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Respose to Equity & Excellence: Liberating the NHS

Wiltshire & Swindon Users’ Network and our Members response

Foreword

 

The Wiltshire and Swindon Users’ Network (WSUN) is a user-controlled organisation that meets the Department of Health “Design Criteria” for an established User Led Organisation (ULO). WSUN supports people who come with the experience of having physical or sensory impairments, using mental health services, being an older person, or having a range of learning difficulties.  (Hereafter referred to as marginalised groups, which will also apply to the other 6 equality strands.)  Our members are supported to become involved to develop ideas to shape Services, such as Health, Social Care, Community Partnerships with Wiltshire Police Equality Unit and through this contact WSUN supported a Disability Forum.  WSUN has also taken a recent commission to set up Focus Groups to undertake Access Audits and scrutinise plans for Disability Access Issues.

 We also host a very successful award winning Wiltshire Independent Travel Scheme (WITS).

 

WSUN has recently taken on, (from the 1st August 2010) the Host responsibility for the Wilshire LINk (locally known as “Wiltshire Involvement Network – WIN” and now co-produces this function with Age UK Wiltshire.

 WSUN believes, and is totally committed to the vision and values of social inclusion, (including Equality and Human Rights for all).  Ensuring and promoting Dignity and Respect for all in our local communities.  But all Local Authorities (with Social Care Responsibilities) need to ensure ULOs are supported appropriately with continual funding to ensure this vision becomes a “true reality for all,” not just a few.      

 

Note:

This report has two main sections:-

Part 1 – WSUN’s own organisational Strategic Overview on the White Paper “Equity & Excellence: Liberating the NHS”

The numbering in Part 1 relates directly to the numbering in the White Paper, for ease of cross-referencing and if there are gaps it means WSUN has no comment to make on those sections:

 2.3. A patient-centric NHS

Patients and the public will be empowered through transparency of information about service quality and outcomes, shared decision-making with clinicians about their treatment and care; and choice about who will provide their treatment and care.  Local HealthWatch is set to have a strong voice and, according to the proposals, will have a strong relationship with local authorities.  Patient and public involvement will be the responsibility of local GP commissioners.

 2.4. Commissioning

Perhaps the most significant shift in structure and culture is the creation of around 500 GP commissioning consortias that will decide local priorities for buying healthcare within a framework established by the NHS Commissioning Board. According to this new system, the Commissioning Board will be responsible for some regional and national specialised services.

 

3. The GP Commissioning Revolution

As WSUN understands the proposals; the most significant and ambitious proposals set out in the White Paper are plans that will see the creation of GP Consortia to take on the role of GP commissioning. Consortia will take over commissioning for the majority of NHS services, including elective hospital care and rehabilitative care, urgent and emergency care, most community health services, and mental health and learning disability services.

 The Board will also assume responsibility for purchasing dentistry, community pharmacy and primary ophthalmic services, as well as national and regional specialised services, maternity services and prison health services, but all with the help of GP consortia to ensure appropriate input at the local level.

 3.2. Patient engagement

One of the most positive aspects of the White Paper is its patient-centric feel and intent.  Indeed, Andrew Lansley has said himself that “no decision about me, without me” is the very essence of the Government’s approach. Patients should have more choice, and to this end the White Paper has promised to scrap “top-down targets” in favour of measuring standards and performance through collecting information on patient health outcomes. The new NHS will be required to provide information based on key indicators such as hospital acquired infection and MRSA rates, whilst ensuring patients through the use of Patient Reported Outcome Measures (PROMS are asked about the quality of their care.

 Under the proposals, Local Involvement Networks (LINks) will now become local

HealthWatch organisations. Local HealthWatch will aim to ensure that the views and feedback of patients and carers are an integral part of local commissioning across health and social care. It will be funded by and be accountable to local authorities. If the local HealthWatch is not performing, the local council will have the responsibility to put in place better arrangements. Health and Wellbeing Boards will also be set up to promote integration and partnership working between the NHS, social care, public health and other local services and improve democratic accountability.

