Please note that the following is just rough notes, and should be supplemented by viewing the video of the event;
26/9/2016 Democratic Accountability in the NHS
Chair Chris Bain
Speakers:
Dr Brian Fisher: Vice President of the Socialist Health Association: Brian firmly believes that patients should have full access to data about them and that this will enhance safety and care.
Andrew Gwynn MP: was appointed to the Shadow Health team by Ed Miliband, and was reappointed in September 2015.
Dr Ivan Bennett: sits on the GM Clinical Senate and is a Non-Executive Director at the Central Manchester University NHS Foundation Trust with an interest in Patient Experience and is ‘Freedom to speak out” guardian
Estephanie Dunn: regional director for the Royal College of Nursing’s North West region.
Chris Hopson: Chief Executive NHS Providers
Brian Fisher: ACCOUNTABILITY IN THE NHS – THE LEFT’S BLIND SPOT
The streetfighting in the LP about democracy has no echoes on the left in the NHS. The left appears to have almost no interest in enabling patients and communities to shape their care and their NHS.
Communities have huge commitment and love for the NHS. In Lewisham we had 25000 people on the streets to save our A+E. And the same is happening up and down the country in face of the govt’s austerity and dismantling of the NHS.
But policy discussions on the left rarely consider how that energy and intelligence can be hard-wired into our plans for the NHS. We talk endlessly about privatisation and restructuring and the powers of the SoS. If we want a thoughtful, responsive and personal health and care service, we need to pay as much attention to how individual patients and communities can become part of the decision-making in the heart of the NHS.
I am shocked and angry that the debate remains at the level of “Let’s bring back CHCs”. Yes, we need such formal structures, but this remains a totally inadequate policy programme for accountability and transparency.
We need to offer a vision of health and involvement that enhances care, improves health and makes sure that NHS and LA organisations are responsive to the communities they serve.
We now have good evidence that health improves when people can:
- CONNECT with others
- CONTROL more of their lives
- Gain CONFIDENCE
So, to integrate accountability and transparency throughout the NHS we need to ensure that these relationships and support for them are built and sustained by every NHS worker and every NHS structure. Here are 2 ways that illustrate what I mean and about which I have personal experience.
E-HEALTH AND RECORD ACCESS
IT offers huge scope for improving the responsiveness of the NHS to individuals and communities. I am co-director of a company that makes all this possible, as part of the NHS now.
- Feedback
- Links with community groups through social prescribing
- Record access +
- All integrated
- PHR
- Understanding and control
COMMUNITY DEVELOPMENT
Experience from across the world, backed by good evidence, shows that by building face to face social networks between people through processes such as community development, huge changes can happen – to people’s lives, to professionals’ lives and to the lives of communities. By supporting communities and their own assets to develop their own agenda for change and then working with statutory agencies to meet the issues that matter to them, we can:
- Improve health
- Improve the responsiveness of the statutory sector
- Help tackle Health Inequalities
- Improve individual health behaviours
AND it appears to be a good investment. 1:4
We need Community Development Workerss throughout communities linked to the NHS and Local Authorities, and probably housing as well.
WHY ARE THESE ISSUES NOT ROUTINE ON THE LEFT?
They are being implemented now. The LP and the left has a huge legacy of community action and social movements. The right wing is hijacking these right now. This should be our agenda. We can offer real and powerful ways that push the boundaries of accountability and transparency – let’s do that together.
Andrew Gwynn MP:
Parliamentary accountability for healthcare was though the Secretary of State for Health, and it is a disaster this link has been broken. Jeremy Hunt can now say it has nothing to do with him as its NHS business, but by the same token he can’t claim at the same time to be the voice for patients. When patients want to complain they should be able to take it up with the Secretary of State for Health.
The agenda for the devolution of health in Manchester was developed from spring 2016. We must be careful. there may be some positives, but there are also some risks. Manchester’s’ 6-billion-pound health budget can help forge new relationships and plan better, more patient centred services, but there is still a funding gap. By 2021 that gap is projected to be £1.7 billion, and there are endemic health inequalities in the region. Is devo being set up to fail? Manchester is one of the first care and health integrated regions. Thameside local hospital and clinical Commissioning group work with a single aim and budget. So is national accountability reclaimed at a local level? We need more MPs aware of what is going on and Local authorities to hold the integrated care organisations to account. Too many councillors just nod through decisions therefore we must upscale the capabilities of councillors and hold them to account. Local Authorities are well placed to meet the challenge, but they must invest in training and their capabilities to hold the NHS bodies to account.
