LINks and the Big Society

I went to a meeting of London LINk last night at City Hall, where there was a heated discussion about how those involved in patient and public involvement will continue to operate under Healthwatch as now laid out in the Health and Social Care Bill, soon to be Act. Listening to the discussion and the difficulties which many of these people already face in dealing with local authorities - Merton has a particularly difficult situation with an uncooperative local authority - the set up for Healthwatch, which will replace LINks in one year, looks even more difficult.

As someone who has been involved in PPI work for some years, listening to the discussion, I asked myself, who would sign up for this in their right mind? For all the talk of the 'Big Society' this demonstrates how difficult the government are making it for volunteering patients and members of the public, who spend vast amounts of time and energy on this, to be treated as part of the current involvement buzzword, 'co-production'. Malcolm Alexander, who has struggled valiantly against the provisions of the Bill on public involvement, was quoted in the debate on the Bill in the Commons on Tuesday. His arguments (contained in Hansard) are below. The key quote for me is:
“existing LINks members and volunteers become disenchanted about the new arrangements for local HealthWatch and leave the system”

From what I heard last night I would not be at all surprised if this happens. And as Malcolm said at the meeting, every time the government reorganises public and patient involvement (and it has happened 3 times over the last 11 years) it takes on average 2 years for the new organisations to bed down. If one were a conspiracy theorist, one would assume that the government's intetion is to wreck public and patient involvement.

HOUSE OF COMMONS - HEALTHWATCH

20 Mar 2012 : Column 737    -  8.30PM

Liz Kendall: I start by sharing with hon. Members a letter to the Prime Minister on 13 March from Malcolm Alexander, who is the chair of the National Association of LINks Members, the national body representing statutory independent local involvement networks that promote the public and patient voice in health and social care. The letter is about the amendments to HealthWatch that were made in the other place and are before us now. He wrote to register his

“strong objections to the government’s major policy change on Healthwatch—specifically your decision to abandon plans to establish statutory Local Healthwatch bodies…Instead of creating independent statutory bodies led by local people who can monitor, influence, involve the public, hold the local authority and NHS to account; the government plan to create weak bodies that will not be independent, but will be funded by and accountable to the local authority they are monitoring. There will be no genuine accountability to the public.”

He then makes this rather perceptive comment:

“Plans for a statutory Healthwatch body were probably the only part of the Health and Social Care Bill that had any public support.”

He continues:

“Your government’s ambition”—

not your Government, Mr Deputy Speaker, but the Prime Minister’s—

“to establish independent, statutory Healthwatch organisations that would help achieve equity and empowerment in relation to access to NHS and social care services, has been diminished to such a degree, that Healthwatch will have little impact…The aspiration to achieve equity and excellence in public involvement in health and social care, especially for the most vulnerable people, has been replaced by a model that has lost its central purpose of building effective patient and user led bodies that can influence the planning of health and social care.”

I will continue reading from this letter because if the Government really want to hear the patient and public voice, Members should do too, and that is what Malcolm Alexander represents. He writes:

“In our discussions with the Earl Howe and”

the Department of Health

“over the past year, we were led to believe that LINks would evolve and go through a transition into Healthwatch. It is incomprehensible to us that the plans that were developing for Healthwatch have been replaced, at very short notice, by a highly confusing set of amendments to the Health and Social Care Bill that are very unlikely to achieve the objectives of the Transition Plan and will be very poor”

value for money. He continues:

“It was the stated policy of the Coalition that patients and users of social care must be at the heart of everything that is done—not just as beneficiaries of care, but as participants, in shared decision-making.”

Malcolm Alexander also writes that the Secretary of State

“has continuously said, ‘there should be no decision about us, without us’. Why has this promise and aspiration been abandoned and why is the government planning to abolish plans for an effective statutory model of local Healthwatch and replacing it with one that will be chaotic, diffuse and weak with no leadership role for patients and the public? Instead of engaged and empowered patients and users of social services taking a leading role—many

20 Mar 2012 : Column 738

volunteers who have led LINks are feeling disempowered, demoralised and demotivated. We had hoped and believed that at last Healthwatch would genuinely empower”

patients and the public

“through being populated by ordinary people in the community. This hope is now lost.”

