Name and Shame and Patient Choice of GP Practices

Jeremy Hunt's latest announcement is that GPs should be "named and shamed" for poor cancer referral rates. (The article is in the Mail on Sunday, I won't link to it here, but you can find it through an internet search.)

"Under the Government’s planned reforms, surgeries will be ranked as ‘green’ for cancer on the NHS Choices website if they quickly refer patients to hospital when they are showing possible signs of cancer. But if they miss too many cancer cases – or if patients have to return numerous times before being sent for tests – they will be classed as ‘red’."

This plan has been criticised by doctors,

"the Royal College of GPs has criticised the proposed rating system as ‘crude’ and said the Government should be ‘supporting GPs, not criticising them’"

This sentiment was repeated on BBC Broadcasting House on Radio 4 by Dr Sarah Wollaston, Chair of the Health Select Committee and a GP. Dr Wollaston said that the policy could lead to over-referral which would "clog up the system".

There are other reasons to reject this idea. Over-referrals are bad for patients because they cause anxiety to "false positive" patients, cause unnecessary tests and potentially damaging interventions.

The announcement also doesn't recognise that cancer is more effectively beaten with improved public health.

The whole "naming and shaming" idea is flawed. At present GP patient lists are geographically based, and while there is some choice at the boundaries, most patients are registered at the practice in the area where they live. It is well known that this ideologically-driven government want to change this.

What happens when the cancer diagnosis rankings appear on the NHS Choices website and a patient finds that their practice is 'red' rated? Hunt's gut feeling is that the patient will move to another practice with a better rating, and this "market" behaviour will improve incentives and quality. However, under current situation, this will not happen because changing practices is not a simple thing for patients to do. A 'red' rating will cause unnecessary anxiety amongst a community who will have no choice other than the practice badly rated (even though it may well be unwarranted). So why has Hunt come up with this policy?

In the 2010 Health White Paper the government said:

"Give every patient a clear right to choose to register with any GP practice they want with an open list, without being restricted by where they live. People should be able to expect that they can change their GP quickly and straightforwardly if and when it is right for them, but equally that they can stay with their GP if they wish when they move house."

So what has happened to this policy? The results are mixed. The BBC, as ever acting as the mouthpiece for the Department of Health says:

"The lead author, Prof Nicholas Mays, said: "While demand for the pilot was modest, our evaluation found that patients had positive views of the scheme."

However, Pulse Magazine, the trade magazine for primary care, is less enthusiastic:

"The long-awaited report into pilot sites concluded that, despite positive feedback from users, there was little demand from patients or practices and called on the Government to consider alternatives to support increased access."

Pulse reported figures from the study that the BBC chose to ignore: "More than a third of the practices taking part in the Government’s ‘choice of GP practice’ pilots failed to register a single patient from outside their area". This is hardly the "modest demand" that the BBC reported, it is a wholesale rejection of the idea.

There are good reasons why this idea should be rejected. Pulse says of the study:

"It also found that commissioners had big concerns about the potential destabilisation of general practice and impact on the wider health service if it was to be rolled out nationally."

Commissioners are under immense pressure at the moment to meet increasing demands due to an aging population, government diktats about integration and moving care out of hospitals, while at the same time having to meet unachievable targets to reduce A&E attendances. All of this must be done with a budget that is static and inadequate. The last thing they need is one more destabilising policy.

The "choice of GP practice" pilot has shown that few people want to change practice, so it is possible that someone in the Department of Health has said: if there's no demand for this policy, why not create it? If a GP practice has been labeled "poor" at cancer diagnosis then there will be demand from some worried patients to change to a practice that has a good rating. Thus cancer diagnosis rating has a potential to create the demand for patients to practices.

It is not too far fetched to suggest that the whole point of Hunt's cancer rating announcement is to create the demand needed for the failed "choice of GP practice" policy.

UPDATE 23.00

Dr Clare Gerada tweeted the following at 21:36:

This puts another perspective on Hunt's cancer name & shame: cancer is rare and so the diagnosis rate of each GP is small. This means that it will be difficult for NHS Choices to come up with a criteria to use to determine when to give a "green" or a "red" flag. Going on this tweet, it seems that the cancer diagnosis rating flag will be a non-starter.