Empowering the patient: The NHS does things to you. With new technology we can genuinely empower patients to be far more involved locally. STPs have planned health and care to meet budgetary needs, but now there is an opportunity to meet health and care needs. Health cuts backs have been to the detriment of tackling health inequalities, Life expectancy in Denton South is 10 years less than Denton North, therefore we need to empower patients to ensure we determine the social needs of an individual – inoculations, housing, environment and wellbeing. We need to develop a wellbeing strategy to narrow inequalities. However we devise accountability we must retain the N in NHS. We can deliver locally, for local needs but the N is crucial. There must be no postcode lotteries. Best practice should be picked on and developed nationally. Accountability must be strengthened to restore the powers of the Secretary of State for Health. We need accountability in Parliament, Councillors, neighbourhoods and local communities.
Chris Bain: We should also emphasise the S for Service in the NHS – not a privatised S for system.
Estephanie Dunn:
I put patients at the heart of whatever I do. We came early to the idea of devolution, but there was no conversation with nurses around concerns with service quality and sustainability. Details about how funding will work were not laid down. We now have the added challenge of economic uncertainty. A lot of the investment was going to come from the EU. It is crucial that the people on the ground change their behaviours, but the numbers of nurses, doctors and other health professionals is reduced, the numbers and role of school nurses is reduced at a time when safeguarding is needed more than ever, due to bullying, suicide, deprivation and people are disengaging. There is an increasing number of women in single parent households who are disadvantaged. Activated patients take more responsibility for their health and we need to re-educate society how this will work. People need to take more control, but there must be a safety net. When people feel disadvantaged and dis-empowered they don’t take care of themselves. They use social tranquillisers like drink, smoking illegal drugs, overeating and poor diets. The change will not happen overnight after generations of disadvantage. There is a lack of awareness as to how the body works. A massive education programme is needed. 80% of the local population in Manchester didn’t understand how devolution works. There should be “nothing about us without us”. We need to be held to account not by the Local authority, but by the people. They should know we now have a system with insufficient resources – we lack the numbers needed of doctors, nurses, and other healthcare staff.
Ivan Benett:
I have an interest in the patient experience. What say do patients have in the service they receive? There is some demonstration of accountability in the NHS, but not a lot. The Health and Wellbeing Board in Manchester works well, and is a positive force for change. The Health and Wellbeing Board has a say in strategy for the city. The Health Scrutiny Committee reviews and scrutinises health services and acts as a consultative body to local health providers when they have a duty to consult. It is not responsive to patient’s needs.
The Clinical Commissioning Group is thought to have more power than it does. It is made up of GPs, and is accountable to group practices. If they don’t want to do something, then they don’t. Patient Participation Groups. PPGs can speak, but they are not really listened to – they are a kind of add on. CCGs hold the secondary care budget as well as the prescribing budget.
We need better input from people. Group practices are not a part of the health service and have no more accountability than a greengrocer. Most just pay lip service and they should be doing much more. Acute Trusts are more reasonable. The public can have a role and can influence. By becoming a Governor, you can hold the board to account. Governors can appoint and dismiss the chair and non-executive directors. To sum up there are a number of gaps in accountability.
Chris Hopson:
The NHS budget is £120 Billion, around 1/6th or 1/7th of GDP. It provides a vital national service. The NHS is the one thing that stands out making us proud to be British. Since the NHS has so much of public funding then the Secretary of State for Health should be capable of scrutiny by Parliament. The NHS has 1.3 million staff, so we are dealing with a complex structure. However there is the implication that the Secretary of State should make all the decisions. Too many roads lead to the Secretary of State’s office, and he has been meddling. Initially Alan Milburn thought he should be solely accountable but later he felt it was too complex and there should be local accountability. A key role of local government is as commissioners of care. There is a need to support local people better. Clinical Commissioning Groups have an important role to play, along with Foundation Trusts.
It is an important model. The system is under huge amounts of pressure and clear governance is needed. Who do we hold to account if things go wrong? A single unitary board, acting as a whole seems the most practical model.
Questions:
Corrie Lowrie: I felt that as a governor I was just there for window dressing. Too much money was wasted on booklets to tell people “how good they were”. Nobody has mentioned the elephant in the room – privatisation, or the people who don’t want to share their medical notes. Nobody asked me if I wanted to be devolved. The amount of money going into private companies is not mentioned at all in the Socialist Health Association, nor are the numbers of private health organisations hiding behind the NHS banner. A sugar tax would be more effective in supporting people to live healthy lives than these private companies with their interest in profit, and Milburn owns a private health company. If we had true democracy then we should let the public know how the NHS is being sold off, and the government is Americanising it. I hate to see all this “manage your own health” rhetoric. It is an empty slogan.
