Defending the NHS from the Inside

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Richard Grimes

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  • Email: richard.grimes@gmail.comTwitter: @richardbloggerWebsite: http://nhsvault.blogspot.com
  • These are estimated figures from the number of existing FTs (from Monitor) and the remainder of NHS Trusts that are yet to become FTs (from DH figures of NHS providers).~165 Acute Trusts~55 mental health trusts~30 community health service trusts11 ambulance trustsThe slide does not mention ambulance trusts. The British Dental Assn says there are 11,000 dental practices in UK, so that means about 9,000 in England. The figures of 8,500 GP practices, 10,000 optician practices and 10,000 pharmacies in England come from the NHS Info Centre. Figures about the new structures (NCB, NCB regional arms, NCB local offices, CCGs) come from DH GP commissioning subsite and from NCB website.
  • Most of this slide comes from information in the documents on this page:http://www.commissioningboard.nhs.uk/resources/resources-for-ccgs/auth/Information about Patient Reference Groups can be found in this document:http://www.nhsemployers.org/Aboutus/Publications/Pages/Patient-participation-enhanced-service.aspxDetails about how GPs are represented in the CCGs, and the “other structures” mentioned in the slide can only be found from looking at the constitution of individual CCGs. There is no defined structure that has to be used. It is likely that in many areas GP representatives of each GP practice will sit on some kind of governing body, and similarly it is likely that there could be a patient representative for each GP practice involved in some kind of patient forum. However, there is no statutory requirements.
  • Details about Foundation Trust boards and Council of Governors can be obtained from Schedule 7 of the 2006 NHS Act (as amended by the 2012 Health and Social Care Act). Non-executive Directors (including the Chair) are appointed by the Council of Governors. These are part time and are not responsible for day-to-day running of the Trust. Their key role is challenge and scrutiny of the board. The executive directors (blue on this slide) have day-to-day responsibility of running the Trust. The constitution of the trust outlines what organisations provide appointed governors, the categories of staff governors and constituencies of public governors. It also outlines membership criteria (for staff and public memberships). Typically public membership is anyone over the age of 16 living within the catchment area of the Trust. The public governors must be the majority on the council.FT Governors hold NEDs to account and can remove the Chair. They can also report the Trust to Monitor for investigation. They do not determine trust strategy, nor have any right in being involved in day-to-day running of the Trust.The responsibilities of FT governors with respect to private patients are given here:http://falseeconomy.org.uk/blog/the-nhs-and-private-patients
  • There is very little information about provision of Local Healthwatch (LHW). These organisations will carry out statutory duties, but are not statutory bodies. They are appointed by Local Authorities via tendering. Some local LINks (Local Involvement Networks) are currently converting to Social Enterprises to bid to provide LHW, and other voluntary organisations may bid. However, there is nothing to stop a private company like Capita or Serco providing LHW in an area.http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_130184.pdfLHW are responsible for obtaining views and experiences of public of NHS and social care and make them known through reports; they highlight lapses in safety of providers; they signpost to and/or provide, an advocacy service for people with complaints; they provide information about choice and provide an “effective user voice” with CCGs, HWB boards and providers.Health and Wellbeing Boards. http://www.adph.org.uk/files/latest_news/Operating%20principles%20for%20health%20and%20wellbeing%20boards.pdfhttp://healthandcare.dh.gov.uk/hwb-guide/Responsibilities: strategic influence over commissioning; oversight over Joint Strategic Needs Assessments report; leading role in developing integrated care.
  • The quote on this slide comes from the NHS Handbook.Commissioning involves assessing of the needs of a population, prioritising those needs and planning the provision. The information for commissioning comes from Health Observatories, local authorities and (at the moment) Primary Care Trusts. In the future Commissioning Support Services (CSS) organisations, and possibly some private management consultancy companies, will also perform some of this work.CSS and private companies will also be involved in drawing up contracts with providers (“procuring the services”). Commissioning also involves monitoring providers so that there is statutory equity of access (regardless of gender, race, religion, disability etc), and to ensure that the care is high quality and value for money.Any patient/public involvement with commissioning should involve influence in all of these areas: identifying needs and prioritising, choosing providers and assessing providers. (LHW will be involved in this latter responsibility.)
  • These are estimates from figures about current FTs from Monitor. At the moment there are 144 FTs with 4546 governors (811 staff, 1208 appointed, 2527 public). There are 900 FT NEDs (including Chairs), scaling this up to 250 FTs gives the figures on the slide.Its not known what patient involvement there will be in CCGs, so the 8,500 estimate comes from the fact that there are 8,500 GP practices in England and assuming one patient representative from each. All CCGs will have at least two lay members, but they can have more.The Kings Fund published a survey of 50 HWB in April 2012. The figures here are estimates from that survey. In most areas there will be one councillor from each district or borough council and usually an upper tier councillor too.The point to make about this slide is that there are about 1,200 councillors in HWB (and a similar number as appointed FT governors); about 4,500 public FT governors and potentially 8,500 public representatives on CCGs; and 1,500 FT NEDs and 450 CCG lay members. Therefore, there are several thousand public/patient people involved in the scrutiny of NHS organisations. If there is to be political involvement, there is a need for a mechanism for all of these people to network.
  • Leading on from the last slide: the folk left with the faith to fight for the NHS are the several thousand people involved in public/patient involvement in the NHS.
  • How do you influence the NHS from within? Here are some suggestions.How are patients represented? For example, through a citizen jury (randomly chosen panel); representatives of patient support groups (ie each rep representing a specific group like the elderly, diabetics, people with learning difficulties, the homeless); representatives of individual GP practices (so each rep is location-based and represents everyone in that area); of self-nominated elected (ie anyone in the CCG area can stand for election, give a personal statement and the most popular are elected). Should just one method be used?How do patient reps get involved in commissioning? This is quite complex. How do we make CCGs aware of patient opinions?   How do we get the patients' opinions? How do we make sure that the process is transparent while still recognising that there are confidentiality issues? How do we handle the situation when a CCG decision is not the same as the patient reps decision (ie setting up some kinds of dispute process, who adjudicates)Personalisation. How do we personalise treatment? Commissioning usually creates a one-size-fits-all solution for a large patient group, how do we make sure that the treatment can be customised for the patient's needs? How do we make patients aware of the personalisation available? How do we know that patients have had the best, most appropriate treatment possible?Disputes. What happens if a CCG makes a decision that the patient reps do not agree with? How can this be handled without disrupting the service to patients?Bear the following in mind:What are the cost implementations? (we cannot assume there will be money for everything, a costly solution will impact on other treatments available)Will the solution work for patients in urban areas, rural areas?Will it cover the entire community? (ie think about ethnic groups, transient groups, the homeless, housebound people, people with learning difficulties, etc)How do we share the experiences so that others can benefit?
  • The BMA have produced these principles as a voluntary “charter” for clinical commissioning groups.http://web.bma.org.uk/nrezine.nsf/wd/RTHS-8TPCEW?OpenDocument&C=28+April+2012
  • John Lister and KONP have produced these pledges for clinical commissioning groups.
  • Defending the NHS from the Inside