Self-care "Payment by Results"

For forty years I have had regular doctors' appointments for my diabetes. This has been mostly with hospital doctors, but from about the mid 90s it was GP diabetic clinic appointments too. For the first thirty years they all had the same format: blood results, told to do better, given form for the next blood test, dismissed. Years after I had taken my last exam, every six months I would be given a test, fail it and then be chided for not trying harder. I would always leave those appointments angry. My blood tests were not bad, they were simply not perfect; and it wasn't that I was not taking responsibility for my condition, I was, I just had a busy life and sometimes I could not understand why I had high results or how to get them lower.

Then about ten years ago, for some reason, my diabetic appointments changed from a personal test of my responsibility to a conversation with my doctor. No longer were my non-perfect results treated as a personal failure, and entirely my responsibility. Now the doctor was interested in how I could be helped to understand my results and improve them. The doctor no longer looked down on me as a problem, but instead treated me as part of the solution. This is Shared Decision Making.

Today the right wing organisation, 2020Health have come up with an idea that the rate of tax I pay should depend on my blood sugar.

We propose ‘Payment by Results’, a financial reward for people who become active partners in their health, whereby if you e.g. keep your blood sugar levels down, quit smoking, keep weight off, take on more self-care there will be a tax rebate or an end of year bonus. This could be monitored by the GP, linked to QUOF or facilitated by electronic patient records.

(I have no idea what QUOF is. Are they referring to the Quality and Outcomes Framework that is usually initialised to QOF?)

So now, the very person who I hold in my deepest confidence - my GP - will be determining my tax bill. Does this make sense?

We know that type 2 diabetes is associated with deprivation, National Diabetes Audit 2009-10 says "Type 2 diabetes is strongly associated with age, ethnicity and social deprivation":

The prevalence of Type 2 diabetes rose from 3.18 per cent in the least deprived quintile (Q1) to 4.49 per cent in the most deprived quintile (Q5). Furthermore, the effect of deprivation on the prevalence of Type 2 diabetes is most pronounced in the 16 to 55 years age range (Table 2). In those aged 70 years and over, similar numbers of Q1 (12.1 per cent) and Q5 (14.8 per cent) have Type 2 diabetes, but under the age of 55 Type 2 diabetes is more than twice as common in Q5 (3.0 per cent) as Q1 (1.3 per cent). This may reflect lifestyle differences in exercise, diet and weight.

Because there are more type 2 diabetics in the most deprived areas, this means that the 2020Health's "Payment by Results" will be applied to the poor, who are least able to afford a healthcare plan that has a financial basis, rather than the rich. Further, after the debacle of the care.data programme, where Tim Kelsey will be selling your GP medical records to insurance companies, we now have an equally abhorrent idea that your "electronic patient records" will be made available to HMRC. When will these right wingers realise that our confidential medical records should remain confidential?

Finally, it is worth quoting Dr Phil Hammond's reaction to this report:

Real Personalisation Will Never Happen

I really get sick of a small minority of people with vested commercial interests saying that personal healthcare budgets (PHBs) delivers "personalisation". I am sick of it because they don't seem to understand what personalisation is. Such people insist that by turning patients into consumers will personalise their care. It won't, it just turns them into consumers with the responsibilities and worries that come with spending budgets carefully.

Let me give you an example of where we need personalisation, where PHBs will not deliver this personalisation, and a subject which commissioners obsessed with their version of "personalisation" have shown no interest. Prescription medications.

I have three long term conditions and so I take seven different drugs. Since one of those drugs is not available in the dose I take, I take three pills of it. That means I take five pills in the morning, two before I go to bed (the other medication I take is two types of insulin). That is a small number of pills compared to many elderly people. I am middle aged, with relatively good eyesight (OK I have diabetic retinopathy, so that increases my count of long term conditions to four). I have good co-ordination and memory. Yet I still forget to take medication. Sometimes I get to the end of the fortnight and realise that there is one pill left over in the blister pack, so clearly I had missed that pill sometime during the last 14 days, with no idea when.

