“What’s the point? They never take any notice of what we say” is a very common response when we invite people to become involved in local NHS issues.
However it is not always the case, as some of us have discovered over the last two years in working through the CCG EDEN Committee and now through Brent Patient Voice.
Peter Latham, a member of the BPV Steering Group and Chair of Willesden Locality Patient Participation Group, has provided a mini-history of selected issues on which we have so far engaged with the CCG – with greater or lesser success. In brief these are:
➢ Writing a new complaints policy for the CCG to reflect the Francis Report on Mid-Staffs, but failing to persuade them to add a local appeal panel to the process;
➢ Helping to make the Commissioning Intentions plan for 2014/2015 more intelligible and holding local public engagement events on 4 key topics, but not persuading the CCG to repeat the exercise for 2015/2016;
➢ Complaining successfully to NHS England about the removal of the EDEN Strategy from the CCG constitution by means of a flawed process and without any notification to the public;
➢ During the process to design the now-abandoned proposed MSK and gynaecological community outpatient clinics, insisting on rigorous impact assessment and the maintenance of patient choice;
➢ Drawing attention to the inadequate arrangements for dealing with and reporting conflicts of interest on the CCG Governing Body and the need to publish details of all contracts;
➢ Submitting written evidence to the Mansfield Commission on Shaping a Healthier Future leading to an invitation to BPV to meet and question the leaders of the project on 30 June.
These initiatives are explained more fully in what follows.
Some successes and failures in working together to influence CCG plans
The 5 chairs of the Brent locality patient participation groups have found that by working together and other colleagues with patience and persistence NHS Brent Clinical Commissioning Group can sometimes be persuaded to change their position on issues that affect local patients. We list a few examples in the hope that it may encourage others to become involved through Brent Patient Voice.
Revised New Complaints Policy.
In 2013 just after Brent Clinical Commissioning Group started they requested input from the members of their Equality Diversity and Engagement (EDEN) Committee on their draft Complaints Policy for their constitution – limited to comments on its plain English. The PPG chairs quickly saw that the draft Complaints Policy needed much more revision to its substance than just its language. For several months there was resistance to our contributing to the content of the policy but in the end the CCG were persuaded of the merit of our suggestions especially as to clarifying who was entitled to make complaints under the policy, and to limit the exclusions from the policy. We drafted a complaints form to assist patients put forward their complaints. We were unsuccessful in persuading the CCG to introduce any independent assessor in their complaints procedure. We succeeded in agreeing a draft revised Complaints Policy with the CCG which is now in their constitution. The CCG confirmed that the final revised policy was better than their first version.
Brent CCG Commissioning Intentions 2014/15
Each year Brent CCG has a public consultation before publishing its Commissioning Intentions for the following financial year. Much of this is continuation of existing projects. In December 2013 the CCG approached its Equality Diversity and Engagement Committee for views very shortly before the draft was due to be published. The 5 locality PPG chairs proposed that the public consultation be broken down into clinical subjects to encourage public involvement in subjects of concern to them e.g mental health. The CCG adopted this proposal with meetings at short notice in January 2014 chaired by the locality PPG chairs. These produced lively meetings attended by just over 100 participants with written recommendations to the CCG. There was a controversy with the CCG as to whether this was statutory public ‘involvement and consultation’ or ‘engagement’ that was never resolved, and which did not impede the meetings. The CCG acknowledged that this had been a successful project. After some delay and pressure the CCG produced a statement suggesting how the public recommendations had influenced the draft Commissioning Intentions. Where this project failed was that despite repeated requests we were unable to obtain any statement of what if any part of the public recommendations had been carried through into the CCG actual healthcare commissioning.
For 2015/16 Commissioning Intentions Brent CCG did not invite the PPG chairs to repeat this project.
Reversing the irregular amendment of Brent CCG Constitution.
In January 2014 Brent CCG obtained approval from NHS England for amendments to their constitution that included deleting its Appendix that defined its patient/public engagement policy. This was not published until May 2014. When we realised the extent to the changes and investigated how approval had been obtained from NHS England we discovered that Brent CCG had not described these changes in their letter requesting approval. On our complaining NHS England cancelled these amendments because they had not been pointed out in the letter seeking approval. So the provisions in the CCG constitution preserving the prime function of the locality PPGs in the CCG patient/public engagement were restored pending any further appropriate application.
Monitoring the design of the proposed out-of hospital gynaecology and MSK projects.
