National Voices

Lay influence on commissioning

Don Redding, Director of Policydon.redding@nationalvoices.org.uk

Nuffield Trust seminar4th May 2011

In this presentation

• Historical context

• Performance of PCTs

• Where do GPs come in?

• Charities’ perspective on the Bill

Sources

o Patient and public involvement in PCT commissioning, Picker Institute Europe, 2007

o Patient and public engagement - the early impact of World Class Commissioning, Picker Institute Europe, 2009

o The quality of patient engagement and involvement in primary care, Picker Institute Europe/King’s Fund, 2010

o Evidence to the Commons Public Bill Committee on the Health and Social Care Bill 2010, National Voices, 2010

Historical context

• Before 2006, ‘involvement’ focused mainly on providers – legal duty to consult + PPI Forums

• Separation of commissioning and provision

• LINKs – from 2007/08 – local h&sc ‘economy’

• PCTs & World Class Commissioning, 2007

• ‘Real Involvement’, DH, 2008

PCTs before WCC• PPI a well established practice, but with

limited budgets and expertise• Limited techniques – surveys and consultation• Consultation did not = influence• Challenges: understanding local community and patient

experience; reaching ‘seldom heard’; skills/training

Consultation vs influence

The leadership thing (2007)PCTs:

“Still aiming to ensure that NHS staff at executive level really understand PPI and most importantly support PPI and not just using words to make them sound as though PPI is important to them. Old cliché, but words are cheap.”

National Audit Office: “PCTs have structures and processes for patient and public involvement in place, but patient and public involvement is one of the least well developed components of clinical governance... patients’ expectations have been raised and as yet PCTs are unable to meet these expectations.”

World Class Commissioning3 relevant competencies: Locally lead the NHS

Work with community leaders

Engage with public and patients -- ‘proactive, meaningful and continuous’

‘Real Involvement’: S242 means NHS organisations should aim “to develop relationships over a period of time with continuity on both a personal and organisation level... It is important to be proactive and comprehensive”

PCTs: impact of WCC

• New leadership – chief exec/board level• Culture change: PPE a ‘must do’, ‘everybody’s

business’• Increased budgets and staffing• Patchy evidence of new strategies and

techniques – better targeted, more participatory

• But public still not ‘influential’ on commissioning or PPI strategies

Influence on PPE strategy, 09

Where do GPs come in?• GP practices not ‘NHS organisations’ – outside

scope of S242 and currently outside scope of CQC provider regulations

• No statutes, guidance or performance framework for PPE in primary care

• PCTs carried the duty to engage

Picker: “Established involvement techniques used at general practice level have often sought patients’ feedback on one-off issues, rather than their influential involvement.” (2010)

Engagement in primary care• Mixed leadership – fitful DH interest, BMA lack of

interest, RCGP more committed• Patient Participation Groups – 40% of practices –

‘friends’ rather than ‘critical friends’ -- fundraising, service extension

• PBCs – no strong evidence; but DH survey shows some increasing interest

• Enlightened GPs, eg with community development approaches

King’s Fund: “General practice needs to strike a new deal with patients, in which patients are active participants in decisions about their care and the services they receive.” (2011)

Charities’ perspective on the BillWelcome --• attempt to carry through White Paper agenda,

‘Putting Patients First’• clear separation of ‘patient’ and ‘public’

involvement• involvement duties on NHS-CB and consortia• continuation of LINKs into HealthWatch, and

HealthWatch England

Charities’ perspective on the Bill

The influence question – will lay people really influence commissioning?

• LINKs and scrutiny bodies can monitor, scrutinise and comment

• Health and Well Being Boards can monitor and comment

• Consortia can consult and survey• Commissioning plans must be publishedBut• No involvement of public in governing consortia• Not clear how to ensure NHS-CB capability

Charities propose...• Statutory definition of what ‘public involvement’

means• Advisory committee to NHS-CB• More lay involvement in HWBs• LINKs elect members of HealthWatch England• Protect LINKs independence and funding• Protect independence of HWE and scrutiny

committees

Charities propose...• Commissioning consortia should have Boards of

governance (cf select committee)• Boards should have substantial lay membership

drawn from practice population – preferably 50%• Role of lay members: to safeguard the public

interest in the use of public resources• Requirement on both NHS-CB and consortia to

involve relevant patients/service users and organisations in service redesign (the ‘advice’ duty revised)

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