The Francis Report and LINks/Healthwatch

The “Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry chaired by Robert Francis” – aka ‘the Francis Report’ – was published last week.

If you work in health, or patient involvement, then you must at the very least read the Executive Summary. It is very readable and concise and I’d recommend you print off a copy for bedtime reading and scribble on it.

I’m publishing on this blog the particular points that I think that LINks/Healthwatches need to read, digest, ponder and respond to. I think they are really important (and in fact, I’ve copied these paragraphs and put them in our LINk Legacy Document to be passed on to Healthwatch Somerset).

N.B. For the full chapter looking at patient involvement, you need to read Chapter 6 of Volume 1 of the full report.

Extracts from The Executive Summary:

The voice of the local community

  • 1.17 It is a significant part of the Stafford story that patients and relatives felt excluded from effective participation in the patients’ care. The concept of patient and public involvement in health service provision starts and should be at its most effective at the front line.
  • 1.18 Analysis of the patient surveys of the Trust conducted by the HCC and the Picker Institute shows that they contained disturbing indicators that all was not well from long before the intervention of the HCC.
  • 1.19 Community Health Councils (CHCs) were almost invariably compared favourably in the evidence with the structures which succeeded them. It is now quite clear that what replaced them, two attempts at reorganisation in 10 years, failed to produce an improved voice for patients and the public, but achieved the opposite. The relatively representative and professional nature of CHCs was replaced by a system of small, virtually self-selected volunteer groups which were free to represent their own views without having to harvest and communicate the views of others. Neither of the systems which followed was likely to develop the means or the authority to provide an effective channel of communication through which the healthcare system could benefit from the enormous resource of patient and public experience waiting to be exploited.
  • 1.20 Patient and Public Involvement Forums (PPIFs) relied on a variably effective, locally provided infrastructure. The system gave rise to an inherent conflict between the host, which was intended to provide a support service but in practice was required to lead with proposals and initiatives offered to lay members, and members of the forum, who were likely to have no prior relevant experience and to be qualified only by reason of previous contact with the hospital to be scrutinised.
  • 1.21 In the case of the Trust’s PPIF, the evidence shows quite clearly the failure of this form of patient and public involvement to achieve anything but mutual acrimony between members and between members and the host. A preoccupation with constitutional and procedural matters and a degree of diffidence towards the Trust prevented much progress.
  • 1.22 If anything, local Involvement Networks (LINks) were an even greater failure. The, albeit unrealised, potential for consistency represented by the Commission for Patient and Public Involvement in Health (CPPIH) was removed, leaving each local authority to devise its own working arrangements. Not surprisingly, in Stafford the squabbling that had been such a feature of the previous system continued and no constructive work was achieved at all.
  • 1.23 Thus, the public of Stafford were left with no effective voice – other than CURE – throughout the worst crisis any district general hospital in the NHS can ever have known.
  • 1.24 Under the new reforms, local healthwatch is intended to be the local consumer voice with a key role in influencing local commissioning decisions through representation on the local Health and Well-being Board. They will be expected to build on existing LINks functions. The responsibility for establishing Local Healthwatch will rest with the local authorities in the same way as it had for LINks. As is the position with LINks, the DH does not intend to prescribe an operational model, leaving this to local discretion. It does not prejudice local involvement in
  • the development and maintenance of the local healthcare system for there to be consistency throughout the country in the basic structure of the organisation designed to promote and provide the channel for local involvement. Without such a framework, there is a danger of repetition of the arguments which so debilitated Staffordshire LINks.
  • 1.25 The local authority scrutiny committees did not detect or appreciate the significance of any signs suggesting serious deficiencies at the Trust. The evidence before the Inquiry exposed a number of weaknesses in the concept of scrutiny, which may mean that it will be an unreliable detector of concerns, however capable and conscientious committee members may be.
  • 1.26 Local MPs received feedback and concerns about the Trust. However, these were largely just passed on to others without follow up or analysis of their cumulative implications. MPs are accountable to their electorate, but they are not necessarily experts in healthcare and are certainly not regulators. They might wish to consider how to increase their sensitivity with regard to the detection of local problems in healthcare.
  • 1.27 There are a wide range of routes through which patients and the public can feed comments into health services and hold them to account. However, in the case of Stafford, these routes have been largely ineffective and received little support or guidance.
  • 1.28 Local opinion is not most effectively collected, analysed and deployed by untrained members of the public without professional resources available to them, but the means used should always be informed by the needs of the public and patients. Most areas will have many health interest groups with a wealth of experience and expertise available to them, and it is necessary that any body seeking to collect and deploy local opinion should avail itself of, but not be led by, what groups offer.