 WSUN believes, these proposals could be boosted by ensuring that the new position of Director of Public Health in local authorities are appointed “Local Commissioning Champions” and work alongside Local HealthWatch and ULOs. The Health and Wellbeing Board in Wiltshire will need to ensure patients input is actively sought. It will be crucial that Local HealthWatch and ULOs work effectively with Local Authorities. By involving Directors of Public Health, the implementation of these proposals will be significantly aided.


Regarding 2.4; 3 and 3.2

As guidelines are not available at present (we understand that this may differ from others interpretation.)  WSUN broadly agrees with interpretation of the Paper;-

  • importantly, the consortia will not purchase primary medical services, which will instead be the responsibility of the NHS Commissioning Board.

 However WSUN does have concerns in the following areas regarding the general implementation and accountability of the above:-

  • WSUN is concerned because Wiltshire does not have an acute Hospital service in its county (apart from Salisbury Foundation Trust Hospital, in the South of the County), so it is our belief GP consortia may be formed outside of Wiltshire, with GPs forming alliances around Great Western Hospital (Swindon) and Bath’s Royal United Hospital. In a worse case scenario this could leave a vacuum of a Consortium in the centre of Wiltshire, which would mean the deprived and marginalised groups would have even further to travel to receive primary care. This will be hugely costly to people who can least afford it!
  • HealthWatch and ULOs need ring fenced funding because these organisations can at times be required to challenge the Local Authority (LA) on issues of service delivery especially in these “challenging economic times.” This can cause problems/conflicts of interest for advocacy organisations when it comes to contact monitoring and general involvement of the LA
  • WSUN also understands HealthWatch is to be modelled on CAB’s and as yet LINks are not constituted organisations in their own right, and currently rely on the Host to perform these functions on their behalf. LINks are made up volunteers who largely have an interest in specific areas. Generally they are not trained as professional advocacy skills or appropriate knowledge. If it is anticipated the future Host of HealthWatch will take on this professional advocacy role. This in WSUN’s view will change the dynamic between the Host as a support to the volunteer LINk members, to an organisation that will have a more directive role, in certain situations. Based on previous experience these members will resist if not handled very sensitively. This can evidenced in the transition period from PPI Forma to include Social Care in LINks

 Therefore WSUN would recommend as a Co Host of the Wiltshire LINk (WIN) and an established ULO for these functions of funding and monitoring of the HealthWatch be taken away from LAs and given to the CQC, ULOs and HealthWatch would then truly be independent and autonomous!

 Whilst WSUN endorses the broad principle of empowerment of patients, GPs need to improve the way in which they present and explain peoples’ options, considering some of the following areas, where appropriate:-

  • The Deaf community have told us GPs and acute Hospital services need to provide British Sign Language (BSL) interpreters for appointments, as they have strongly said, English is not our first Language, BSL is!
  • Blind People have said they miss vital appointments because the GPs & NHS generally write to them, WSUN believes there is a general assumption people have daily support to read to them, this is not always the case.

 WSUN’s possible solution would be: with the permission of the patient, of course. On the front of everyone’s file should be a section on – “Access Requirements”. Fundamentally, covering what support the person needs to be involved in the “informed decision making” of our treatment which might include some of the following, but not exclusively:-

 What is your preferred way of communicating with us?

  • Plain English formats – Easy Read,
  • Different languages formats (to include BSL)
  • Do you need a professional advocate to support you, or is there a friend or family member, who we need to contact too?
  • Would you like to be offered some emotional support, during your appointment? Please tell us who this would be?
  • Would you like some counselling after a new diagnosis (Including; peer support of experienced people with the same condition?)
  • Are there any Physical, Emotional barriers, Cultural, or Religious or lifestyle choices we need to take in to consideration when discussing your proposed course of treatment?

