Let's rethink the NHS's public engagement

Now the dust is settling on the authorisation process, clinical commissioning groups are having to face up to the perfect storm of rising demand for healthcare, limited resources (that keep getting arbitrarily topsliced), competition regulations and provider instability. It’s an unenviable scenario that will be worsened if patients and the public turn nasty about the consequences of service reconfiguration.

‘There is nothing wrong with information and feedback exercises but, alone, they will fail to engage patients and the public in meaningful ways’

Public and patient engagement in the NHS has been weak ever since Bevan’s centralised model trumped Morrison’s municipalism in the 1940s. A succession of ineffective bodies have come and gone since the creation of community health councils in the 1970s, and few believe local Healthwatch will break the mould (the Francis report concluded that long-gone CHCs actually were the high point of public engagement).

At the same time, the Health Act 2012 seems to have upped the engagement stakes − it was a crucial part of CCG authorisation and is said to be central to the Everyone Counts guidance and Putting Patients First, NHS England’s first business plan.

NHS England’s recent interim CCG assurance framework states “the approach will focus heavily on the role of CCGs in securing patient and public engagement” and even refers to “our collective vision of a health system shaped by patient and citizen participation.”

The problem with all of this? The envisaged mode of engagement is stunted. In line with market conceptions of healthcare, the focus is on “empowering consumers” through access to better information and by gathering “feedback”. The imminent choice framework will depend on access to the right information on which to base choices, and there is currently much ado about gathering “real time” feedback from patients via the “friends and family” test.

Serious about governance

There is nothing wrong with information and feedback exercises but, alone, they will fail to engage patients and the public in meaningful ways. We need to get beyond market governance as the only approach to engagement and start looking at two alternatives: representative and participatory governance.

‘CCGs are having to make tough decisions and are encountering a surge of opposition from patients, the public and staff in affected agencies’

Representative governance could consist of a reprise of Morrison’s municipal control of the NHS via local authorities − the commissioning model seemingly favoured by Andy Burnham. If CCGs themselves wish to gain public legitimacy, they could follow (but improve on) the foundation trust member and governor model.

Just as NHS England is planning a national Civil Society Assembly, so CCGs could launch their own local models. Making best use of digital technology as well as traditional approaches, the mission should be to build up the highest level of CCG public “membership”. From this, a public and patient congress could be elected with a remit strong enough to attract people with skills and knowledge.

But even this will be insufficient to sustain legitimacy for commissioning decisions. CCGs must embrace participatory governance; this must be better than traditional set piece consultation exercises or ineffective GP practice patient reference groups.

The bottom line

Central to this approach is the idea of an ongoing active partnership between citizen and state. The task facing CCGs is to ensure services are co-commissioned, co-designed, co-delivered and co-assessed in line with the popular engagement cycle. There are many practical ways of achieving this, including citizen’s juries and developing a cadre of patient leaders along the lines proposed by the Centre for Patient Leadership.

‘Many CCGs have inherited a communication and engagement strategy from their primary care trusts. Now is the time to rewrite them’

Across England, CCGs are having to make tough decisions and are encountering a surge of opposition from patients, the public and staff in affected agencies. Unlike primary care trusts tucked away discreetly in obscure business parks, CCGs are in the public gaze, with the public having been told repeatedly by the government their GPs are now in charge of the budget. If politics (by one definition) is about who gets what, when and how, CCGs are inescapably politically embroiled.

The bottom line for public sector organisations is defensible decision making − upwards to a higher authority, outwards to a local community. While a robust engagement strategy will not eliminate controversy around a difficult decision, it will show views are being heard, add understanding of the reasons behind the decision and increase trust in the inclusiveness of the governance process.

Many CCGs have inherited a communication and engagement strategy from their primary care trusts and are using it as a template for authorisation. Now is the time to rewrite these strategies − recast them conceptually, relocate them into local contexts and show some courage and ambition in engaging with local populations. The public doesn’t have to be a problem, it can be an important part of the solution.

Bob Hudson is honorary professor at the School of Applied Science, Durham University