Extract from the Table of Recommendations:

  • Patient, public and local scrutiny
    145 Structure of Local Healthwatch There should be a consistent basic structure for Local Healthwatch throughout the country, in accordance with the principles set out in Chapter 6: Patient and public local involvement and scrutiny.
  • 146 Finance and oversight of Local Healthwatch
    Local authorities should be required to pass over the centrally provided funds allocated to its Local Healthwatch, while requiring the latter to account to it for its stewardship of the money. Transparent respect for the independence of Local Healthwatch should not be allowed to inhibit a responsible local authority – or Healthwatch England as appropriate – intervening.
  • 147 Coordination of local public scrutiny bodies
    Guidance should be given to promote the coordination and cooperation between Local Healthwatch, Health and Wellbeing Boards, and local government scrutiny committees.
  • 148 Training
    The complexities of the health service are such that proper training must be available to the leadership of Local Healthwatch as well as, when the occasion arises, expert advice.
  • 149 Expert assistance
    Scrutiny committees should be provided with appropriate support to enable them to carry out their scrutiny role, including easily accessible guidance and benchmarks.
  • 150 Inspection powers
    Scrutiny committees should have powers to inspect providers, rather than relying on local patient involvement structures to carry out this role, or should actively work with those structures to trigger and follow up inspections where appropriate, rather than receiving reports without comment or suggestions for action.
  • 151 Complaints to MPs
    MPs are advised to consider adopting some simple system for identifying trends in the complaints and information they received from constituents. They should also consider whether individual complaints imply concerns of wider significance than the impact on one individual patient.

Other useful links:

What to do with this data:

  • Read it and digest it.
  • Circulate it to your LINk volunteers and colleagues.
  • Consider how you will respond to the recommendations and lessons learned.
  • Ask your local CCG and providers how they are responding to the recommendations.
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Mapping 4-hour A&E Targets

Tactix4 Performance Map

Tactix4 Map

I was recently rummaging around the internet when I came across a very cool map put together by healthcare software developers Tactix4. The map showed how hospitals were faring on their 4-hour Accident & Emergency targets by placing red, amber or green pins on an interactive map. (Acute Trusts release this information once a week.)

I dropped them an email saying that interactive maps are really my absolutely most favourite thing, and asking whether they could make this map a little more useful for LINks by showing a little bit of historical data on the map as well, so that we could compare the last week’s performance against previous weeks.  A lovely man called Dave Green replied and said he would give it a go! Dave is obviously the sort of chap who can’t quite resist fiddling with a good idea until he has cracked it, and two days later he’d produced the maps. And if there’s anything I love more than an interactive map, it’s an interactive healthcare software developer.

Cool Map 1: A&E 4 Hour Waiting Target Performance >>

Click on your local acute trust and see how it performed in the last week against the A&E 4 Hour Waiting Target. You will also see a link to the relevant page on Patient Opinion.

Cool Map 2: A&E 4 Hour Waiting Target Improvement >>

This map shows how your local acute trust’s performance compares to the previous four weeks. Green means it’s improved since last week, amber means it’s stayed the same, and red means that it’s got worse (it still might be within the targets, but it’s declined from the previous week). Hover over your local acute trust with your mouse and you will see the last 4 weeks’ performance, listed with dates.