3.3. Service quality

With an increased number of commissioning bodies, there is a greater likelihood of different approaches to the prioritisation of treatments and funding decisions. Furthermore, this is likely to result in a postcode lottery with some consortia being more successful than others.  In theory, with the new ability of patients to register with GPs away from their home territory, this should result in patients choosing the best practices and in turn helping drive up standards.

 However, WSUN believes not all patients will be able to afford to move GPs and there is a danger that patients in deprived areas and marginalised groups may be limited to their local consortium. It is a positive step that the GP Commissioning Board is to be held responsible for health inequalities and it will be crucial for the new Board to ensure that the performance of consortia in the most deprived areas is carefully monitored to facilitate better patient health outcomes.

 From previous research conducted, it was found that the GP contract has led to a great variation in the number of GPs and registered patients in deprived areas.

Although Wiltshire is considered wealthy there are still areas of deprivation compounded by the rural nature of Wiltshire leading to further social isolation of marginalised groups.  This could also be said where access to GP services is limited, for example, some areas of Wiltshire have smaller numbers of eligible patients, whereas other areas of the country may have increased numbers particularly in urban areas. It should be evident that addressing this disparity is fundamental to tackling health inequalities and ensuring all patients have decent access to local healthcare services.

 WSUN believes the constitution of these new Commissioning Boards should have local and regional ULO representation on them, as well as HealthWatch members. This should be a mandatory requirement to influence long-term health conditions.  For example dementia, stroke, mental health.

 WSUN believes the Government needs to take another look at the implications of their proposals for mental health, specific learning difficulties, and long-term conditions.  To consider whether commissioning these and other marginalised groups, specialist Health and Care services should be under the remit of the NHS Commissioning Board and have ULO and family carer organisations representatives as a mandatory requirement on these Boards. WSUN believes many GPs lack the expertise to commission some care services especially when it comes to certain conditions, and their proposed new powers could lead to a disparity in provision.

 For example, the mental health charity Rethink found that only 31% of GPs felt equipped to take on the role of commissioning mental health services.

4. Quality and Outcomes

A substantial part of the White Paper is dedicated to outlining how the improvement of healthcare outcomes for all will be the primary purpose of the NHS.  At a National level, the government believes that the focus and accountability should, as far as possible, be centred on the health and clinical outcomes.  Locally, the structures and processes of care will need to be monitored and evaluated using Equality Impact Assessment (EIA).

 WSUN, would strongly recommend that the processes of care are transparent and fully accessible in a variety of different formats to meet need and to be fully inclusive of all marginalised groups.

 A new NHS Outcomes Framework will be the main mechanism for driving up quality and promoting equity and excellence across all services.  This will provide an indication of the overall performance of the system within an international context.  It will include a focused set of national outcome goals determined by the Secretary of State, against which the NHS Commissioning Board will be held to account, alongside overall improvements in the NHS.

 Therefore WSUN believes the NHS Outcomes Framework should be credited for its declared focus.  It is clear that the primary focus of any healthcare system should be placed on improving patient health outcomes.  The patients “Experts by Experience” programme model should be expanded with ULOs leading on this to empower people, along with clinical input where appropriateHowever, it will be crucial that the outcome framework is not too prescriptive and allows flexibility and choice and control for all patients, ensuring consortiums can still be innovative.  In the recent evaluation of the QOF, evidence shows that one of its central flaws was that targets were set at national and central level not allowing local areas to prioritise their own local needs.  It would be deeply regrettable if the Government were to transfer this flawed way of thinking to the new NHS framework.  The new framework must support the delicate balance of providing national leadership, but also allowing local consortia to innovate when considering patient choice, control and appropriate lifestyle decisions.

 

 Part 2 – What WSUN’s members’ said to the Department of Health questions

 Whilst WSUN actively promotes, supports and believes in the Social Model of Disability, because we have circulated and asked our members to respond there may well be some medical model views in this report.   WSUN has compiled this report to reflect the diverse and cultural views of the individuals who were consulted.  

