Beyond the tick box: integrating patient and public engagement in clinical commissioning

Research shows the public trust GPs to make tough decisions about their healthcare, so why not work together in the nation's interest? By Georgina Craig

Engagement on clinical commissioning between GPs and the public can go beyond the restrictive 'tick box' approach (Photograph: JH Lancy)
Engagement on clinical commissioning between GPs and the public can go beyond the restrictive 'tick box' approach (Photograph: JH Lancy)

Gaining the trust and support of the local community is a must-do for commissioners. With the public unprepared for the pending financial squeeze, GPs have to maintain their valuable reputation as the most trusted profession once they become responsible for inevitable cuts. To do this, they have to show they have engaged with local people about tough decisions.

The public think GPs are the right people to make these decisions. An Ipsos MORI poll in 2010 showed that 90% want GPs and nurses to have more control over health services. 

So how can GPs work in partnership with the public more effectively? The following three case studies show how thinking radically differently about engagement can make patient and public involvement much more than a tick-box exercise.

Let experience lead the way
Because patients say they want and expect a great experience of care, Health Works - a pathfinder clinical commissioning group (CCG) in The Black Country - is piloting a new approach called experience-led commissioning (ELC). ELC aims to engage people with relevant experience of care throughout the commissioning process so that commissioners focus on describing a great care experience as great clinical care.

ELC mirrors the four basic steps in the commissioning cycle and does things differently. ELC programmes are built on secondary analyses of health experience research data, undertaken by the department of primary care at Oxford University.

ELC transforms the commissioning process into a series of co-design workshops with local people and clinicians working together to co-design the care experience that Health Works will commission.

All ELC workshops start with the group watching an ‘ELC trigger film’ together. These video montages of stories of care take the multidisciplinary group out of their comfort zone and build a positive group dynamic so that both lay people and professionals feel united in a shared understanding of how it feels to use current services. The films also legitimise how local people feel. Participants report that it is like ‘listening to myself talking’.

Within needs assessment, ELC research provides the context for epidemiological, demographic, cost and service usage data and helps identify key quality improvement themes. Creating a shared vision of great care is also key. The co-design team chart a route map towards progress in three years’ time and then work back to now, setting clear milestones that commissioners then use to monitor progress.

Even the contract and performance management process is inclusive and subject to co-design. All interested providers work together with the ‘commissioning co-design team’ (local people and clinical commissioners) to agree it.

Engagement as community development
Adopting a community development approach to commissioning means recognising that health is about more than the NHS. It sees listening to and working with the local community as the starting point so that whatever is getting in the way of the community healing itself get sorted out first. Transformational health improvement usually follows. 

The Health Empowerment Leverage Project (HELP) provides GPs with an evidence-based, accelerated form of community development. It has been used to support change in some of the most deprived estates and in both rural and urban settings.  A HELP facilitator connects the community’s residents and local public service providers through a structured seven-step programme called Connecting Communities or C2 for short (see www.healthcomplexity.net for details).

HELP succeeds by letting the community set the agenda and helping local agencies like the police, the NHS and schools to work together. Local people and public service providers create a partnership to drive local action.

As well as measurable improvements in health outcomes, the community feels truly involved in the process. They often invest significant time and resource in volunteering to make things change. This further improves health and is a great asset – especially in a difficult financial climate.   

Consultation or brand development?
After the practice-based commissioning group in Louth, Lincolnshire, decided to introduce a primary care-led hospital, NHS Lincolnshire worked closely with it to apply a new approach to public engagement.

It began by building a ‘brand’ for the work programme called Shaping Health for Louth Hospital

Next they empowered local people and clinicians to develop and own a vision for the service – making sure commissioners really understood what mattered to people about it. 

They also invested energy in building relationships and creating trust. They committed to being open and transparent. In fact, relationships mattered more than completing tasks in the early days. This paid off because by the time plans went to public consultation, there was a groundswell of support. Local GP leaders championed the change and because they felt passionate about it, they were a very persuasive sales team. Consultation could then become more than a statutory process. It provided a further opportunity to talk with the community and local stakeholders and turn them into even bigger fans of the proposals.

To help others learn from the experience, NHS Lincolnshire has summarised its learning as 10 principles in a document called Publicly Engaged GP Leadership.

Conclusion
Whilst all of these approaches have tackled the challenge of engagement in slightly different ways, they are all moving towards the same place – one where local people and clinical commissioners are part of the same team, working to improve services and make change happen. And that feels like a very different kind of patient public involvement. 

  • Georgina Craig heads the NHS Alliance’s Pharmacy Commissioning Network

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