. Look out for information in your area.

Other voluntary sector organisations take an interest in health and social care issues.  The Women’s Institute in Buckinghamshire recently ran a campaign to improve stroke services. http://www.bucksfwi.org.uk/index.php/wi-campaigns/bucks-activities.html

Influencing the Clinical Commissioning Groups

The government has placed great importance on the need for the new Clinical Commissioning Groups (CCGs) to undertake “Meaningful engagement with patients, carers and their communities.” as part of their authorisation process.  They are also required to “…to involve the public on any changes that affect patient services.”

This means that they should be asking all people about their experiences of the health care they have received and also asking how they can be improved. Ideally patients and the public should also be involved in designing the changes to services as in this example:

http://www.improvement.nhs.uk/audiology/presentations/national_audiology_conference_july2010/Workshop2_presentation.pdf

It will be interesting to see how CCGs engage and involve individual patients in decisions about patient services. In an ideal world GPs will have time in a consultation to discuss with patients and carers the issues and priorities that face the CCG.  Then they should have time to collect together all the comments made during the working day and pass those onto the CCG. The CCG then will look at all the comments from all the GPs, analyse them to help their decision making.

In my experience I fear that scenario is unlikely!

So ask your GP and your local Clinical Commissioning Group how they will involve the patients and the public in any changes that affect patient services.

Lay Person's guide to Commissioning Healthcare

A Lay Persons Guide to Buying Healthcare

The Government's recent reforms of the NHS in England have changed many things.  These changes are intended to improve the quality of care provided by the NHS and ‘to offer doctors and nurses the opportunity to play a major role in improving local health and wellbeing’.

One of those changes is that healthcare will be bought or ‘commissioned’ for all those who live in England by new organisations called Clinical Commissioning Groups (CCGs).

All GP practices in England must belong to a CCG.  There will be 212 CCGs in England.

The CCGs will buy:

Elective (planned) Hospital Care (outpatients and inpatients),

Urgent and Emergency Services (A & E),

Community care and rehabilitation services,

Mental Health Services,

Learning Disability Services,

The Government provides a certain amount of money that the CCG will use to buy our healthcare. The CCG will decide how that money is spent.

The CCG will decide how much of each service to buy and where it will buy it from. So it has to choose which hospitals will provide our health care. They will be required to use any provider who is qualified to provide health services. This could be from NHS hospitals or it could be from private companies.

Commissioning is more than just simply buying healthcare.  It is also about discovering what are the needs of the population, identifying the services required to meet those needs, deciding how services should be provided (pathways) and setting quality standards.

The CCG will then agree a contract with the service provider on an annual basis (April to March).  Some contracts, especially those with private providers, will last for longer than a year, perhaps up to 5 years.  Negotiations on contracts will usually start in the summer and are expected to be signed by the end of March in each year.

The price for each outpatient appointment and each treatment & operation is set by central Government.

Having bought the care the CCG will need to make sure that it gets what it paid for, both in the amount of care (the number of outpatients and inpatients, the number of tests etc.) and also the quality of care that is provided for patients.

The CCG also has to make sure that the quality of care improves each year.

The Government expects that each year the CCG must break even financially.

Some services will be commissioned by a national organisation called the NHS Commissioning Board.  These include GP services, Pharmacies, Dentists and specialist services.

CCGs will be run by a board which has GPs as members, as well as a nurse and a hospital consultant.  There are also two lay representatives and a number of other board members who will look after the finances and other activities.

Most of the managing of the contracts and the administration will be carried out by another organisation called the Commissioning Support Unit/Service.

The CCG will be held to account by its member practices and also by the National Commissioning Board.

The CCG is required to involve patients and the public in decisions about how it commissions our healthcare.  I assume that it will do so through the Patient participation Groups but also through public meetings, surveys. The CCG may also involve patients through service users groups and voluntary organisations. One of the roles of the lay representatives on the board is to act as champions for patient and public involvement (Health and Social Care Act 2012 Section 14u).

So if you want to influence how health care is delivered in your area I suggest you join your Practice Participation Group.

The zone of uncertainty

I am sure that I am no different from many people who think about blogging. I wonder if my thoughts and words are important to anyone else but me.

But having started to use facebook & twitter it seems that some people are interested in my opinions.

So I have taken the plunge and started this blog.

I will try to contibute something to the vast amount of opinion that is available on the internet.  Some of it has value, some is informed, much is uninformed. Only time will tell into which category my opinions fall.

My interests are varied but this blog will be about my thoughts on the Health and Social Care Services in the UK.

I have either worked in or been involved with the National Health Service in lots of different roles since 1971. I started as a junior technician in Histopathology (those were the days - there were several changes to what we were called, now I think they are biomedical scientists) looking at a tiny part of the kidney. using an electron microscope.  I worked in a couple of GP surgeries.  I worked in a PCT in Clinical Governance.  Now I am a lay person with an interest in improving services for the population of a whole county. 

From the microscopic to a population of half a million.

I also picked up a couple of post graduate certificates along the way.

I am not sure what I really do now.  I guess I will explore that zone of uncertainty in my future posts.