Forging partnerships for a people's NHS

Friday, March 12, 2010

In recent years the NHS has moved away from its traditional 'doctor knows best' approach and has become more prepared to listen to the people it serves. But, says Dr Brian Fisher, there remains great scope for patients to have more influence over the decision-makers

There are so many ways in which the NHS would be better if people were able to harness their experience to improve services. But, while most people agree that an effective strategy for patient public involvement (PPI) makes sense, when it comes to committing time and resources to the process – and, more importantly finding ways to act on feedback from patients – the story couldn't be more different.

The NHS has come a long way in terms of participation, but it seems that the journey is far from over. These days, every hospital, primary care trust (PCT), practice based commissioning group and practice have a pretty good idea of how users view their services. However, there is little evidence that NHS organisations understand these views or respond to them. This seems to be true both at a collective level (listening to local people) or at an individual level (responding to the patient's needs at a consultation).

With this in mind, and aware of the fact that PPI in the NHS is a key aspect for both parties, the NHS Alliance organised a national debate on PPI – Whose NHS is it anyway? – at the end of last year, on which we will base a manifesto for PPI in the run-up to the election.

The debate, which has drawn responses from a wide range of people, was not about what went wrong, but what the NHS and its stakeholders need to do to get it right. At the heart of Whose NHS is it anyway? is the fact that PPI cannot exist in a vacuum and that NHS organisations need to be able to demonstrate that services have changed in response to local views.

There is increasing interest in low-tech approaches such as community development. Here outreach workers go out to communities, support them in creating their own agenda and help them bring that to fruition, by assisting in negotiation with key decision-makers such as the PCT, local authority and the police.

Evidence shows that this approach leads to significant change, with improvement in health protection, health inequalities and community engagement. Although low level community development can be done by health trainers, health visitors and LINKs (Local Involvement Networks), better outcomes are likely to come from community development workers.

This kind of approach minimises demands on patients and clinicians. And the work is done where the people are, which means local people can do as little or as much as they like, secure in the knowledge that their views will be taken into account and be used to improve services.

Although the NHS Choice agenda is meant to offer leverage for patients, participants in the debate have voiced their doubts regarding the effectiveness of such a strategy.

One of the solutions offered is to make it difficult for NHS organisations to not respond. One way of doing this is to boost the Care Quality Commission requirements to demand evidence of responsiveness from providers. This will require the Department of Health to change the regulations.

The same criterion should be applied to commissioning services to ensure they too are committed to implement changes as a result of feedback from the public and patients.

By the same token, new requirements for PCTs to explain how they have responded to their local populations should also be a priority.

Although participants in the debate stated they would like to see clear channels that ensure PPI is taken seriously, there is also a feeling that changes are needed to ensure that organisations can respond more easily.

There are many possibilities which could facilitate that. Firstly, there is a strong feeling not only that local authorities need to be an integral part of health planning and commissioning, but that PCTs could be folded into local authorities – the democratic function would then become central to the NHS. This is already starting to happen in London.

Despite their complexity, elections were seen as a good way to heighten responsiveness, so long as they are effective and not tokenistic. In Scotland, Health Boards (the equivalent of England's Strategic Health Authorities) are about to be elected and we hope that this will show whether this is a good way forward. If people can throw out the health decision-makers, they are likely to become more responsive to their populations.

Payments, linked to the level of responsiveness, could also be used as incentive; for instance, if a PCT can show that it has altered its decisions in response to its local population.

Regular user feedback on performance and methods to ensure that this feedback is considered at board level could also encourage NHS organisations to put PPI at the centre of everything they do.

Clinicians need to forge a partnership with their patients and share their decision-making process, so that patients are aware of how their views are being considered and also the impact these can have on the service as a whole.

We also need to make it far easier for patients to understand what is being done and why. Here, recommendations include online patient access to their full GP record, decision aids and group appointments.

All the above suggestions, which have been gathered through Whose NHS is it anyway?, build on current policy. But there is a potential here for real transformation. We need to close the talk-shop and start to implement solutions that can be easily implemented and, above all, which will bring PPI to the forefront of NHS services. Only by listening to and acting on what our patients have to say, will the NHS become a truly responsive service that works and grows in partnership with all involved.

Dr Brian Fisher is the national public and patient involvement lead for the NHS Alliance