Notes for MSLC Members & Maternity Commissioners
The NHS Constitution, and the 160-page Handbook, that accompanies it are interesting & exciting documents. Worth a browse if you are interested in co-design as an MSLC member, whether a service user or professional member. Key to your work if you are a maternity commissioner. Here are some notes from an hour, a cup of coffee, and some musing on what this means for us in maternity (as at 1st May 2016)
So, looking at and working with the NHS Consititution:
- Some highlights
- Driving improvement in maternity care
- Designing services
- A message to Commissioners – benefits of involvement & co-design
The NHS Constitution – highlights
All NHS bodies in England, including CCGs and NHS trusts, are required by law to take account of the NHS Constitution in their decisions and actions. (Handbook p.3) The Constitution contains high level principles that are ‘rules’ governing how the NHS operates and seeks to achieve its purpose.
It also contains values developed by patients (service users, in maternity), public and staff which seem to be aspirational words to make everyone feel good about collaborating to support the principles. Then there are rights, pledges and responsibilities, for both patients and staff.
With me so far? We’re on page 5 of 160 in the Handbook to the NHS Constitution (I find this more helpful than the constitution document itself, as it explains what each constitution section means. The constitution pdf is only 16 pages – I did start there!)
Rights are legally binding; pledges are aspirational beyond rights, and are not legally binding. Responsibilities are expectations. I’m not sure whether principles are legally binding. There are also Fundamental Standards that are the source of some Rights – these are legally enforceable by CQC but not directly by individuals, though they could be relevant in a negligence claim by an individual. (Handbook p. 20)
A duty to promote means that both NHS England and CCGs must act with a view to securing health services that are provided in a way which promotes the NHS Constitution, and promotes awareness of the NHS Constitution among patients, staff and members of the public. (Handbook p.6) Don’t be confused – there are other ‘duties to promote’, including one about involving patients (the Constitution term – no concessions to maternity service users) in decisions about care or treatment. (Handbook p.6)
It’s good to know that the Constitution ‘empowers patients, staff and the public to know and exercise their rights in order to help drive improvements in the services that the NHS provides’ (Handbook p.9)
These ‘underpin’ the NHS and are intended to be used as a basis for individual NHS organisations to develop their own values. (constitution p.5) In summary, they are:
- Working together for patients
- Respect and dignity
- Commitment to quality of care
- Improving lives
- Everyone counts
All of these are important. For those of us interested in improving maternity care – thinking about the quality of evidence-based care, access to real choice for women (a priority in the NHS mandate 2016/17 ) and experiences of care – the ‘Commitment to quality of care’ is striking. Here are the words:
‘The NHS aspires to the highest standards of excellence and professionalism in the provision of high quality care that is safe, effective and focused on patient experience. Quality should not be compromised – the relentless pursuit of safe, compassionate care for every person who uses and relies on services is a collective endeavour, requiring collective effort and collaboration at every level of the system. The delivery of high quality care is dependent on feedback: organisations that welcome feedback from patients and staff are able to identify and drive areas for improvement.’ (Handbook p.13,emphasis added)
Does collecting feedback to drive improvement depend on one-off surveys, Friends & Family Test, or topic focus groups? Well no. Because there is a right to involvement in the planning of healthcare services:
‘You have the right to be involved, directly or through representatives, in the planning of healthcare services commissioned by NHS bodies, the development and consideration of proposals for changes in the way those services are provided, and in decisions to be made affecting the operation of those services.’ (Handbook p 78)
What does this mean?
If we look now at the current guidance on patient and public involvement (‘Transforming Participation’), supporting the legal duties binding CCGs and NHS England, we find that involving means,
‘Working directly with communities and patients to ensure that concerns and aspirations are consistently understood and considered. For example, partnership boards, reference groups and service users participating in policy groups’. p.30
‘Evidence suggests that engaging and involving communities in the planning, design and delivery of health and care services can lead to a more joined-up, co-ordinated and efficient services that are more responsive to local community needs. Public participation can also help to build partnerships with communities and identify areas for service improvement.’ p.28
and collaborating in service co-design means,
‘Working in partnership with communities and patients in each aspect of the decision, including the development of alternatives and the identification of the preferred solution’ p.30
So how could this be done? Is there a mechanism for arranging broad-based, meaningful community involvement in maternity, with women, commissioners and others working together in equality, as contemplated by Transforming Participation, to co-design services?
I have posted previously on this blog about what ‘MSLCs’ are, their rich history, and how they work: local, independent NHS working groups, providing advice. With a focus, too – where adequately resourced – on local action: see case studies here.
