Edward Andersson reflects on a little understood opening for citizen and patient engagement in the NHS.
The NHS is going through a dramatic time of change. The Health service is of course one of the areas of the public sector most prone to reforms and changes, often to the frustration of staff. One of the more hopeful developments at the current time is a push for more transparency and openness.
Traditionally the NHS has been accountable to Whitehall rather than the public. Doctors and other health professionals have been accountable to their professional bodies, rather than patients.
The process of ‘revalidation’ represents one of the most interesting opportunities for patient influence. It is not widely understood, but I believe it may mark the beginning for something significant. So what is revalidation?
It is, simply put, a new process by which licensed doctors regularly need to demonstrate that they are fit to practice. The process for each individual doctor happens every five years and started in December 2012. From Involve’s perspective the most interesting part is that one of the six forms of information required as part of the revalidation process is feedback from patients. Of course many good doctors have been gathering patient feedback for many years as part of their daily work; but patient feedback is now part of a legally mandated process. We mustn’t get over excited –the GMC guidelines suggest that as little as 34 pieces of patient feedback in the form of questionnaires would be enough –not much over five years!
Still, revalidation represents an opening, even though it may seem insufficient. Revalidation is supported by groups such as National Voices, the Patients Association and the National Association for Patient Participation, who state “The scope and frequency of patient feedback in the initial revalidation model is, in our view, too limited, but it does establish the principle of patient feedback in the process”. (PDF document)
From my perspective one of the key limitations of revalidation as it stands is that it relies heavily on formal questionnaires. These aim to track how well the doctor assessed the patient’s medical condition, listened to them and involved them in any decisions about their treatment. This is all useful, but my experience tells me that questionnaires often fail to capture vital nuances. It will be all too easy for the patient feedback aspects to become another exercise of box ticking.
Involve is currently working with Shared Services part of (Health Education England) to look at more innovative ways to gather feedback as part of the revalidation process. We’re looking at applied theatre based approaches and other more creative approaches which allow patients who struggle to express themselves in writing to take part, and allow more qualitative nuances of care to be explored.
Revalidation represents a very important opening for patient voices –while on its own it’s not enough, it could provide a vital narrative for shifting both thinking and practice about patients in being there to be consulted with, to one of ongoing active engagement and involvement in holding health and related services to account. If you know of good examples of innovation around revalidation do get in touch, particularly if you know of good creative approaches.
Happy New Year! I thought I’d take the opportunity to reflect on where we are heading and what we might see in the next 12 months. 2012 as a year has been associated with all kinds of vague and misleading theories about Maya prophesies of impending apocalypse. Even though we are unlikely to see the end of the world, 2012 is still very likely to be challenging.
Take my predictions with a pinch of salt. As Niels Bohr quipped: “Prediction is very difficult, especially about the future”. It is humbling to remember that in 1962 the Decca Recording Company rejected the Beatles because “We don’t like their sound, and guitar music is on the way out.”. Let’s hope that my predictions are more successful.
Turbulence is almost a given; it is instructive to reflect on where we were a year ago. None of the big events of 2011 were ones that we could have predicted. The Arab Spring has toppled seemingly unmovable dictatorships, seemingly calm streets in England erupted in riots and City centres of financial capitals around the world are occupied by disparate and angry protestors. What we expect of democracy is likely to be in transition. One thing is sure for 2012 –we’re bound to be surprised.
Another prediction is we are likely to see frustrations with democratic decision making spill into violence in parts of the world. For states in Middle East and elsewhere the coming year will be dangerous (as recent clashes in Tripoli and Cairo shows). Dictatorships seem to be less dangerous than the transition period to democracy and there is plenty that can go wrong. On a lesser scale communities in the UK and the rest of Europe are experiencing similar transitions and the corresponding risk of violence.
We are also likely to see increased non-violent conflict -2011 has seen a record number of court cases around engagement and consultation, from the Royal Brompton Hospital to London Councils. This is a development I view with unease. Judges are in no way equipped to rate the quality of consultations. It is also likely to encourage Councils to take a ‘back covering’ strategy, rather than focussing on a genuine conversation. We’re likely to see more court cases, and more conflict about engagement, consultation and the big society.
The economy will continue to be a problem. With fewer staff on hand the need to build skills in conflict resolution and facilitation will become acute in many areas. Funding engagement work with clear links to efficiencies and savings won’t be a problem; funding work which makes economic sense over the longer term and where investment is needed will.
Politicians will still mention and support engagement, at least on paper. There seems to be cross party agreement that politics is broken. Expect at least a few high profile initiatives around this topic launched by politicians.
Innovation. The flip side of all this turbulence is that there is a willingness to challenge old ways of working. We’ve seen Councils willing to embrace new ways of working, for example through the NESTA Creative Councils programme (which we are assisting on). Involve and RSA will shortly publish a pamphlet looking at examples of Radical Engagement –genuinely different approaches to citizen influence and we hope we’ll see many more new examples in the year to come.
