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Notes from the field of public involvement

Friday, 24 June 2005

Public say on health outside hospitals – be careful what you wish for

“Beyond the ballot box”
Trailed just after the election, the anticipated “major public engagement exercise” on finding out the public’s views on “health outside of hospitals” was announced today by Health Secretary Patricia Hewitt. No one is going to object to “shifting the focus of services towards promoting good health as well as treating disease … and managing long term conditions like diabetes, heart disease and obesity.” The real questions are 1) how might this be done that hasn’t been tried already; 2) what does “engaging people beyond the ballot box” mean? and 3) who might provide this care outside of hospitals that isn’t doing it already?

“Deliberative democracy” – a phrase dear to Ms Hewitt - conjures up citizens juries, electronic “town meetings” and focus groups writ large – none easy or cheap to organise. The US state of Oregon tried this approach to give a public mandate to its health priorities funding debate (aka “rationing” depending on your perspective). Results were mixed. It isn’t a panacea and can produce contradictory outcomes.

So what could “beyond the ballot box” engagement produce in England? Predict what the public will say, if it bothers at all, is high risk. Much depends on what questions are asked (“where would you like to die?” is said to be one of them). But as it ruminates, the public needs to be aware that a clear danger is already appearing from the Foundation Trust corner.

“Vertical service integration”
For FTs, “vertical service integration” could become a major business objective if it can be correlated with public views emerging from the Hewitt consultation. Put simply, this would see Foundation Trusts buying out or otherwise taking over control of primary care practices and services. It could happen here because most UK GPs are private contractors and the NHS doesn’t own their businesses. The FTs could then run primary care as they thought best as “outreach services”.

Don’t think that “health outside hospitals” precludes the hospitals themselves from going out through their own front gates and setting up a new kinds of health shops. Quite the opposite. It happens elsewhere, just look to the US for the implications. Urban areas of England with poor GP services could be low hanging fruit for business-minded expansionist FTs. But if previous efforts to improve primary care had not worked well enough or fast enough, should this “FT mission creep” be welcomed or resisted?

Public health endangered
There is one imperative reason to resist it – public health. Nigel Crisp, CEO of the NHS, said recently that he thought PCTs should lose their service providing roles (community hospitals, community nursing, therapy services etc) and focus only on “managing primary care”. A “fitness for purpose” review of PCTs will start shortly to push that idea forward. If FTs start taking over primary care, there won’t be much left for PCTs to manage. What FTs do all comes under the eye of Monitor, the increasingly powerful FT regulator whose priorities are balance sheet orientated.

If we end up waving goodbye to PCTs we need to be aware that with them will go any hope of public health progress to address our stark health inequalities. Hospitals aren’t about public health. Monopoly provider hospitals with outreach services are not the right organisations to address the health needs of whole populations and they would have no incentives to control costs or manage demand of offer services that didn’t pay.

So there is both an opportunity and an implied “health warning” for the Great British Public in Ms Hewitt’s sortie into what she calls “new politics”. We should be sensible about what we wish for from “health outside of hospitals”. As is the way with wishes, we just might get it but in a way that is quite different from what we expected.

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Andrew Craig | Send feedback