Thursday, 01 February 2007
PPI and PCTs - NAO has a go
A SECOND HELPING OF THE FEBRUARY FLAVOUR
"Patient and public involvement has a direct impact on the quality of the patient experience" claims the NAO report. We got all excited because we have been searching for the proof of that for a long time. But sadly we were to be disappointed - the NAO has not provided that proof.
When you look at the NAO claim, their evidence is a diagram showing a 'model of dynamics between patient involvement and experience'. Actually what the diagram shows is an indirect impact at best by treating patient involvement as an input and the patient experience as an output linked by education and active involvement of both clinicians and patients. A proof of direct impact needs a bit more than this graphic assertion.
Perhaps we should not have been surprised at this claim remaining unproven. Looking beyond the Health Service and the public sector, customer care and customer service theory in general has looked long and hard for its version of the grand unifying theory to help service deliverers understand their customers and deliver a good service to them all. Various theories come and go and currently the private sector front runners are variants of the loyalty and recommend syndromes referencing Fred Reichheld and his Net Promoter® approach. But a day in the market place is enough to demonstrate how few organisations consistently translate a theory - no matter how compelling - into the reality of quality service.
The difficulty has always been to translate intention into a view of the customer that is shared and acted upon by the whole organisation. I am sure we have all had the experience whereby one day you enjoy excellent service and the next, the same organisation treats you like shoe scrapings.
And this can happen even with an organisation with a well-organised and competent customer-facing department dedicated to liaising with and understanding the customer. Wonderful people and enlightened policies in one bit but then deal with someone else or a different department - billing in the private sector or an over-stretched clinical department - and see what happens. The promise of the empathic customer connection evaporates like spit off a red-hot shovel.
I find myself believing less and less in the power of a single department within an organisation to instill, install and enforce a consistently excellent service delivery across the rest of that organisation. I am not surprised therefore that half the 14 voluntary organisations researched for the NAO report said that there had been either no or minimal improvement in PCT engagement with client groups. Yet the NAO reports that structures and processes are in place in Primary Care Trusts. But the evidence is that the PCTs are not delivering. They are not making the connection between the organisational investment in those processes and departments they claim to have in place and the individual experience. Again, this is hard and difficult stuff to get right.
So where do we go from there? What do we do? Whom do we work with? Our experience and that of the NAO research combine to highlight the role of the voluntary organisation as the most promising enabler for patient and public involvement.
The successes quoted in the NAO report come from focussed shared work initiatives where for example seven PCTs have supported the Society for Mucopolysaccharide (MPS) Diseases and their regional specialist clinics where experts work with local paediatricians and adult physicians to provide local expert help to patients and families.
This is the big lesson we have learned from work we have underway linking a PCT with the Motor Neurone Disease Association. Reaching commissioners and working with them to evolve a year of care pathway programme has been a very important learning experience in terms of designing appropriate care for patients which, most importantly, they agree is acceptable. No one is in the business of teaching clinicians how to suck clinical eggs.
The learning coming out of the MND pilot work with commissioners has been around a process which admits the external element into decisions hitherto the preserve of people within the system. The key to the success of that process is outputs which are easily translatable into executive and clinical action e.g. is the care pathway affordable by commissioners? Is it deliverable by providers? Is it acceptable to people with Motor Neurone Disease. The process which we have developed together meets the needs of those service designers and deliverers to manage cost and deliver a high quality of clinical care in a way that we know the person with motor neurone disease wants.
This is the best clinical governance. Public and Patient Involvement is not an organisational add-on but an operational asset. Can the proof we are all looking for, be far behind?
National Audit Office: Improving Quality and Safety: Progress in Implementing Clinical Governance in Primary Care: Lessons for the New Primary Care Trusts (links to PDF). Read Part Three Patient and public involvement and the quality of the patient experience need strengthening.