2012 probably won’t bring a Maya Apocalypse. It will however be a year to remember; difficult but ultimately worthwhile.
So what about New Year’s Resolutions? For myself as a democracy practitioner I’ll suggest the following:
Edward Andersson considers why it takes a crisis for us to think innovatively about democracy.
With parts of London going up in flame and the Prime Minister cutting his holiday short it seems appropriate to write a blog about crisis and its role in democratic innovation. I wasn’t planning to write about the riots. Instead I wanted to reflect on the Icelandic Constitutional Assembly, a group of 25 elected citizens who have been busy over the past few months drafting what the media is calling ‘the world’s first crowd sourced constitution’.
The Assembly has now handed in their recommended constitution to the Althingi (Icelandic parliament). This has rightly been hailed as a major democratic innovation; Iceland is rapidly establishing itself as a world leader in Open Government and e-Participation. Unlike examples of crowd sourcing we’ve seen elsewhere which have used a simplistic approach (akin to throwing something online, calling for anonymous comments and hoping for the best) the Icelandic Constitutional Assembly has avoided the risk of flame wars and interest group capture by complementing online engagement with face to face deliberation and in depth discussion. Writing a new constitution is serious business and the Icelandic organizers have risen to the challenge admirably.
I would love to see a similar level of inventiveness and boldness from UK policy makers. A similar approach to that taken in Iceland could have made the referendum on electoral reform more meaningful for example. Annie Quick wrote a good piece on why deliberation was vital back then.
The thing is democratic innovation at the moment seems to be largely driven by crisis; game changing innovations follow system shattering events. In Iceland the galvanizing crisis was the financial meltdown in 2008. Known locally as ‘Hrun’ (Icelandic for ‘downfall’) the country found itself owning over ten times its annual GDP, with an almost worthless currency and at the mercy of the IMF. This led to unprecedented uproar in the otherwise stable small nation of 320,000 inhabitants. Protests and demonstrations led to the fall of the government followed by soul searching and a growing realization that something had been systematically wrong in society. This is the background which helps explain Iceland’s efforts to involve citizens in rewriting its constitution. Without the crisis Iceland would probably have muddled through with the constitution they had before.
It is a similar story with many other democratic innovations across the world.
Participatory Budgeting in Porto Alegre (PDF document), (PDF document) possibly the most quoted (some would argue over quoted) example of democratic innovation in the world. In the celebration over the past decades we easily forget that the innovation only happened in 1989 when city was on verge of bankruptcy. In hindsight politicians are quick to claim that Participatory Budgeting was the result of foresight and genius, whereas at the time it was an act of desperation.
Another rightly celebrated innovation is the 2004 British Columbia Citizens’ Assembly on electoral reform. This great example of far reaching deliberation around voting systems only occurred after the 1996 election where the party which won the largest percentage of votes got fewer seats than its main rival and was unable to form a government.
There are also good examples from the UK where long needed innovation only happened after things went badly wrong; for example in 2001 riots in Bradford, Oldham and Burnley led to much needed investment in community cohesion and engagement (hopefully we can expect to see the same thing happen in London post riots). In the same year the general election had a record low turnout which prompted politicians and policy makers to take action on citizenship and democracy. This was an area which had needed attention and investment for a long time, but only received after things clearly went wrong.
So we clearly don’t innovate just because something is important; it has to be urgent as well. Is this a problem? After all, most of us probably procrastinated at school – delaying essays until the night before – and we survived. There’s even a school of thought which celebrates crisis as a driver for change. Rham Emmanuel (Obama’s former chief of staff) famously said “You never want a serious crisis to go to waste”.
I think that relying on crisis to provide the impetus for innovation is dangerous and the Obama administration shows why. Buffeted by too many crises that have been allowed to grow too big (including the political gridlock, the downgrade of credit rating and discord around health care reform) the administration is overstretched, underfunded and understaffed. Innovations driven by crisis can be tokenistic, ill conceived and demoralizing.
The wide range of project ideas submitted to NESTA for the Creative Councils programme (PDF document)shows that democratic innovation is alive and well in local government. However, many of these ideas have only become politically possible in the context of the economic crisis, which ironically means that it is hard to fund them. How much more effective could these innovations have been if they had been implemented in a time of economic wealth?
Surely it shouldn’t need to be like this? How do we innovate and democratize without having to see things taken to a crisis point beforehand? There must be a way to pick up on the signals that change is needed before the economy tanks, public trust nosedives or storefronts erupt in flames. Something for me to ponder as I carefully cycle home on streets strewn with crushed glass and shattered trust…
This blog is a repository for posts I have made over the years at Involve as well as more personal reflections.