He finishes with an apt comment on the entire Bill:

“This is a betrayal of public trust and an appalling waste of public money.”

The Government have repeatedly claimed that the Bill will put patients and the public at the heart of the NHS and that a crucial core purpose of the Bill is that for patients there will be “no decision about me without me.” Nothing could be further from the truth. Opposition Members have consistently argued, since the first Commons Committee stage, that the Government’s proposals for HealthWatch are weak and ineffective, and will fail to give patients a strong and independent voice to shape local health and council services. [Interruption.] The Minister chunters from a sedentary position. We always saw through the Government’s plans; now everyone else has too.

More than 67 Government amendments about HealthWatch England and local healthwatch bodies were tabled in the other place. These amendments make major changes to the Government’s original proposals, ensuring that they will be even weaker still. The Government’s amendments 181 and 366, tabled in the other place, remove clause 179 and the related schedule 15, which place a requirement on local healthwatch organisations to be statutory bodies. As the NALM rightly says, the Government made this change without any prior mention to the House, or even in Committee in the other place, and more importantly without any consultation with patients’ groups.

Local authorities will now contract social enterprises or voluntary organisations to provide local healthwatch functions. Councils will be able to split these functions if they choose. The small voluntary groups, social enterprises and, indeed, private sector bodies will be expected somehow to provide a strong and critical voice on behalf of patients about local services—services that may be provided by the very local councils contracting and funding them. The joint effect of these amendments is to divide up the functions of HealthWatch, to break down the synergies between the different roles, to require bidding to win tenders for the delivery of various services and to leave local healthwatch bodies with no automatic consistency or authority to speak on behalf of a community.

The Government have repeatedly argued that the Bill is necessary to give clinical commissioning groups statutory status, to guarantee that professionals are in the driving seat. The question is: why are the Government giving organisations that are supposed to empower professionals a statutory status, but now removing that status from the bodies that are supposed to empower patients? The weak status of HealthWatch England nationally remains. It is still a mere committee of the Care Quality Commission. All that the Government have done is say that a majority of members on the committee should not be members of the CQC. HealthWatch England should be the voice of the people in the NHS. Making it a committee of the CQC is a fundamental error. Patients and the public must have confidence that HealthWatch England will speak up for them, including where it believes that the Care Quality Commission has failed to monitor or

20 Mar 2012 : Column 739

inspect local NHS services or local council services properly, including care homes. How will HealthWatch England do that if it is funded and housed within the CQC, an organisation that has already been criticised for lacking strategic focus and the resources necessary to do its job effectively?

The Government say that HealthWatch must be part of the CQC in order to get access to information and other resources. However, if the duty in the Bill on all NHS organisations to collaborate—a duty that the Government have made much of—is so strong, why would it not also apply to the CQC in collaborating with a separate, independent HealthWatch England? The Government have also completely failed to ensure that HealthWatch will have the ring-fenced funding that it needs to do its job properly. Funding for HealthWatch England and local healthwatch bodies is only £20 million, compared with £492 million for the NHS Commissioning Board and £140 a year for Monitor. HealthWatch would have already struggled to provide an equally strong voice in the NHS for patients and the public on the basis of those resources, but now the Minister in the other place, Baroness Northover, has made it clear that funding for local healthwatch bodies will not be ring-fenced, but instead be part of the formula-based grant to local councils. Failing to ring-fence local healthwatch funding will virtually guarantee that those bodies will fail to provide a strong local voice.

That is not just my view: it is the view of National Voices, the organisation that represents 150 patient groups, which says that giving local healthwatch groups a strong voice will be possible only if

“the funding is ring-fenced. Otherwise local authorities will continue to use the funding for what they regard as higher priorities.”

National Voices says that HealthWatch is being “set up to fail”. It is right. In its latest briefing on the Bill, it says that the risks the Bill poses include a

“lack of independence at national and local levels…insufficient power…insufficient funding,”

weak support for the transition, and

“reform fatigue among local activists.”

Andrew George: I am listening carefully to the hon. Lady’s arguments about the structure and funding of local healthwatch bodies and HealthWatch England. I ask this question not to be deliberately mischievous, but in view of her comments and criticisms, what is the preferred option of the Labour party for those scrutiny bodies?