My pharmacist knows what drugs I take, it's on my prescription script and she attaches a label telling me when to take them. Instead of me having blister packs for seven drugs, why not blister packs for the seven days in the week? Half of the strip for morning, half for evening. It's Tuesday, so I take the strip that is marked (IN BIG BOLD LETTERS) Tuesday. I do not have to go hunting for the right blister pack for the right drug, because that has been done by the pharmacist already.

That strip of pills can only be used by me, because no one else has my combination of long term conditions requiring exactly those doses. This is real personalisation and it will never happen.

What I would have said

Norman Lamb was on BBC Radio 4 Any Questions last night. The things he said about the NHS made me decide to call Any Answers today to refute his assertions. I called their number and spoke to a researcher who noted my response and said she would pass it on to a producer. I was then called back by a producer who checked my details but warned me that there was unlikely to be the time to discuss the NHS on this edition. She was right, the public apparently are more interested in a fiddling minister, an English Parliament or the middle class habit of taking kids on holiday in term time than the NHS.

This is what I told the researcher, and I would have said on air.

I am calling to refute the statement from Norman Lamb that the NHS is "horribly fragmented" and that his government is moving to a "joined up system". The effect of Norman Lamb's government's policies are that we are going in the opposite direction, the system getting more fragmented, not more integrated as Lamb claimed.

I have had diabetes for 40 years and for the last 20 years I have had diabetic eye disease - retinopathy. I use diabetic services in my local hospital, I use services at their eye clinic and I use GP diabetic services. Before the election all three services were commissioned by one commissioner, the local Primary Care Trust. The commissioner plans a service and ensures that patients are able to access the service, and since there was one commissioner this meant that they could decide which services were carried out in hospital and which were provided by GPs.

Since the Health and Social Care Act was enacted last April my care is commissioned by three different commissioners. The local Clinical Commissioning Group commission diabetic hospital services, the NHS England Area Team commission GP services and Public Health England commission the monitoring of my diabetic eye disease. Three different commissioners instead of one. Norman Lamb talked about "treating the whole person" but his policies have made that more difficult because there are three commissioners instead of one. I know where the CCG is located because the CCG are high profile, the other two organisations are not. I have only just found out that the NHS England Area Team who commission GP services are based 40 miles away from where I live and they commission GP services for 1.6 million people. GP are a thoroughly local service but are now commissioned by a remote and aloof organisation. I still do not know where Public Health England are based, they keep themselves to themselves.

These three commissioners do not work together. I know this because my local CCG have announced that they intend to cut the number of hospital diabetic outpatients appointments by a third, but when I asked at their public board meeting if they will ensure that local GPs have the skills to care for these diabetics denied access to the hospital clinic, I was told: "we do not commission primary care". So the CCG are allowed to decommission services at the local hospital without first ensuring that local GPs will be able to care for the patients from the cut service. If the PCT had decided they wanted to move services out of the hospital they would have been able to do this because they commissioned both hospital services and primary care.

The result of the mess of my care being commissioned by three different organisations who do not talk to each other is that NHS services are becoming far more fragmented.

Sweet Tea and Diabetic Wee

Thirty eight years ago, aged eleven, I was discharged after a week in hospital. I was sent home with a glass syringe, a plastic tub and a bottle of surgical spirit to store the syringe, five reusable needles (a year's supply), a couple of bottles of insulin and a chemistry set.

I had been diagnosed with juvenile onset diabetes, later called insulin dependent diabetes and now known as type 1 diabetes. Simply put, my body had ceased to make any insulin and so I could no longer control my blood sugar. The treatment was to inject insulin refined from the pancreases of cows. The chemistry set was so that I could determine whether I was injecting the right amount of insulin. It contained a test tube, an eye dropper and a bottle of tablets containing caustic soda and copper sulphate. Five drops of urine, ten drops of water, then drop a tablet in the tube and wait 30 seconds while it fizzed and turned the liquid a colour between blue (no sugar: good) and bright orange (2% sugar: bad). The value was recorded in a notebook to show the consultant at the six monthly appointments. Although it is almost forty years ago, I remember my book was littered with 1% and 2% readings.

