Healthwatch Birmingham, consultations, engagement activity and the public
Healthwatch Birmingham’s responsibilities include ensuring that patients, the public, service users and carers (PPSuC) are at the heart of service improvement in health and social care in the city of Birmingham. As part of our role we actively seek to help those who plan, buy, monitor (commissioners) and deliver services (providers), to continuously improve their Patient and Public Involvement (PPI) activities. Responding to consultations and other engagement activities in health and social care presents an opportunity for Healthwatch Birmingham to:
- Ensure that local people are the focal point of key decisions on changes to health services.
- Communicate patient feedback we have received.
- Notify organisations of concerns and issues with PPI and the impact decisions will/have on health outcomes and health inequality.
We emphasised the importance of listening to and acting on the feedback from patients, carers and service users in the service specifications NHS England and NHS Improvement are designing for Primary Care Networks. Our response was based on the experiences of members of the public who have contacted us to raise such issues as long waits for appointments and referrals or difficulty accessing specially-trained staff.
We highlighted that the main issues across the experiences received relate to the integration of services for young people with mental health problems. In particular, around who will accept responsibility for patients in crisis and actually provide the care, support and joined-up treatment needed? Other experiences have been around the lack of awareness by staff of age related services, the length of time service users have been on the waiting list, referral delays, out of area care, changes to services leading to poorer care, and lack of training and support for carers to enable them to support children and young people when discharged.
NICE consulted on a Draft Quality Standard for people’s experience of using adult social care. Through this consultation we were able to use HWB’s Quality Standard to help shape NICE’s Quality standard. We highlighted the following:
- The importance of ensuring that the standard is clearly about high quality care;
- that the use of service user feedback is not limited to service improvement but that service user feedback is sought at all key decision-making points;
- that a statement is included on the governance arrangements that ensures that all feedback is being used to influence decisions;
- that a statement is included on the need for staff training on collecting and using feedback. We suggested the following statement – ‘staff are trained and aware of their role in collecting feedback, they understand the reasons and there is buy in across the organisations of the importance of service user’s feedback’.
- That ‘equality and diversity considerations are not limited to enabling access for different groups to share their feedback. We suggested that this go further to include how the feedback from these groups is used to ‘identify, understand and address the potential consequences of service improvement, design and development on health inequalities and barriers to improvements in health outcomes (including increasing independence and preventing worsening ill-health)’.
- That there is a statement on the involvement of carers and family members, and how their feedback and insight feeds into decision-making.
Although this consultation was around proposed changes to how NHS England commissions, contracts and pay for care in light of digital innovations in primary care, there were questions around potential benefits and disbenefits for patients. Therefore, through our comments we shared feedback that HWB received from the public between 2017 and 2018 on their experiences accessing GP services. We stated that one of the main issue across the experiences received relate to difficulties with getting appointments. We also shared our findings from the 2017 GP study on the difficulties people face in getting emergency appointments. We therefore agreed that in principle, digital first primary care would help improve access.
However, we also highlighted some concerns service users have expressed around accessing online and telephone consultations. This feedback demonstrates that although there are benefits to digital services, it is more appropriate for some individuals more than others. We argued that if the NHS is to ensure that it meets one of its core founding principles ‘that NHS services meet the needs of everyone’, it needs to understand the needs and preferences of different groups. These needs should underpin decisions around how GP payments are amended. Thus the introduction of digital-first should really be aimed at offering service users varied modes of accessing GP consultation rather than to replace some other modes (i.e. face to face) that other individuals might prefer.
Birmingham City Council consulted with the public on a strategy setting out a collaborative approach with its citizens of all backgrounds. We welcomed that Birmingham City Council is developing a strategy that will ensure that Birmingham residents have a shared vision of fairness and greater social integration.
We therefore agree generally with the proposed guiding principles and the outlined plans in ensuring that these principles are met.
We expressed concern that this consultation does not seem to be designed in such a way that it is accessible to many. We noted that the only way to respond to this consultation is through email. There is no indication that other means of commenting, such as through the post, are available nor have hard copies been made available. This has the potential to exclude some groups from contributing to the consultation. In addition, the strategy document is not offered in any other format or language. Considering the diversity of Birmingham city and differences in the level and pattern of deprivation, it is important that when consulting, all people are given the same rights to contribute and have access to the means to enable them to contribute. This ensures that the needs of the community affected by the proposals in this strategy are taken into consideration and resources are distributed fairly across the city. We believe that, the current process for involving the public has failed to address this, hence the needs of some groups will not be present in the final strategy.
We raised concerns around the following:
- How providers will demonstrate compliance with the guideline especially around transparency and patient choice. How will they verify that patients are provided with the right information that enables them to make an informed choice? We highlighted the findings from the CQC report on online services that indicated that some online services are well run but others are not following guidelines, thereby putting the lives of people at risk.
- How will they ensure that people with different needs are catered to?