 The view expressed by individuals in this report do not necessarily reflect the views of WSUN

 The process by which WSUN consulted;

 WSUN summarised the “Easy Read Version” of the Department of Health’s “Liberating the NHS” we developed a presentation and questionnaire, using the questions in the easy read version (attached appendix 1)” We independently supported people to  complete the questionnaire.  We also outreached to a number of WSUN supported groups.  You will also see from our appendix 1, we gave our members and service users the contact details of the Department of Health Website and address so they could reply directly back to you if they so wished.

 WSUN has also used extracts from a report of an event, in May 2010 for people with Sensory Impairments covering the entire spectrum of sensory impairment, including British Sign Language Users and Blind People.

 

Part 2 – Findings: What WSUN’s members’ said and general comments or views

The comments below are individual views to the specific questions in the “Easy Read” version of the “Equity & Excellence: Liberating the NHS”

Question One

How should the NHS decide on the most important things to work on?

Answers:

  • By consultation of the public
  • The measure of this should be based in what improves health (not ticks a ‘quantity’ box)
  • Make the access to, and follow up after, service provision eg leaving hospital
  • Key’ worker to make it easier for individuals/families
  • Opportunities (eg fora/think tank (comfortable/local) for users to voice their views and see some results/outcomes
  • Focus on maintaining mental and physical well being
  • Empowering people to be in control – we are the ‘experts’ in our condition
  • Look at the cuts backs, how people are looked after. What medicines are necessary
  • Consult with service users
  • Ask the doctors, surgeons, nurses etc who are the people at the coalface and experts
  • I think that when NICE decides who can have what drugs, they should get them to those who have a useful life before them, rather than prolong the elderly persons life by a few months
  • Patients are the people who should be the ones that are important. We need more ground staff than management and more permanent staff than agency

Question Two

How can health and social care services work better together to help people be healthier?

Answers:

  • By removing a lot of unnecessary administration
  • Shared process of assessment and getting ok from client/patient to pass notes on confidentially
  • Clarity about what is a social or health need and recognition that isolation or lack of independence leads to depression and medical conditions
  • Recognise the difference groups/clubs/support make to an individual
  • Innovative ideas: – microwave lessons for visually impaired – pub lunches for say four people who have to make an effort to get out and meet company. Have an informal monitoring that they are ok: shared homes rather than abandon all and go into care. Small health needs eg nail cutting/laundry and hearing aid use and pill-week-boxes all pay great dividends to keep people healthy – value of counselling
  • More exercise, keep clean ie bath every day
  • Take medications at right time of day
  • Meetings and training both at same time. Understanding each others roles and making sure Users are involved with both.
  • Users need to be involved in training of nurses and social worker students from interview onwards
  • Communication – get them to talk and discuss with other organisations
  • More communication and monitoring of services by users
  • Make sure the health and social care services link up their actions and outcomes with us
  • To give more information as they become unwell so they can have an understanding and more support

Question Three

How could local doctors and social services work better together to make sure there are the right services?

Answers:

  • By consulting with public
  • ‘Handover’ essential so that no one slips through the net between the two
  • Agreement reached about access to records
  • Discussions leading to joint commissioning of services
  • Agreement/joint training about eg risk management, teenage pregnancies, contraception, giving up smoking, healthy heart etc so agreed targets across the board
  • Make sure have right check ups
  • Blood tests, tables, sugar levels
  • Have open communications with service users. Better referral each way eg Single assessments
  • Communication – liaise with each other
  • To talk to one another at all times. Communication is the key
  • Cover night response for local people with local staff that the client views Ensure people can understand each other, ie speak the language well
  • To connect and work together to include patient and families in drawing up plans and information

Question Four

To make services better local doctors and the new NHS board need to involve local people.  What is the best way to do this?