Just think about this: regularly, 2% of my urine was sugar. If a teaspoon holds about 4g of sugar, and a mug of tea is about 200ml, a mug of tea with a teaspoon of sugar is about 2% sugar. On a regular basis, my urine was as sweet as your tea*. (Diabetes mellitus comes from the Greek word diabetes meaning siphon - to pass through - and the Latin word mellitus meaning honeyed or sweet, in other words sweet urine.)

To get that sweet, empirical measurements show that on average my blood sugar would have to be about 12 mmol/l and this is about double the recommended level for a diabetic. The urine tests gave results up to 2%, so when I got the bright orange result it mean that the concentration of sugar in my urine was 2% or more. Since the test didn't show a value higher than 2% I have no way of knowing how high my urine sugar really got. (In fact, I now know that I could have repeated the test with two drops of urine rather than five, and this could have measured up to 5% of sugar.) I was also prescribed urine dipsticks to test for ketones. Ketonuria occurs when the body breaks down amino acids to get energy rather than glucose, and in a diabetic this can occur when blood sugar is over 15 mmol/l (due to too little insulin). From memory, I occasionally detected ketones, so my blood sugar was likely to be three times or more the recommended level.

The problem with urine testing is that it is hours after the fact. My bladder could have several hours of urine (eight, for the early morning pee) and hence my blood sugar could be high for all of this time. Worse, four decades ago, there was not the concept of taking an adjustment dose of insulin to correct a bad result. Re-usable needles meant that injecting was an unbearable pain, and blunt needles (and the impure animal insulin) affected the injection sites (scarring and fat loss) so it was always best to have as few injections as possible. For the first ten years I had two injections a day: one before breakfast and another before dinner. Consequently, without an adjustment dose, a high urine test could mean a high blood sugar for at least half a day. Controlling blood sugar in the 70s and 80s was not easy.

These days diabetics have finger prick blood testing monitors, so we can instantaneously test blood sugar, we also have insulin pens that can accurately deliver small adjustment doses of insulin and (the most significant innovation) we have sharp needles. Controlling blood sugar, though easier, is still not easy because injected insulin does not act immediately, and (depending on the type of insulin) it may continue to affect blood sugar for a couple of hours. Further, some foods are digested quicker than others and hence affect blood sugar in different ways. Managing diabetes is always a case of finding out what works and then sticking with it. Change is the worst word in a diabetic's life.

In my next blog I will describe the issues with the controlling diabetes using finger-prick blood glucose tests, and what could be done to improve the situation.

[*] This is all very approximate, but figure 1 in this paper suggests that 2% Clinitest represents between 2.5g and 4.5g (say about 3g) in 100ml of urine, which means my urine was as sweet as one and a half teaspoons of sugar in a mug of tea.

Are You Involved?

Whose Patient Are You?

There really is just one type of patient: a patient. A patient is a person who is ill and needs care, simple as that. It could be elective or emergency care, but it is still care. It could be a single episode, or a lifetime of treatment for a long term condition, but it is still care. The patient is the receiver of care.

When pushed, I would set up a dividing line between NHS and private patients for the simple reason that private patients have made a conscious decision that they want to opt out, and are choosing not to be the same as everyone else. People who choose to have private care have the same rights to NHS care as the rest of us, but they choose - for a variety of reasons - not to exercise those rights. It is their choice, but they can opt back in any time they like. However, for the rest of us, private care is not an option, which is why it is so important to defend our access to the NHS and to get involved in the improvement of NHS care.

Thus, there are just two types of patients: private patients and NHS patients. This is pertinent to this blog because this is about public and patient involvement which is a concept unique to the NHS. The relationship private patients have with their healthcare provider is a simple customer-provider relationship, if you do not like the service you take your money to another provider. The relationship an NHS patient has with their healthcare provider is far more complicated than this. NHS patients do not have control of the money spent with providers and I would argue it is incredibly important that they don't. The reason is that providing good care is very different to providing a profitable service. Many NHS services cost more than the money provided, so "taking your money elsewhere" is often a case of "taking the deficit elsewhere".

Which Parts of the NHS Do You Use?