    1. 1. Defending the NHS From The Inside Richard Grimes(False Economy, NHS Vault,Socialist Health Association)
    2. 2. 4 Regional National Commissioning Arm Board NHS Private GP 8,000 Dentist 9,000 Local Local Office Local Office Local~50 Office Pharmacy 10,000 Office Optician 10,000 Acute ~165 FTs 158 units, 10 orgs CCG Mental ~55 FTs ~30%212 CCG Community ~30 FTs 40 SEs, VirginDefending from the inside Defending from the inside
    3. 3. Clinical Commissioning Group Board +CEO Finance Medical Audit Patients Specialist Nursing Other GPs Defending from the inside Representation GPs Other Patient Ref Grp Structures Defending from the inside
    4. 4. Foundation Trust Board + CEO Finance Medical Other Execs NED NED Defending from the inside Council of Governors Appointed Staff PublicDefending from the inside Defending from the inside Defending from the inside
    5. 5. Local HealthWatch Health and Wellbeing Board + Adult Childrens Public NCB CCGs Cllrs HealthwatchSocial Srcs Srcs Health Defending from the inside
    6. 6. Commissioning“ Commissioning is the process by which the NHS decides what services are needed, acquires them and then ensures that they are provided appropriately.“ It involves assessing the population’s needs and deciding which are priorities, procuring the services ” to meet them and managing the providers. ” The NHS Handbook, NHS Confederation, 2012 defending patient’s needs and priorities ensuring the right providers are commissioned monitoring providers Defending from the inside
    7. 7. Defending from the inside: NumbersFoundation Trusts There will be about 250 FTs. Total Each will have ~6 NEDs 1,500 Each will have ~18 public govs 4,500 Each will have ~14 other govs 3,500CCGs There will be 212 CCGs Total Each will have 2 lay members 450 Each will have ~40 GP patient reps 8,500HWBs There will be about 145 HWBs Total Each will have ~8 councillors 1,200
    8. 8. The NHS willlast as long asthere are folkleft with thefaith to fightfor it. Aneurin Bevan
    9. 9. How can the public influence the new NHS bodies?Principles: There will be less money Always put patients first Solutions must be universalQuestions: How can patients be represented? How can patients get involved in commissioning? How can services be personalised? How can disputes be handled?
    10. 10. BMA Seven Principles• Work to improve the quality of and access to local services, and reduce health inequalities• Develop a culture of genuinely clinician-led commissioning• Engage with patients and the public• Operate in a transparent and open manner, and not engage in any contracts or negotiations that impose conditions of commercial confidentiality• Resist any qualified provider being imposed from external sources• Consider relationships between individual GPs and patients• Establish and strengthen working relationships with local medical committees
    11. 11. KONP CCG Pledge• This Clinical Commissioning Group will uphold the principle of "first do no harm". We will take no action and adopt no policy that might undermine our patients continued access to existing local health services that they need, trust and rely upon.• In the spirit of clinically-led commissioning, we reserve entirely the right to decide who we contract with to provide services for our patients. We will take those decisions on the basis of the best interests of our patients and wider local communities, and we will refuse to allow Any Qualified Provider to be imposed on us from above.• In the interests of transparency we will not engage in any contracts or negotiations which impose conditions of commercial confidentiality. We will consult local communities before implementing any changes that affect them, and our Board will make all major decisions relating to services in public session.

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