Mike Hobbs: consultant psychiatrist; Public and patient engagement forums are not engaging and are not well heard. How do we engage with the community and at the level of the people who use the services? Healthwatch is still very patchy and the budget is stripped out. Local authorities are increasingly taking on the role of commissioning in health and social care, but they are not very accountable.
Responses:
The NHS needs to go back to basic principles. An integrated health and care system would strip out the waste of tendering and break down the commissioning split. I don’t agree with the free market approach, it is inadequately challenged through democracy. Andy Burnham has been looking at how to bring the care system back into the public sector. Local authorities cannot put sufficient packages into place as numbers and quality are not adequate. The NHS is looking at how to bring care provision in house. Care is integral to the NHS. Some decisions Parliament has made are detrimental to the public NHS, and the Shadow Health team are working on how to put “Public” back in the NHS. But it is not just the public who are in the dark. I sometimes only get to hear things via my opposite numbers. Shadow Health Ministers are cut out of any discussions. Devo is an opportunity, but also a risk. Not only does the government cut our grant, but then Hunt ignores the good stuff and concentrates on the bad bits cause by his governments funding gap…he puts the blame on Labour, Manchester.
There is a difference between organisations which must put profits and shareholders first and for example, hospices. The hospice movement has made a fundamental contribution. It is not profit making, and there is an appropriate role for non-profit making organisations.
Taking responsibility and looking after yourself; People should get support to do that, but they must also get the support they need if more specialist healthcare is needed.
There is an opportunity to make it better with formal democratic involvement. The NHS is undemocratic. Parliament under the Health and Social Care Act is becoming less and less accountable, due to among other things the STPs. There are informal ways in which communities can make a difference in shaping care locally. Become a member of a Trust, and PPGs can be really active.
Katy Gardner: Already councillors are too overworked and underfunded. They must be really on the ball or they will be run by council officials. The SHA has a role to play in upskilling councillors – you don’t know what you don’t know.
Derek Timmins: Talking about elephants in the room, think of Kaiser Permanente. It is a nightmare. We are five minutes to midnight to the breakup of the NHS. It has the second lowest funding in Europe. This is a political choice and political ideology. As for public accountability. Look at the case of Cheshire sexual health. The contract was awarded to Crewe. The councillors raised objections, the chair of the clinical commissioning groups raised objections. Everyone thought the weight of opposition was such that the day had been won, but the chairman pushed it through on a nod (his nod). To fight such huge injustices is beyond most peoples’ capabilities.
Patient Participation groups. The patient voice has been disenfranchised to be replaced with that of transactional costs, lawyers, management consultants and accountants. Locally we see increasingly the phenomenon of revolving doors, for which I blame the influence of MPs. There is a huge democratic deficit. One last point on conflicts of interest. Conflicts of interest are all too often simply not declared. MPs are supposed to represent us. They need to get their act together, and we need to get ours together and make sure they do. It’s down to our representatives doing their job better.
Jos Bell: There is a lot of consultation work around child and family services, but evaluating projects is now a token gesture. Shaping a Healthier Future; Imperial College Healthcare NHS Trust closed two A&Es and there was a massive spike in the demand on A&E services in the one A&E department left. It became the worst in the country. They want to demolish Charing Cross hospital. Meetings are held in secret and doors guarded by security staff. They wouldn’t even let the MP in. There is a massive funding deficit. STP plans are barely known. We could swing a Tory majority to a Labour one by making these issues known about the NHS. Councils could start by refusing to sign off STPs or Shaping a Healthier Future. Councillors are told they won’t get public funding if they don’t sign up, but STPs are not a good thing. They might have potential, but not given the lack of funding and lack of staff. 90 minutes is the average length of time for a serious ambulance call out.
Brian Fisher:
STPs are another example of magical thinking. There are heroic assumptions but in practice the NHS will just experience cuts and privatisation as a result. The laws for tendering are still in place. Hunt is still in place as nobody else wanted to do it, and the press liked the Milburn version not the Burnham version. We are up against it. We have some fantastic MPs but there is a Tory majority. See ministerial appointments e.g. Phillip Dunne
Chris Bain:
Thank you for a fantastic discussion. We must work on ideas on how to engage the wider community, and hold up a mirror to where things need to be done differently. There are huge challenges, especially around private sector involvement, a world where they would rather have an empty bed than be commissioned at a loss. We also need to deal with the poor quality of care and somehow make things work again. I had hoped there would be more positivity. We must find a simple and easy to operate system which does not come at the expense of the running of a complex system like the NHS.