The NHS is often viewed by managers and politicians as primary, secondary and tertiary care, but from the patients perspective this is either GPs (primary care) or hospitals (secondary and tertiary care). There is also a dividing line between acute (or physical health) and mental health; and typically, if you have a mental health issue which results in hospitalising that will be in a mental health hospital even if you have a physical health condition that would otherwise mean that you should be in an acute hospital. In addition, there is a grey area within the NHS: community health services. As the name suggests these are services delivered in the community, in small clinics or in the patient's home. Community services are largely a historical relic of local authority involvement in healthcare before the establishment of the NHS. You could argue that community services are primary care that should be delivered by GPs, or alternatively, you could argue that they are step-down services of hospitals, and in some cases (like Continuing Healthcare) hospital services delivered in the patient's home. In some areas community services are delivered by acute hospital trusts, in others they are delivery by mental health trusts, and in others they are delivered by private companies.

To us patients, we need care from the NHS as a whole. We may have physical or mental issues, we may need episodic care or have a long term condition needing long term care. We may need the care in our homes, in a GP surgery, a community clinic or in a hospital. In all cases we are simply a patient. Treating us as a patient rather than a consumer of multiple services is the philosophy behind whole person care.

Getting Involved

Public and Patient Involvement (PPI) is a legal responsibility of NHS organisations. The Health and Social Care Act 2012 (HSCA) created two new commissioners, NHS England and Clinical Commissioning Groups (CCGs) and the Act created a responsibility for PPI for both (as outlined in this document by National Voices). Section 23 and section 26 of the Act, add section 13H and two sections 14U and 14Z2 to the NHS Act 2006 to place a duty of PPI on, respectively, NHS England (called "The Board" in the Act) and CCGs.

PPI is a legal requirement of NHS commissioners and there are requirements for NHS providers to have patient involvement too; private providers of NHS care do not have to have PPI and consequently do not.

An NHS England Patient?

NHS England commissions primary care (GPs, opticians, dentists, pharmacies), care for prisoners and military personnel. They also commission tertiary care and care for rare conditions. The HSCA places a duty for NHS England to "promote the involvement of patients, and their carers and representatives (if any)" in the decision making of "the prevention or diagnosis of illness in the patients" and "their care or treatment". NHS England has put some effort into the PPI for rare conditions but have been largely quiet about the much bigger issue of PPI in the commissioning of primary care. Primary care is commissioned on a regional basis by the so-called Area Teams. These rather shadowy groups do not hold meetings in public and their board papers are not published, so the public do not know what these groups are doing, nor able to challenge their decisions.

Logically, the Area Team should be recruiting patients through GPs, opticians, dentists and pharmacies because they commission the services patients use from these providers, but there is little evidence that Area Teams are doing this. If you want to be involved in the commissioning carried out by your Area Team there is little information about who to contact.

Shadowy is perhaps being too kind to them, the Area Teams seem to want to avoid the public entirely.

A Clinical Commissioning Group Patient?

Clinical Commissioning Groups commission secondary care (ie hospital care), mental health, GP out of hours services, urgent care services like ambulance and 111, and community services. CCGs are membership organisations in that every GP practice has to be a member of a CCG. (These GP members of CCGs are involved in their decision making, but unfortunately the so-called members councils emulate NHS England by meeting in secret and refusing to publish their minutes.)

The new section 14U that the HSCA adds to the 2006 NHS Act a duty to promote PPI on CCGs, and in addition it says that NHS England should publish guidance on how CCGs should do this. This statement appears to be the case of the tail wagging the dog: CCGs can tell NHS England a lot more about PPI than the other way around. The new section 14Z2 goes into more detail about the responsibilities of CCGs. This says that patients should be involved "in the planning of the commissioning arrangements" and in the "changes in the commissioning arrangements" of the CCG.

As part of their authorisation CCGs had to provide their PPI strategies to, and these be approved by the largely PPI-free NHS England. Consequently every CCG has some form of Patient Participation Group (PPG), and most of these are based upon the PPGs of their member GP practices.

A GP Practice Patient?