Liz Kendall: I would encourage the hon. Gentleman to read the Opposition Front Bench amendment tabled in the House of Lords which set out how we could have a separate independent body with clear lines of accountability to local healthwatch organisations. That is the policy of the Opposition. Unfortunately, however, that amendment was not accepted.

National Voices represents 150 patient groups. I was interested that the Minister said that the Richmond Group of charities somehow supported everything that the Government were doing in this area. However, I should remind the House that National Voices includes groups such as Asthma UK, Arthritis Care, the British Heart Foundation, Breast Cancer Care, Carers UK, Cancer Research UK, Diabetes UK, Dementia UK,

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Mencap, Mind, Macmillan Cancer Support, Rethink Mental Illness, the Stroke Association and many others. Those groups are saying that the Government are setting HealthWatch up to fail, because it will not provide a strong enough voice for patients and the public.

Interestingly, officials within the Government’s own Department are saying the same thing. Hon. Members will know that the Government have refused to publish the transition risk register, but today I have been passed the risk register from the Department of Health’s programme board for HealthWatch. It is marked “Restricted”, and it sets out clearly what the Department’s officials see as the risks involved in the Government’s proposals on HealthWatch. It deals with high risk in terms of impact, as well as with likelihood, so it does involve prediction.

The risk register says that there is a high risk that

“existing LINks members and volunteers become disenchanted about the new arrangements for local HealthWatch and leave the system”

because of “insufficient consultation”. It goes on to say that there is a high risk that local authorities

“will not invest in establishing effective relationships with existing LINks and other community organisations”

because the process has been poorly managed. It states that there is a high risk that there will be a “narrow engagement group” and that HealthWatch

“doesn’t work effectively with providers and commissioners. HW is not fully representative.”

It identifies the cause for that as the engagement process having been “insufficiently inclusive”. It sees a further high risk in relation to HealthWatch England:

“The establishment of the HWE committee within CQC is either too isolated or too prescribed by DH/CQC plans.”

The cause is identified:

“Early design processes for establishing HWE do not engage broad range of partners resulting to ineffective regulations being laid.”

Those ineffective regulations are being laid by this Government, according to the risk register of the Department of Health’s own HealthWatch programme board.

Some of the Lords amendments in this group would make minor improvements to the Bill in relation to the National Institute for Health and Clinical Excellence and to the functioning of the information centre. I want to return to the Minister’s earlier claim that huge improvements would be seen in public health. Some amendments relate to the employment of public health professionals by local authorities. The trouble is that the Faculty of Public Health, the body that represents those people, opposes the Bill and wants it to be dropped. It has stated that the Bill will widen inequalities, increase health care costs and reduce the quality of care. It says that there are significant risks—[ Interruption. ] If hon. Members are making claims that their Bill will improve public health and that the amendments will improve arrangements for public health professionals, perhaps they should listen to the views of those public health professionals. The Faculty of Public Health has identified

“significant risks associated with the NHS structures, the new health system and environment that the Bill will enact.”

The right hon. Member for Bermondsey and Old Southwark (Simon Hughes) was, perhaps courageously, trying to get the Minister to set out what powers local

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authorities would have under the new system. He will know, however, that health and wellbeing boards will not have the final say over GP commissioning plans. They will not be able to stop them. The only course left to them will be to appeal to the NHS Commissioning Board. I would respectfully point out to the right hon. Gentleman that if he thinks that the NHS Commissioning Board will automatically agree to complaints from local authorities, his experience of the NHS is very different from mine. We need to be clear that there will be no sign-off by health and wellbeing boards.

LINk London Meeting

With the future of patient and public involvement in the Health and Social Care Bill in a state of chassis - possible privatisation of public and patient involvement etc, this meeting next Wednesday of London's LINk is vitally important. LINks will be abolished soon but will be followed by what? The new Healthwatch system as envisaged in the Bill seems doomed. An important meeting for anyone involved in health and social care.

