Public Involvement- influencing health and social care delivery - A useful change in perspective
Peter Mayer MA FRCP
There are many opportunities to be involved in improving patient services and developing the future in health and social care and research within many countries and this is central policy in the UK. Any locality will have many forums in commissioning primary and secondary care as well as national and local government groups.
I retired as a physician in 2007 with a long cross sector experience and sought routes for continued participation. One route is that of public participation and I detail my present role is as an elected public and lead governor in the Birmingham Community Healthcare NHS Foundation Trust. There are many potential roles and I briefly describe some of the routes for participation and some studies on impact.
Involvement can be through political party action such as campaigning and through issues explored by think tanks such as the Birmingham Lunar Society.
There are a number of statutory bodies accessing the public voice e g Healthwatch, LA scrutiny committees. Many health and social care bodies have public/patient participation groups. Foundation Trust governors were initially created in the Health and Social Care Act 2003 and further statutory duties added in 2012.
- The 2015 NHS Providers Survey showed that Trusts had an average of 13,500 members, with a range of 5,000 to 24,000
- The size of councils of governors ranged from 15 to 48, with the average size being 29
- On average councils are made up of 53% public governors, 19% staff governors, 23% appointed governors, 4% patient/service user and 1% carer governors
- Two thirds of trusts have four council of governor meetings a year, with one third having five or more
- The “lead” governor’s role of liaison with Monitor is extended, by agreement, in many trust’s to include Chairing governor only committees and internal liaison with NEDs and executive
- The latest Monitor survey (2015) found that 63% are public governors of whom 46% are of retirement age
Governors are one of the formal voices of the membership of the Trust (and required for all NHS Foundation Trusts) The Birmingham Community Trust has over 10000 Members who select their level of engagement. Public Governors come from those wishing to be very involved.
The council has specific responsibilities which include appointing the board non executive directors (NEDs) including the Chair of the Trust and ensuring that they are able to carry out their responsibility appropriately by holding them to account, representing the public and membership of their constituency and some specific functions including appointing the external auditors and agreeing “significant transactions” This involves visiting services, attending Board and Board committee meetings and forums for public interaction including a separately chaired patient experience group and public displays and meetings. The lead governor, specifically, liaises with the regulator when profound governance or financial concerns likely to lead to a breech of contract exist.
One can at times see a significant impact when there is good joint working between the Board and governors where service issues can be effectively addressed.
There is though debate and some research into the effectiveness of these voluntary activities. The outcomes in the 2015 Monitor survey suggest the need for a better understanding of the roles especially in holding NEDs to account and the lack of clarity in delivering the staff governor role.
Many of these approaches are forms of Co-production a way of working that involves people who use health and care services, carers and communities in equal partnership; and which engages groups of people at the earliest stages of service design, development and evaluation. Co-production acknowledges that people with ‘lived experience’ of a particular condition are often best placed to advise on what support and services will make a positive difference to their lives. Done well, co-production helps to ground discussions in reality, and to maintain a person-centred perspective. Co-production is part of a range of approaches that includes citizen involvement, participation, engagement and consultation. It is a cornerstone of self-care, of person-centred care and of health-coaching approaches.
Figure 1 the ladder of engagement looks at a model of levels of engagement and Figure 2 at levels of involvement in research
In more general terms NHS England advise on the governance of public participation in useful bite size guides. National Voices (2016) describe the 6 principles for engaging people and communities of public engagement as part of the roll out of the NHS 5 year forward view and is a guide for ensuring such participation for public bodies.
It would be excellent if we could receive examples of good and bad practice and experience especially of services for older people for what I have found is a very powerful and productive way to assist in improving services in the very difficult environment facing health and social care.
Figure 1 NHS England
Figure 2 Shipee 2013
Survey of NHS Trust Governors Monitor 2015
A Guide to Annual Reporting on the Legal Duty to Involve Patients and the Public in Commissioning NHS England 2015
Bite-size guides to patient and public participation Governance for participation NHS England 2015
Six principles for engaging people and communities , people and communities board National Voices 2016
The impact of patient and public involvement on UK NHS health care: a systematic review Carole Mockford et al Int J Qual Health Care (2012) 24 (1): 28-38.
Governors are vital to a foundation trust's success Kings Fund 6 December 2013
Lead Governors Lois Howell NHS Providers Presentation 2014
Shipee ND et al Patient and service user engagement in research: a systematic review and synthesized framework JO - Health Expectations JA - Health Expect VL - 18 IS - 5 SN - 1369-7625 2013 in John Wiley 2015
Co-production Model Five values and seven steps to making this happen http://coalitionforcollaborativecare.org.uk/a-co-production-model/