General Practices have had PPGs for many years. PPGs are paid for through Directed Enhanced Services (DES) (until the end of this financial year) so GPs are actually paid to provide them. Most practices take this money because they recognise the benefit that patient feedback from a PPG can provide. One requirement of the DES payments is the annual patient survey which practices can use, through locally determined questions, what patients want and how the practice can improve their facilities and services.

There is another distinct advantage that practices gain from having a PPG that GPs are only now starting to realise: CQC. If a practice is CQC inspected the first thing the inspector will ask is "can I talk with your PPG?". A negative response is not going to allow the rest of the inspection to go well, and, as practices are starting to learn, a friendly PPG can do wonders for their CQC rating.

Or A Foundation Trust Patient?

Foundation Trusts (FTs) are a special case because they are the only part of the NHS where there is elected patient representation. Foundation Trusts have a membership (usually opt-in for public and patient membership, but opt-out for staff membership). The membership elects governors to the FT's Council of Governors. More than half of the Council must be public or patient elected governors and the remainder of the Council are elected staff governors and stakeholder appointed governors. The public and patient elected governors represent the constituencies that elect them but the HSCA (section 151(4)) says that in general governors "represent the interests of the members of the corporation as a whole and the interests of the public" (the "corporation" here refers to Public Benefit Corporation which is the legal term for a Foundation Trust).

In general governors have a responsibility "to hold the non-executive directors individually and collectively to account for the performance of the board of directors". Foundation Trust Board of Directors meetings must be held in public (section 152(5)) however, as a public body it means that the Foundation Trust can use the Public Bodies (Admission to Meetings) Act 1960 to exclude the public (which includes governors) from parts of the Board meeting where it "would be prejudicial to the public interest by reason of the confidential nature". In spite of this, Foundation Trust governors have a right (section 152(4)) to have access to all Board minutes including the minutes of the confidential section of the Board from which they are excluded, so although governors cannot attend the confidential section, they can see what was said.

Other than the general responsibility to hold non-executive directors "to account for the performance of the board of directors", there are specific responsibilities. For example, if a Foundation Trust intends to increase its income from private patients by more than 5% of the total income of the trust (an event that is as a rare as finding a hen's tooth) more than half of the Council of Governors must approve. In addition, governors must inform the Board of Directors whether it is satisfied that treating private patients "will not to any significant extent interfere" with the treatment of NHS patients (section 164(3)). This last responsibility is fairly toothless because governors do not have any power to stop an FT from treating private patients.

The two most powerful powers of governors are to appoint and remove non-executive directors, and to determine whether significant transactions should go ahead. Governors appoint the non-executive directors (NEDs, including the Chair of the trust) and can remove them, governors also determine the pay of these directors. NEDs are members of of the Board of Directors, and board decisions are made collectively by all directors. NEDs do not have an operational role, they do not manage the trust, instead their role is to challenge the executive directors. NEDs also form the appointments committee that appoint, and determine the pay of the executive directors. Although the NEDs appoint and remove the chief executive, governors have to approve such decisions. Possibly the most powerful responsibility of governors is covered by the term significant transaction (section 167). The Foundation Trust can only enter into a significant transaction if more than half of governors approve. The Act does not define what a significant transaction is other than saying that they must be specified in the trust's constitution. Any changes to the constitution must be approved by Governors and the trust Board of Directors.

What About Private Providers?

The government says that there is a "fair playing field" when it comes to commissioning services, however, the one area where the playing field is not "fair" is where it comes to patient involvement and patient representation. There is no legislation that requires private providers to involve patients in the provision of the care they provide. There is no legislation that requires private providers to have public board meetings or publish their board minutes. If the provider is a charity or a social enterprise, they will have their own rules about patient involvement, however, usually such third sector providers behave as if they are private businesses when providing NHS commissioned services.

If you are offered an NHS service from a private provider bear in mind that no patient was involved in designing the service. No patient is involved in the continuing improvement of the service nor in holding the senior management to account for the service. As a patient you will not have an opportunity to be consulted about the provision of the service. All of this is worth bearing in mind before you consider using a private provider for your NHS care.

So What Sort Of Patient Are You?