Answers:

  • Multiple forms of media
  • There is some consultation disillusionment
  • Clarity of purpose and reality about budgets and options need to be part of the process with adequate time and feedback. (See compact card as a base for ideas)
  • Making use of existing gatherings (eg African/Caribbean club) and using trusted organisations (by staff and user organisations such as WSUN)
  • Make sure going to doctors for regular check ups
  • Area Boards need to be kept going but they also need to be ACCESSIBLE!!!! (I’ve heard other people say they can’t get into rooms where they held and the times they are held are not inclusive, ie vulnerable people trying to get home late at night)
  • Volunteers?
  • Work experience
  • Part/job sharing
  • Local clubs? Church?
  • Need to listen to local people’s opinions/views
  • Engage local people on committees and discussion groups, as happens at present
  • Go to surgeries, Community Mental Health Teams, hospitals and talk to the patients
  • Hold meetings to invite people to listen and put forward views

 

Question Five

HealthWatch is the new group who will speak up for patients.  How can they work with local people to make sure the things people say are heard?

Answers:

  • Isn’t this a duplication of WIN?
  • There needs to be clear publicity now as the make up and procedures of such a body have to be transparent and doing the business on behalf of wider community and links with pay. Equally open so that confidence is developed. Review within 12 months
  • Communicate with the Public. Make sure public speak for themselves
  • Have open meetings in the Community, Web Forums
  • Ensure the HealthWatch panel are service users themselves – I am concerned about the way this question is worded, do you mean these people are staff who speak up? Or are they service users themselves
  • Hold meetings, forums, suggestion boxes in post offices, banks, churches, surgeries
  • To hold regular meetings at accessible venues
  • Get out into communities and tell them (meetings etc)
  • Articles in local publications, local tv and radio
  • To invite people (professionals) so that we (users) can have answers to our questions

Question Six

What can we do to make sure that these new plans treat everyone fairly?

 

Answers:

  • By avoiding tokenistic consultation
  • Help and support us to understand what Doctors are saying – “No Gobbledegook!”
  • Support us to fill in questionnaires and answer what is wrong with us
  • Ensure that new people are included and the HealthWatch. So it isn’t a stagnant group of the same people year in and year out
  • Include everyone and give equal opportunities for all
  • Listen to everyone’s opinion. Give everyone an equal chance on having their say
  • That depends on people knowing what they can expect in the first place I am not sure it ever will be fair, unless people know how to demand fairness
  • To give people the plans and to ask for them to give responses

Question Seven

Healthcare comes from different organisations.  How can we make sure they all have the same chances to get work?

 

Answers:

  • Make them all one operation
  • I don’t quite follow this. Each one has to set out their ‘wares’/demonstrate how they are valued by users and use their monies effectively. A system of referrals self/inter-organisation statutory (GPs) would be good to agree. The decision makers cannot just rely officer advice but need to listen to patients/clients/carers/users
  • Make sure all people get chance to work
  • Over 65 go on pension
  • I am not sure what you mean by this question? Chances to get to work could mean giving staff
  • Bus passes for park and ride, or do you mean how do we make sure people keep their jobs? We must! Make the environment better reduce the barriers for inclusion. Make Buildings Accessible. Eg. Steps, listed buildings use the money to make them ‘Accessible’ Wheelchair friendly but also include accessible formats and to be inclusive/Equality is Vital!!!!
  • Communication – have everyone meeting and liaising with each other
  • Monday morning meetings
  • Not sure about this. This is Management surely
  • By talking to each other

 General Comments

  • People who leave money and assets after death. This money should be put into the care and support fund. What is being done with it at present?
  • There should be stricter monitoring of benefit fraud. This is one way the Government could put money to good use.
  • Government should be strict with the extremely wealthy people who give their money to their family and/or children to enable them to qualify for care and support.
  • Pensions – Many of the group involved stated that they have been paying their National Insurance and were promised care until death, but this is unknown at present
  • Money is currently being spent on unnecessary things rather than benefiting the individuals that need care and support.
  • If you need care you should meet certain criteria. People should receive care on their needs, whether you have any savings or not means testing longer term health contribution could add money to the care or “combined” pot

Page last updated: September 27th, 2011 at 2:21 pm