An MSLC is constituted to advise on maternity commissioning, with equality of members. More representative and sustainable than simply having one or two local women attending a CCG or trust meeting: it is led by a lay person, should have one third service user members, and provides a mechanism for ongoing involvement and project work from year to year. There is training for members, succession planning, and regular liaison with a range of local stakeholder organisations. The lay chair typically manages outreach work by the volunteer members, with attention to planning and quality (which is supported by the national chairs’ and service user reps’ forum online).
The Constitution Handbook explains:
‘In most cases, decision-making on whether to fund a service or treatment is left to the local CCG or local authority. This is to enable CCGs and local authorities to commission services that best fit the needs of their local population,’ and also, ‘Administrative law requires that the decisions of NHS bodies and local authorities are rational, procedurally fair and within their powers.’(Handbook p.49-50)
The MSLC chair should be invited to comment on the local maternity service specification annually – drawing on the feedback reviewed by the MSLC across the past year, including that collected by the service user group. An advisory role that surely makes a well-informed and valuable contribution to rational, evidence-based decision-taking.
While not all areas have an MSLC currently, the movement is strong and growing, and has a new, modern face as an active presence (using the hashtag #mslc) in the #MatExp social media movement – e.g. here. The outreach programmes run by the volunteer MSLC service user members are typically geared to collect views from a diverse range of service users. Where the necessary, modest funding is provided by the CCG, this work can be supported and developed, with service user leadership (lay MSLC chairs undertake a significant and responsible public service role).
A message to Commissioners: do you need more information about best practice, and the benefits of involvement and co-design?
Service user led co-design and project work can fulfil promise of the NHS Constitution to involve local communities – but as the Berwick report foresaw (see notes below), this may need a shift in philosophy and leadership approach in NHS organisations: can you, whether a Commissioner or a healthcare professional, be part of making that change in maternity? What would the first step be? Where would you look for ideas and support?
The Berwick Review recommendations to improve safety in the NHS (2013) included among the principle of action guiding the choice of recommendations:
‘3. Reassert the primacy of working with patients and carers to set and achieve health care goals. Patient safety is better served when patients and carers are as actively engaged in healthcare as they want to be’ (page 10)
Patients and their carers should be present, powerful and involved at all levels of healthcare organisations from wards to the boards of Trusts.
The patient voice should be heard and heeded at all times.
Patient involvement means more than simply engaging people in a discussion about services. Involvement means having the patient voice heard at every level of the service, even when that voice is a whisper. Evidence shows that patient safety improves when patients are more involved in their care and have more control. Patient involvement is crucial to the delivery of appropriate, meaningful and safe healthcare and is essential at every stage of the care cycle: at the front line, at the interface between patient and clinician; at the organisational level; at the community level; and at the national level. The patient voice should also be heard during the commissioning of healthcare, during the training of healthcare personnel, and in the regulation of healthcare services.
The goal is not for patients and carers to be the passive recipients of increased engagement, but rather to achieve a pervasive culture that welcomes authentic patient partnership – in their own care and in the processes of designing and delivering care. This should include participation in decision-making, goal-setting, care design, quality improvement, and the measuring and monitoring of patient safety. Patients and their carers should be involved in specific actions to improve the safety of the healthcare system and help the NHS to move from asking, “What’s the matter?” to, “What matters to you?” This will require the system to learn and practice partnering with patients, and to help patients acquire the skills to do so.’
(p. 18, emphasis added)
What does high quality, safe care look like? One suggestion is the WHO-preferred definition given in the Birthrights letter to the National Maternity Review. There are many other sources and resources – which MSLCs can look at together – including Better Births, the report published by the National Maternity Review, and NICE Maternity Guidance.
This financial year, NHS England is required to expect CCGs to produce a plan to significantly improve choice in maternity (NHS mandate 2016/17 2.2, p. 13). There is much work to do to meet that requirement, complying with the NHS Constitution, and the recommendations of the Berwick report too, of course. Look to existing best practice, and take advantage of the energy, enthusiasm, knowledge and commitment of the multidisciplinary MSLCs in their regional and national networks by developing or founding one in your area.
Join the national conversation online – #mslc #MatExp – and ask us for resources and ideas. All are welcome, and we look forward to learning from you – bring us your energy, enthusiasm, knowledge and commitment!
http://www.kingsfund.org.uk/sites/files/kf/field/field_publication_file/patient-centred-leadership-rediscovering-our-purpose-may13.pdf pp24-5 on ‘leadership by patients’