If you want to get involved in the planning and delivery of NHS services, you have lots of opportunities. The problem is that the different parts of the NHS do PPI in different ways and some parts (particularly commissioners) define involvement as "help us performance manage those other people". When you combine this with the total lack of PPI in the private sector, it all adds up to a mess.

Patient involvement in improving services come from two perspectives: the provider and the commissioner. The commissioner designs the service and monitors delivery, patients can be involved in the designing of a service, and as the recipient of the service, they can be involved in feeding back how well the service is performing. Commissioners monitor services to enforce the contracts they have with the providers, most contracts have some kind of penalty or incentive and often patient feedback is involved in these. Contractually, providers clearly want to avoid the penalties and gain the incentives, so patient participation is important to them.

For example, patients join a GP practice PPG to help improve the services at the GP practice from a provider's perspective. GPs are mostly commissioned by NHS England Area Teams (there are a few GP services that CCGs commission) but the lack of PPI in Area Teams means that there is little commissioner patient involvement in improving GP services. It is very clear that patients join GP PPGs to improve GP services, if they want to improve hospital services the obvious route is to join a hospital PPG (or equivalent PPI). However, most CCGs draw from GP PPGs to form their own patient groups. CCGs do not provide services, and they do not commission GPs, so a patient who joined a PPG to be involved in the improvement of their GP services will find that they are asked by the CCG to improve services they originally did not volunteer to be involved with.

CCG patient participation groups are involved in the commissioning, and improving, of hospital services, mental health services, community services, urgent care services and out of hours through the commissioner-provider relationship. In other words, very few services that involve GPs.

Conflicts of Interest

Commissioners are quite open about that they will use the contract with the provider as a lever to improve services: threats of commissioning another provider, or moving the service to the free-for-all that is Any Qualified Provider. Collaboration has largely disappeared due to the recently introduced procurement regulations.

Gone are the days when the patient group of a provider could collaborate with commissioners to improve the service. The patients of a provider's PPG will have direct experience of the service and are a valuable resource: a patient involved with a public sector provider will have more experience about the service being commissioned than a patient who is not involved with the provider. Thus, it makes a lot of sense for a CCG to involve those patients in redesign of those services. Similarly, if a CCG wants to improve a service, the best course of action would be to consult the existing service provider, since that provider will be more of an expert about the delivery of the service than the commissioner. However, CCGs wary of litigation under the new procurement regulations are reluctant to seek advice from those providers and their patient groups because they may appear to be giving unfair competitive advantage to those providers. From a PPI perspective, if a CCG involves a patient in commissioning and that patient is a member of a PPI group at a provider, that could be regarded as being anti-competitive.

It works the other way around too: there is no incentive for an existing provider to help design services if those services will be put out to competitive tender with the possibility that the provider may not win the tender. The new procurement regulations are a barrier to the improvement of services.

CCGs are rather inconsistent in applying the strictures of the procurement regulations. CCGs can commission Locally Enhanced Services from GPs, and these may replace services formerly delivered in secondary care (so-called "move services to the community"). Since CCGs are membership organisations where the members are GP practices, CCGs have to take steps to prevent "conflict of interest" when awarding LES to member GPs. However, these steps are usually just for show. For example, the GP members of a governance board declining to take part in a vote that awards services to GPs when the decision has already been made out of the boardroom. This, we are told, is acceptable. Furthermore, if a CCG involves its patient group in commissioning LES there is a high chance that it will involve patients who are members of the PPGs of the GP practices who would benefit.

I Am Just A Patient!

Patients are patients, they are not your patient or our patient, they are NHS patients. It is quite clear that public and patient involvement is getting fragmented because of the new competition-based procurement regulations. Patients are excluded to prevent perceived "conflict of interests", while real conflicts are not being addressed. Patient involvement is vital to the NHS, not only does it give a legitimacy to the commissioning by a public organisation, but it has the potential to make significant improvements to the services being commissioned. No patient is restricted to one provider or one service, no patient pathway is limited like that, so why should patient involvement be limited?

