NHS Patient & Public involvement in England – the confusion continues!

This is Blog No 102

I have been looking at the published Model Integrated Care Board Blueprint. It is part of the recently-announced reorganisation of the NHS which includes the abolition of NHS England and a 50% reduction in the management costs of the 2022-created ICBs. Admittedly this is work-in-progress following Wes Streeting’s decisions but for anyone anxious to ensure effective patient and public involvement, it is a document of great importance … and concern.

Respected commentators like Caroline Latta of STAND have found some reassurance in it and have published two excellent Blogs on the current situation. One explains ‘why this is a step forward for public involvement’ . More recently she asked the question: What the model ICB blueprint really asks of public involvement?

In both cases, she makes a strong argument for the continuing needs for specialist practitioners in patient and public involvement. I particularly liked the paragraph:

         Strategic communications isn’t just posters and press releases. It’s how we build trust in a new        

         system. It’s how we explain complexity simply. It’s how we respond to misinformation and support public

         conversations that are open, honest, and human.

For me, however, there was something really disappointing about the Blueprint.

One sympathises with the authors – pressed into service and asked to make assumptions about the fallout from the forthcoming abolition of NHS England and the imminent publication of the totemic Ten-year Health plan. It is also labelled as version 1 and acknowledges that is needs ‘the benefit of wide engagement that will be required to get the detail and implementation right.’ That might be well and good were it not for the timetable. ICBs have been told to develop their plans to reduce their costs by the end of May! If this blueprint gets it wrong, they may well end up terminating the services of the wrong people! Bizarre!

At the heart of the matter is continuing confusion as to who should do what, and within which bounaries. Over the years – as the tide ebbs and flows we have had the regular oscillation between centralisation and devolution. Regions, Areas, Localities come and go. And now - neighbourhoods. The NHS is congenitally unable to decide what area of population’s services to manage.

By far the best document I have recently seen on the way forward comes from NHS London in A neighbourhood health service for London. The case for change. An excellent piece of work.                   But as Benjamin Taylor points out in his LinkedIn article, it is ‘heavy on vision’, but ‘light on mechanism’. In contrast to the top-down Blueprint, London’s vision is informed by a series of recent deliberative events supported by Ipsos Mori and Imperial College Health Partners. It somehow feels more real – and more grounded in its feel for the needs of local communities.

Back to the Blueprint. It  identifies:

• 11 functions that ICBs will grow and invest in over time. They include population health management, the strategic planning of care pathways, local partnerships and commissioning neighbourhood health.
• 6 functions where ICBs will ‘selectively retain and adapt’ ( a marvellously imprecise phrase!) which, worryingly, includes quality management, HR, communications, complaints and PALS.
• 18 activities to be transferred to a variety of other places. It is quite a list and includes the oversight of provider performance (yes, really!), infection prevention, safeguarding, the ‘transformation’ of primary care and the development of neighbourhood and place-based partnerships. Some of these appear to contradict those in the 11 growth functions. For example, the new-look ICBs will invest in care pathway redesign. Yet in the list of activities to be transferred to providers is an item called ‘Pathway and service development programmes’. Who is kidding whom?

I am not an expert in the NHS organisation, and it may well be that there are hundreds of NHS Managers to whom this will make abundant sense. However, I know a little about Patient and Public involvement, and that is why, like others, I found solace in the one paragraph of the Blueprint that struck me as realistic.

Among what the authors call enablers and capabilities is the following:

       User involvement and co-design – _for services to truly meet communities’ needs, people must be

        involved from the very start of planning through to implementation and review. Each ICB should have a

        systematic approach to co-production – meaningfully involving patients, service users, carers, and

       community groups in designing solutions. This goes beyond formal consultation and means working with

       people as partners. ICBs will need to ensure that focused effort and resources are deployed to reach

       seldom heard and underserved people and communities, working with trusted community partners to

       achieve this. Ultimately, this enabler is about shifting the relationship with the public from passive recipient

       to active shaper of health and care, with a particular focus on underserved communities.

I have three comments

1. What an excellent form of words! It encapsulates neatly what is required. However, is it not merely a statement of what is already rightly demanded of the ICBs? Surely, nothing new here.
2. I am open to an argument that, for whatever reasons, these tasks have not or are not being delivered in the ways or to the standards that were envisaged. And that therefore they should be ‘selectively retained and adapted’.
3. But the document presents no such arguments. No rationale. No reference to research. No evidence. Here are important activities that are currently being undertaken, and somehow some management genius believes it will be possible to make substantial reductions in patient and public involvement headcount, lose the skills and the essential ‘corporate memory’ and still do the job. (Unless they dispense with specialists and train lots of clinicians and managers in tricky public engagement skills - great but unlikey!)

Of course, I cannot be sure that in other aspects, the proposals are not perfectly well-researched and backed by considerable management consensus. When I listened to the NHS Health Confederation’s excellent podcast on this subject on 14 May, ( See here – and click on The new ICB blueprint – what’s the future of system working? ) I heard some very sensible analysis. But much else was drowned out by obscure management-speak that was, to be blunt, unconvincing.

We all want the NHS to succeed. This means effective change management, that carries public consent and support. Parliament has long since decreed that the public should be involved - and consulted on significant changes, and rightly, no Government has had the courage to water down these legal requirements. Instead, it has made the task harder by a form of institutionalised kleptomania that subjects its long-suffering staff and the patients to the itch to reorganise at will and at pace. In doing this, it always destabilises the very relationships it needs to cultivate with local authorities, patient groups and a myriad of other stakeholders.

Let us hope that wiser counsels prevail and that essential communications and public engagement functions are retained and enhanced.

In respect of those aspects of the Blueprint which I can judge, my conclusion is that it is not evidence-based. It just reads like an ex post facto rationalisation trying to make the best of fitting quarts into the latest-delineated pint pots and meeting top-down headcount reductions imposed by the Secretary of State and the Treasury.

Rhion H Jones LL.B

For more like this, and to receive the monthly Consultation Catch-up, click here