What are these 4-hour waiting targets?
One of the key performance indicators set by the Department of Health for NHS hospitals over the last ten years has been ‘the 4-hour Target’.  This meant that a target percent of patients (originally 100% but rapidly revised to 98%) attending an A&E department must be seen, treated, admitted or discharged in under four hours.

Last year, the Department of Health announced that the 4 hour A&E target was to be scrapped, along with other targets – and immediately reduced the target from 98% to 95%.

From April 2011 the 4-hour target will be replaced with eight new “clinical quality indicators”. These new indicators will include ‘patient experience’, ‘effectiveness of care’ and ‘patient safety’ (and I am desperately wondering how many doughnuts I would need to send Tactix4 to persuade them to map those for us too…).

What is an Acute Trust exactly?
The figures on these maps are figures from ‘Acute Trusts’. Hospitals are managed by acute trusts. Acute trusts are responsible for hospitals’ services, finances, strategy, development, etc. and employ the staff that work in the hospital.

Most acute trusts will be responsible for just one hospital, and sometimes ‘acute trust’ and ‘hospital’ are used more of less interchangeably. Acute Trusts are also sometimes called ‘Hospital Trusts’. You will probably know what happens in your local area. Bear in mind, though, that some acute trusts are regional or national centres for more specialised care – and others are attached to universities, training healthcare professionals. They can also provide services in the community, for example through health centres, clinics or in people’s homes.

There is an excellent article summarising all the different sorts of trusts in the NHS on the NHS Choices website.

What to do with this data:
Have a look at your local area and compare the performance of your local trust against the 4-hour target. If you are receiving issues from members of the public about a particular hospital, this might be another indicator that things need looking into a bit more.

For the future, this sort of interactive mapping has huge potential for patient choice. For example, if Local Healthwatches have responsibility for giving information that facilitates patient choice, then a patient might want access to this sort of information in order to decide which A&E department to attend. ‘Do you want to be seen quickly?’ – then chose the hospital which meets waiting time targets. ‘Do you want a hospital with a good reputation?’ – then chose the hospital which has good reports on Patient Opinion. Of course, these specific targets won’t exist for much longer, but this gives you an idea of how the data might be useful for patients wanting to exercise choice.

So, while the 4-hour target might be on the way out, these figures are still useful for giving us an idea of current performance, and they’re definitely a great way of showcasing how useful interactive maps can be. Big thanks to Tactix4!


Patient Opinion

Patient Opinion is the LINk’s best friend.  Patient Opinion is an online depository of patient stories. The principle is nice and simple: patients post their stories about their experiences of health services (e.g. a trip to the hospital) and comment on how they found it.  (N.B. Stories posted on Patient Opinion are also posted on NHS Choices, and vice versa, so there is lots of data.)

The site started off as a bit of a renegade grass-roots project, but has now been embraced by lots of (forward-thinking) NHS organisations – many of whom will add their own comments and feedback to patient’s stories.  Here’s a nice simple example.

There are lots of ways that LINks can use this data.  Here are my suggestions:

1. Keep an eye on what is happening in your area. The easiest way to do that is to contact them and tell them that you want to register as a LINk so that you can subscribe to local patients’ stories. (I rang them up and they were very helpful.)

2. Keep track of local trends. Part of the LINks job is to collect local data. You can keep track of trends that are being reported on Patient Opinion easily. If you are registered with them as a LINk, you can log in to the back end of the site where it says “Reports” – click this and run off the Listing Report. TA-DA, you instantly have an excel spreadsheet with another 100 patient stories for you to use when you are analysing local issues.

3. Add a Local Stories Widget to your website. This is a box of stories that will be automatically updated. Here’s one on the Westminster LINk website. This is quite easy for your friendly web-person to do by following these instructions.

Email Patient Opinion: info@patientopinion.org.uk
Phone Patient Opinion: 0114 281 6256