LINk LONDON

Wednesday, March 21^st from 5.30pm to 7.30pm

Committee Room 4, Lower Ground Floor, City Hall, Greater London Authority,

The Queen's Walk, London SE1 2AA

 http://www.london.gov.uk/city-hall/visitor-information/location-map

Agenda –

Time	Agenda Item
5.30	Welcome
5.35	The Bill–outcomes, consequences and letters to David Cameron and from Earl Howe
5.45	Developing Healthwatch in London – priorities and challenges Ian Winter, (Deputy Regional Director, Social Care Leadership and Partnerships, London Region)
	See note from Lynda Tarpey - below
6.10	HealthWatch Advisory Group and Programme Board – Nick, Jeremy, Nim, Malcolm
6.30	The LGA/DH Healthwatch Implementation Programme (attached)
6.40	Patient-led inspections – briefing paper (attached)
6.50	Gus Wilson - Stakeholder Manager - NHS Information Revolution Project  for London – My Health London
7.20	Agreement on dates of future
	AOB

Very special thanks to Gus Wilson for organising the room at the GLA

Gus Wilson - Stakeholder Manager - NHS Information Revolution Project for London, Greater London Authority

020 7983 4120
07824 694 944

Establishing Patient-Led Hospital Inspections

Briefing Paper for Steering Group

15 March 2012

Summary

1.    On 6 January 2012, the Prime Minister announced the introduction of a new patient-led inspection regime in hospitals providing NHS funded care.  The announcement was made alongside a wider commitment to improved patient care.

2.    These inspections will replace the existing Patient Environment Action Team (PEAT) programme and will cover the same specific areas, namely privacy and dignity, food and cleanliness. The outcomes will be reported publicly to help drive up standards of care. A key feature will be the involvement of patients at all stages – system development, carrying out inspections and validating results.

3.    David Nicholson has asked the National Quality Board (NQB) to advise on the work – in particular its alignment with the rest of the new NHS.  The NQB scrutinised early plans at its meeting on 27 February, and made a number of helpful comments.  In particular, they wish the project team to:

• Be as ambitious as possible
• Strive to give real meaning to the term “patient-led”
• Make the inspection scope wide, preferably including small hospitals of fewer than ten beds (not previously included in the PEAT process)
• Ensure that all hospitals comply with the inspection regime

4.    A Steering Group has been established as a sub-group of the NQB, to help embed these principles within the project.  The Steering Group will guide the development of the new patient-led inspections process, providing advice to the teams responsible for its delivery.  The Chief Nursing Officer will Chair this group until the appointment of the NHS Commissioning Board (NHSCB) Chief Nurse, who will take this forward.  Draft Steering Group Terms of Reference (for agreement at first meeting) are below:

• To ensure that the patient voice is integral to the new system
• To provide advice on PLI project alignment within the wider system
• To provide advice and guidance to the PLI Delivery Group as required
• To promote and facilitate stakeholder communications, where appropriate
• To advise on the new patient-led inspection system scope and coverage

5.    A project office has been established within the Department of Health’s Gateway Review, Estates and Facilities Directorate (GREFD) based in Leeds, with Dr Liz Jones as Project Director. 

6.    A fuller description of the project and its aims are at Annex A.  This includes some specific questions that we would like the Steering Group to address.

Liz Jones

Project Director
Annex A

Patient-led inspections of the hospital environment

1.    On 6 January 2012 the Prime Minister announced the introduction of a new patient-led inspection regime, covering privacy and dignity, food, and cleanliness in hospitals.  The results of these inspections (which will replace the current Patient Environment Action Team (PEAT) inspections from April 2013) will be reported publicly, to help drive up standards of care.  The key feature will be the involvement of patients or their representatives at all stages, including development of the system, the inspection process and validation of inspections.

2.    This annex:

• provides a summary of latest thinking about how the new patient-led inspections process might work (informed by the NQB’s initial feedback)
• identifies early decisions which require the Steering Group’s attention/advice

Background

3.    The current PEAT process was designed in 2000 and overhauled in 2004.  It has contributed to the marked improvement in cleanliness across the NHS (in 2000, almost one-third of hospitals were judged to be “poor” or “unsatisfactory”, whilst today only a handful each year fall into these categories).  It has also tracked improvements in food quality and in delivering high standards of privacy and dignity.  It is entirely separate from inspections carried out by the Care Quality Commission (CQC), but is drawn on by them when creating their risk profiles.

