This document summarizes the historical context of lay influence on healthcare commissioning in the UK. It discusses how patient and public involvement has evolved from a focus on consultation to aiming for more meaningful engagement. While structures for involvement have improved under policies like World Class Commissioning, evidence suggests the public still lacks influence over commissioning decisions. The document proposes ways to strengthen lay representation and involvement in the new healthcare system established under the Health and Social Care Bill.

2. National Voices
Lay influence on commissioning
Don Redding, Director of Policy
don.redding@nationalvoices.org.uk
Nuffield Trust seminar
4th May 2011

3. In this presentation
• Historical context
• Performance of PCTs
• Where do GPs come in?
• Charities’ perspective on the Bill

4. Sources
o Patient and public involvement in PCT commissioning, Picker
Institute Europe, 2007
o Patient and public engagement - the early impact of World
Class Commissioning, Picker Institute Europe, 2009
o The quality of patient engagement and involvement in
primary care, Picker Institute Europe/King’s Fund, 2010
o Evidence to the Commons Public Bill Committee on the
Health and Social Care Bill 2010, National Voices, 2010

5. Historical context
• Before 2006, ‘involvement’ focused mainly
on providers – legal duty to consult + PPI
Forums
• Separation of commissioning and provision
• LINKs – from 2007/08 – local h&sc ‘economy’
• PCTs & World Class Commissioning, 2007
• ‘Real Involvement’, DH, 2008

6. PCTs before WCC
• PPI a well established practice, but with
limited budgets and expertise
• Limited techniques – surveys and consultation
• Consultation did not = influence
• Challenges:
understanding local community and patient
experience;
reaching ‘seldom heard’;
skills/training

7. Consultation vs influence

8. The leadership thing (2007)
PCTs:
“Still aiming to ensure that NHS staff at executive
level really understand PPI and most importantly
support PPI and not just using words to make them
sound as though PPI is important to them. Old cliché,
but words are cheap.”
National Audit Office:
“PCTs have structures and processes for patient and
public involvement in place, but patient and public
involvement is one of the least well developed
components of clinical governance... patients’
expectations have been raised and as yet PCTs are
unable to meet these expectations.”

9. World Class Commissioning
3 relevant competencies:
 Locally lead the NHS
 Work with community leaders
 Engage with public and patients -- ‘proactive, meaningful
and continuous’
‘Real Involvement’:
S242 means NHS organisations should aim “to develop
relationships over a period of time with continuity on both a
personal and organisation level... It is important to be
proactive and comprehensive”

10. PCTs: impact of WCC
• New leadership – chief exec/board level
• Culture change: PPE a ‘must do’, ‘everybody’s
business’
• Increased budgets and staffing
• Patchy evidence of new strategies and
techniques – better targeted, more
participatory
• But public still not ‘influential’ on
commissioning or PPI strategies

11. Influence on PPE strategy, 09

12. Where do GPs come in?
• GP practices not ‘NHS organisations’ – outside
scope of S242 and currently outside scope of
CQC provider regulations
• No statutes, guidance or performance
framework for PPE in primary care
• PCTs carried the duty to engage
Picker: “Established involvement techniques used at general
practice level have often sought patients’ feedback on one-off
issues, rather than their influential involvement.” (2010)

13. Engagement in primary care
• Mixed leadership – fitful DH interest, BMA lack of
interest, RCGP more committed
• Patient Participation Groups – 40% of practices –
‘friends’ rather than ‘critical friends’ -- fundraising,
service extension
• PBCs – no strong evidence; but DH survey shows
some increasing interest
• Enlightened GPs, eg with community development
approaches
King’s Fund: “General practice needs to strike a new deal with
patients, in which patients are active participants in decisions
about their care and the services they receive.” (2011)

14. Charities’ perspective on the Bill
Welcome --
• attempt to carry through White Paper agenda,
‘Putting Patients First’
• clear separation of ‘patient’ and ‘public’
involvement
• involvement duties on NHS-CB and consortia
• continuation of LINKs into HealthWatch, and
HealthWatch England

15. Charities’ perspective on the Bill
The influence question – will lay people really
influence commissioning?
• LINKs and scrutiny bodies can monitor, scrutinise and
comment
• Health and Well Being Boards can monitor and
comment
• Consortia can consult and survey
• Commissioning plans must be published
But
• No involvement of public in governing consortia
• Not clear how to ensure NHS-CB capability

16. Charities propose...
• Statutory definition of what ‘public involvement’
means
• Advisory committee to NHS-CB
• More lay involvement in HWBs
• LINKs elect members of HealthWatch England
• Protect LINKs independence and funding
• Protect independence of HWE and scrutiny
committees

17. Charities propose...
• Commissioning consortia should have Boards of
governance (cf select committee)
• Boards should have substantial lay membership
drawn from practice population – preferably 50%
• Role of lay members: to safeguard the public
interest in the use of public resources
• Requirement on both NHS-CB and consortia to
involve relevant patients/service users and
organisations in service redesign (the ‘advice’
duty revised)

18. www.nationalvoices.org.uk/