In 2012 Brent Primary Care Trust proposed a ‘Planned Care’ project in 5 ‘Waves’ seeking to transfer 13 clinical speciality hospital out-patient services into new community services by March 2015. This became part of the new NW London and Brent CCG ‘Shaping a Healthier Future’ project to cushion the impact of closing the acute Accident and Emergency departments at Central Middlesex and Hammersmith Hospitals. It was promoted under the slogan ‘Better Care Closer to Home’ but also with the aim of cost cutting. One major part of Wave 2 was a proposed community based musculo-skeletal (MSK) service completely new for Brent with an integrated multi-disciplinary combined assessment and treatment service. Another was a new gynaecology service. Brent CCG invited patient and public participation in the Stakeholder Engagement Groups and the Clinical Re-Design Group for this project. Three of the locality PPG chairs took part in these groups. It was very hard for us to obtain details of the proposals, and it quickly became clear to us that the CCG methodology was misconceived, and out of line with NHS England guidance.
In December 2013 at a preliminary meeting with Mott MacDonald commissioned by Brent CCG to carry out an Impact Assessment for their Wave 2 project the PPG chairs had to insist firmly to Mott MacDonald that they would not be permitted to get away with a flimsy Impact Assessment that did not master the clinical complexities. Consequently what had been proposed as a short assessment took about 15 months. In the event it may be that the cautions in this Impact Assessment were a key factor in causing the Governing Body on 25 March 2015 draw back from a potential disaster with Wave 2 as it was then designed.
We made successive objections to both the methodology and the lack of information on these proposals including persuading the Brent CCG EDEN Committee to pass a motion in Spring 2014 declining as yet to give the CCG constitutional assurance that it was carrying out its statutory and constitutional patient/public engagement for this MSK project.
During the Brent CCG attempts to design their new out-of-hospital gynaecology and MSK projects they proposed to require GPs to refer all their MSK patients for assessment through the triage unit of the successful bidder. When our protests at this curtailment of statutory patient choice rights, and at curtailment of GP clinical freedom as to hospital referrals were rebuffed by the CCG we appealed to NHS England. Our appeal on patient choice was upheld and Brent CCG were required to insert clarification that patient choice rights were unaffected. Our appeal on preservation of GP clinical freedom was rejected by NHS England.
On 25 March 2015 Brent CCG in secret session resolved to discontinue its current procurement of its Wave 2 gynaecology and MSK projects on concerns about the support that they may attract, and their cost implications. These had formed part of our objections to the Brent CCG defective methodology for these projects. We are pleased that Brent CCG have belatedly recognised these objections, but regret that so much time and public money has been wasted on them when we had pointed out the defects at least a year previously.
It may be that this influence on the prospects for Wave 2 that has been our most significant achievement. As yet we have not seen replacement proposals by Brent CCG despite our requests.
Conflicts of Interest at Brent CCG.
Conflict of interest issues for the GP members of Brent CCG Governing Body have become an increasing problem. Brent CCG have encouraged GPs to form networks to acquire legal NHS ‘provider’ status to bid for healthcare contracts. Many of the GP members of the CCG Governing Body are members GP network ‘providers’ with potential serious conflicts of interest. In December 2014 NHS England recognised this problem in revised mandatory guidance to CCGs about their statutory duty to manage their conflicts of interest. This has been a particular problem for Brent CCG since the chair Dr Ethie Kong, Deputy Chair Dr Sarah Basham, Clinical Director Dr MC Patel, and other Governing Body member Dr Sami Ansari are all GP members of the same Harness Healthcare co-operative forming part of the Harness GP network healthcare contracting provider with Brent CCG. For almost a year we have been repeatedly writing to Brent CCG pointing out these conflict of interest problems including their failure to comply fully with the statutory requirements for publication of a register of interests, and their management of their conflicts of interest. The extent of this problem has now been recognised by Brent CCG in their review leading to the discontinuance of their Wave 2 ‘out-of-hospital’ procurements in that they have had difficulty in obtaining a quorum for their Executive Committee meetings on these projects through conflicts of interest.
A linked problem has been Brent CCG’s long default in complying with its statutory duty to publish details of all its healthcare contracts. When we complained to the CCG about this default they initially refused to publish the details as required by the regulations. When they conceded that they must do so their delay was such that we had to pursue a successful complaint to NHS England who required them to do so by the end of January 2015.
The Mansfield Commission into ‘Shaping a Healthier Future’.
In December 2014 a group of NW London Councils launched an enquiry into the impact of the NW London NHS ‘Shaping a Healthier Future’ project on acute healthcare for NHS patients in NW London chaired by Michael Mansfield QC. This enquiry invited written evidence to lay the foundation for its public hearings. We submitted 4 joint PPGs written evidence of 31 pages. Keith Perrin chair of Wembley PPG and Gaynor Lloyd put in joint separate written evidence. We all gave oral evidence to the enquiry on 9 May 2015 at Brent Civic Centre. Our evidence was commended at the hearing by both the witness from Brent Healthwatch and by the enquiry panel who described parts of our evidence as an education for them. The BPV website has a separate account of this hearing and all the submitted documents. We await the publication of the report and findings of the enquiry which they say is expected at the end of July 2015.
Steering Committee Member Brent Patient Voice and Chair Willesden Locality PPG
Dated 9 August 2015.