4.    PEAT was established 12 years ago in a very different NHS.  It has served a useful purpose, but we now need an inspection regime that is aligned to the new service, and in particular to the commitment to reflect patients’ expectations.  The existing system does not adequately recognise the increasing plurality of healthcare provision, and nor does it reflect the needs of new organisations such as the NHSCB.  Whilst PEAT has always taken account of patient views (around 80% of inspection teams include a patient representative), such involvement has been varied and in some cases minimal. The new system needs to have patient opinions at its heart, and must ensure that their voice is heard.  The PEAT scoring system also needs refreshing to allow exceptional performance to be recognised.

Public commitment - a new system of patient-led inspections

5.    The DH will put in place a new system of patient-led inspections by April 2013, to give patients a strong voice in the assessment of privacy and dignity, food and cleanliness in hospitals offering NHS-funded care.

6.    The spending challenge facing the NHS means that the new system must be broadly cost-neutral once in place and must not represent a significantly greater overall burden than at present.  To achieve this, we plan to retain key features of the PEAT process (for example inspection frequency, publication of figures by the Health and Social Care Information Centre (HSCIC), web-based reporting and the avoidance of creating new “inspector” posts).  As now, the system will apply to hospitals only.  However, the scoring system will be different from PEAT, which will mean it is not possible to compare scores between the two systems. 

7.    Further, the data that the assessments generate must:

• Meet the needs of patients, so that they can understand what standards they might reasonably expect in relation to the hospital environment, and judge their own local hospital in that light

• Meet the information needs of a wide range of stakeholders involved in maintaining and improving quality, including the NHSCB, CQC and DH
• Be aligned to (but not duplicate) other inspection and monitoring regimes

A strong system of governance and accountability

8.    The project’s governance structure (which models central Government best practice) is shown in Annex B.  Responsibility for delivery lies jointly with the Chair of the Steering Group and ‘senior responsible officer’, (Chris Beasley) and Pete Sellars (Deputy Director of GREFD) as head of the Division that will host the project.

9.    The Steering Group will meet quarterly, whilst the DH Delivery Group will meet monthly and its individual workstream groups will meet as required.

Early advice and direction needed

Patient engagement

10. The key feature of the new inspections is that they will be patient-led.  But “patient-led” can mean many things.  The NQB are keen to see that the term has real relevance, and the Steering Group’s take on this is important.

11. At the very least, “patient-led” has been taken to mean involvement in designing the system and carrying out inspections alongside other team members.  Over 80% of current PEAT inspections already involve a patient, but it is important that the new system has full involvement – and that this is more than tokenism.  Patients must genuinely lead the process and have their voices heard at the end of it.

12. However, we do not envisage that patients should have to shoulder the burden of planning or organising visits, nor of submitting reports to the HSCIC (they may well be involved in formulating the response).  Nor do we expect that patients will be the only members of the inspection team; hospital staff, including nurses, will continue to be heavily involved.  Contrary to some reports in the press, this regime does not provide patients with the right to “enter and view” premises – once established, such powers will be exercised through Local HealthWatch.

13. A variety of mechanisms are planned to select patients for involvement in the inspections process, both centrally and locally.  For instance, DH will use national focus groups or seminars to help develop the system, but individual hospitals will recruit patients locally to take part in inspections.  The details will be confirmed following stakeholder engagement, but we expect that Local HealthWatch will always be offered the opportunity to engage in inspections.  Where they decline to do so, organisations will be expected to use other approaches to deliver genuine patient engagement. 

14. Because patient involvement at a very early stage is so fundamental, we have already started our engagement work in respect of the design phase.  We are engaging a specialist communications professional (part-time) to develop our stakeholder strategy, and are also making use of existing engagement groups.

15. Our activities include:

• Identifying stakeholders to support our engagement work, and who may wish to provide input to the project.  Individual groups may be involved in different ways – either directly or indirectly.  We welcome suggestions from the Steering Group for other organisations we should include.  Any organisation or individual who wishes to be involved will be welcomed
• Extending an existing patient engagement project to look specifically at hospital inspections
• Using existing mechanisms such as DH’s “Strategic Partners” group, and the NHS Institute’s patient reference groups
• Undertaking an extensive literature review to tap into patient views from related work (eg information gleaned during DH projects to reduce HCAIs, and eliminate mixed-sex accommodation, and from NHS Institute work)

SG1 ·         What other mechanisms might we use to make sure that the patient voice is pre-eminent at the design stage?  (We will seek advice about patient involvement in development, testing and implementation at the appropriate time)

The inspection process

16. When first introduced, PEAT inspections were carried out by independent assessors and were unannounced[1].  Since 2004, they have been self-assessments, and take place within a pre-announced three-month period.  This has kept costs down, and a reversion to independent, unannounced inspections would be prohibitively expensive – especially in terms of assuring patient representation.  Nonetheless, we could explore the feasibility of shortening the notice time.