Before the fragmentation of services and PPI gets much further we need to stop and rethink. Ultimately we need to remove competition from healthcare planning because it is resulting in competition lawyers determining which providers are commissioned. While we wait for that to happen, the next best thing would be a declaration from the Secretary of State that patients are far more important than competition laws and to tell commissioners that they cannot exclude patients from commissioning on the grounds of "conflict of interest". To ensure that such a declaration is followed, a neutral third party should have not only the responsibility to ensure that patient involvement occurs, but also to enforce it. Such a neutral third party should have the same power over all commissioners and providers: NHS England, NHS England Area Teams, CCGs, Local Authority social care commissioners, NHS providers, GPs and private providers.

At the moment there is no such patient organisation, but there is a possibility that local Healthwatch could be given new powers, responsibilities and resources to do this. Such a revitalised Healthwatch would be able to support patient groups so that they are independent of providers and commissioners, being able to discuss the issues that concern the patients. Healthwatch could be given the power to delay the commissioning of a service on the groups of inadequate patient involvement. It could also have the responsibility to ensure that all providers (NHS and private) have patient engagement and involvement in the delivery of services. Such power would give meaning to Healthwatch.

(Richard Blogger is an elected Foundation Trust governor and a patient representative at his local CCG PPG. He has been excluded from patient involvement in commissioning by the CCG on the grounds of "conflict of interests".)

Integration

Just got back from 2 hour circular walk. We walked along the footpath on the left of the map, above, going along the railway and intending to join the footpath (the diamonds) at Castle Meadow Bridge along the Grand Union Canal. It clearly looks like the two footpaths cross, but unfortunately the footpath does not just cross the towpath, it crosses over the towpath.

When we got to the bridge, there was clearly a path to the canal but there was a locked gate and fence preventing us from getting down from the footpath to the towpath. So we retraced our steps a bit and then walked on to Tythe Barn Bridge to try and get down there.

The following is a photo taken after we had got down from the public footpath to the canal, looking up at the bridge which has the public footpath. As you can see, there are steps, but the route is blocked with a fence and a locked gate.

And just for the record, this photo shows the bridge from the top of the steps, showing the post indicating that it is a public footpath:

The likelihood is that the land owner blocked the access, although why they would do that is unclear.

There are two rights of way here, and two authorities involved. The footpath, the green dashed line, is a public right of way. In England many such footpaths have been rights of way for centuries. The footpath goes across private land (in this case a plantation of poplars and firs). The law gives walkers right of access across the land, but the footpath is owned by the land owner. The local county council have a responsibility to maintain a list of the footpath routes and usually local walking groups ensure that the signs and items like stiles and gates are maintained.

The canal towpath, the green diamonds on the map, is a recreational route with the agreement of the land owner, in this case, the Canal and River Trust. Canals were formerly state-owned by British Waterways, but in part of its privatisation plan (which can be subtitled "we don't own or do anything") the Coalition government first tried to turn British Waterways into a mutual, and then decided it should be a charity. There is nothing in either the Conservative, or the Lib Dem 2010 election manifestos about taking the canals out of public ownership to mutalise them or give them to a charity, but that is typical of this undemocratic government.

Two types of footpaths, yet no integration of the two because the land owner of the footpath (as is their right, it is their land) has blocked access. Of course, we found a way down, climbing over a fence a little further along the canal. We were halfway round the circular walk, so if we hadn't had access to the canal we would have had to retrace our steps along the footpath, and since the canal looked like a pleasant (and less muddy) walk we decided it was worth climbing over a fence. Anyway, I had planned the walk from the map, making sure we were walking along rights of way, and I was annoyed that my plan was wrong because of the inflexibility of a land owner.

The problem with integration is that you have to get everyone involved to work together, if one party refuses to cooperate, integration does not happen. In the case of the access between the towpath and the footpath what was needed was a little bit of leeway from the land owner of the plantation, but the land owner clearly didn't want to cooperate, and hence the fence and gate were installed to prevent integration between the two footpaths..

NHS and social care integration will be far more complicated. Not only are there two public sector organisations commissioning the work (CCGs and local authority social services), there are a myriad of provider organisations, some public sector (hospitals) and some private sector (nursing homes). The possibility of one or more of these organisations deciding not to be flexible is high, and the result will be poor care for patients.