SG2 ·         How might we increase the elements of independence and short notice, within the financial constraints we face?

Scope of the inspection

17. The Prime Minister has confirmed that the new system should cover at least the same broad areas as the current regime.  These are the environment (including cleanliness), food (but not extending to nutritional care), and privacy and dignity. 

18. PEAT includes a small number of questions that are essentially clinical (eg questions about nutritional screening), but the main focus is on facilities and the environment.  In the past, there has been pressure to increase the number of clinical questions, especially where facilities management and care overlap.  This is particularly the case with the links between food quality and nutritional care. 

19. This has meant PEAT can generate information that would otherwise be unavailable and this has been especially helpful to CQC in allowing them to generate Quality Risk Profiles.  However, it has also distorted the original purpose of PEAT (to assess the non-clinical hospital environment).  There is an opportunity now to decide the scope of the new patient-led inspections process. It could continue to cover clinical content, although any significant increase in clinical questions would run counter to our commitment to cost-neutrality. Alternatively, it could be restricted to non-clinical topics only, but this may threaten alignment with CQC’s (and others’) needs.

SG3 ·         Should the new inspections include a similar small number of clinical questions as now?

The scoring mechanism

20. PEAT assessments use a five-point scale – unacceptable, poor, satisfactory, good and excellent.  To emphasise the new focus on patient views (and thus distinguish these inspections from PEAT) a new scoring system needs to be developed.  Feedback from the NHS indicates a preference for a three-point scale – “clear pass”, “fail”, and “needs attention”, whilst the NQB has asked that we include a mechanism that allows a small number of hospitals to be recognised as outstanding.  We will be seeking patient views as part of our early engagement.

SG4 ·         How might the new system recognise outstanding performance? ·         How might we categorise hospitals which, although meeting minimum standards, are in need of improvement? ·         How might we categorise hospitals which are not reaching their full potential, even though they may be good in comparison with others (“coasting” hospitals)? ·         Might there be hospitals that cannot achieve excellence because of issues of design or configuration (eg no 5* hotel is without a lift)?

Compliance

21. The PEAT process is voluntary, but has extremely high compliance (all NHS hospitals of 10 beds or more participated last year, including all foundation trusts) and an increasing number of independent sector hospitals also take part (over 120 last year).  Other data collections (eg breaches of mixed-sex accommodation guidelines) require every hospital providing NHS-funded care to report, and this review would offer an opportunity to follow that same principle.  Mandating the data collection would not increase the cost to the NHS (as coverage is already universal), but independent providers wishing to take up NHS work might need to introduce inspection in order to comply with contracts.

22. Mandating patient-led inspections could only be carried out via the contracting process, and would therefore need to be included in the NHSCB’s instructions to commissioners.  An alternative would be to maintain the current voluntary approach.

SG5 ·         How might we ensure that all hospitals participate in the new inspections?

Next Steps

23. Early stakeholder engagement should be completed by summer, allowing time to develop the technical specification and pilot the proposed model by autumn 2012.  This will give us time to make any amendments before the new system becomes operational in April 2013.

24. Because the current PEAT inspections fall within the ambit of Official Statistics, any change must be subject to public consultation.  This is expected to take place at around the same time as the pilots.  This consultation relates entirely to the new collection’s status within official statistics guidelines – the more fundamental issue of whether the collection meets the needs of patients and the service will be addressed much earlier by extensive stakeholder engagement.

Conclusions

25. Action is already under way to engage patients in the development of new hospital inspections.  We seek the input of the Steering Group to ensure that the patient voice is heard properly, and that the inspection regime delivers useful information.

Dr Liz Jones

Head of Patient Environment

Annex B

Governance Structure

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[1] Note – “unannounced” means that less than 48 hours’ notice is given of the visit.  This is so that relevant staff can be available to meet the assessors.