- How well does the guideline align with NHS England’s advice that prescription only medication should be taken in consultation with a healthcare professional? (So that there is clear guidance on the suitability of medication, dosage, side effects and the medications interaction with other medicines the individual might be taking).
Healthwatch Birmingham was invited to comment on Birmingham and Solihull CCGs proposed service specifications for Urgent Treatment Centres (UTCs) prior to public engagement.
Healthwatch Birmingham’s comments focused on the following:
- Location – we were happy to see that the location for the proposed UTCs will remain the same as the walk-in centres that they are replacing. However, we expressed concern that there is a possibility that some locations might change based on developments under Birmingham and Solihull CCG’s Primary Care Access Transformation Plan. We asked that should such change occur, then a full consultation would be needed and the specification has to make clear what engagement needs to take place when locations are changing.
- The Scope of service and workforce requirements – we asked for more clarity on the services offered by UTCs as the current walk-in centres provide different services and have different staffing arrangements. We welcomed the inclusion of mental health staff and paediatrician in the specification but we believed that the specification was not clear on the minimum requirement of the staffing structure.
- Waiting times – we asked for more clarity on waiting times and the requirement to undertake an initial assessment or triage.
- Patient satisfaction and complaints – we asked that the specification should go beyond requiring UTCs to carry out surveys and having a complaints procedure to include a requirement to demonstrate how they use this data.
We also highlighted the project that Healthwatch Birmingham is implementing with walk-in centres based on the requirement of the NHS Standard Contract (SC16 16.2.1) which asks for health providers to display clear information about how to make a complaint, share feedback or how to contact local Healthwatch for service users and members of the public.
Through this consultation response, Healthwatch Birmingham was able to share feedback we received from parents and carers through a targeted engagement activity. The feedback we heard through this activity highlighted that there are gaps in information that families need in order to support their children.
From accessing health services, knowing the right services to access, accessing social service support, and support with information/training on how to support their children. This feedback also highlighted important considerations the Trust needs to take in order to understand and tailor support towards different groups in Birmingham such as those with language barriers. Healthwatch Birmingham asked the Trust to consider doing the following:
- Develop a strategy for communicating with family and friends at different points of their journey from pre-accessing services right up to when they have accessed services and ongoing support.
- Consider how it can work in an integrated way with other health and social care services through these support hubs so that support is looking at the whole person.
- Develop ways of collecting continual feedback from friends and family to ensure that services provided at these hubs support their needs and are person-centred.
Birmingham City Council, BSOL CCG, Birmingham Children’s Trust and Birmingham Community Healthcare NHS Foundation Trust’s consultation followed an inspection report that found SEND services in Birmingham inadequate in quality and provision.
Therefore in our response Healthwatch Birmingham shared feedback received from service users and the public during 2018 on their experiences accessing SEND services. We stated that the main issue across the experiences received relate to concerns on lack of early intervention, poor follow up support following assessments; lack of clarity on EHCP forms on who delivers particular aspects of care; long waiting times to get EHC plans completed; delayed referrals by GPs; and failure to diagnose appropriately.
We also highlighted other concerns that service users have expressed around the quality of services provided by SEND. There is a real struggle for some carers to get the support they need for their children and most crucially problems with early year’s intervention. Other quality issues have been around effectively identifying children’s needs and ensuring that those needs are met. Another concern has been the lack of timeliness of EHC plans. This has meant that there is a delay in accessing the necessary educational provision leaving some parents to home-school their children. There appears to also be problems with people understanding the processes around the local offer. In many of the above cases, Healthwatch Birmingham had to send out information on the EHC process including information on statutory waiting times, how to challenge assessments, how to complain about staff conduct and information around the referral process.
Birmingham City Council’s (BCC) Adult Social Care and Health directorate, Clinical Commissioning Group for the National Health Service and Birmingham Children’s Trust consulted on a vision and commissioning strategy for carers in the city.
We shared feedback from carers that we have received highlighting the various problems that affect carer’s health and wellbeing, finances, relationships, and social life. We shared feedback on concerns with assessments (timing, quality); carers feeling ignored; patients with complex needs (i.e. dementia) being told to remain in their home when the carer also has needs of their own; social workers not having the expertise of the illness to carry out assessments; carers being told that they do not need certain services or that the council has no money to support them anyway; financial assessments driven by what social workers can get for carers and service users; care agencies not reliable as service users are left without care; respite care not given to carers and no joined up care between health and social care.
We indicated that the feedback we presented demonstrated that there is need for ensuring that service users have:
- Clarity and communication around dental fees and what this covers in terms of treatment. Including, charges when a course of treatment is over a certain period of time and does not conclude in one visit.
- Information and advice that is tailored to different groups such as those with a disability, those with difficulties understanding or speaking English etc. Dentists need to therefore understand the patient as an individual and ensure that treatment is tailored to their needs. Dentists need to address access and health inequality issues.
- Clarity on treatments that are included within each NHS dental band charge and those that are private.
- Clarity on referral pathways, waiting times and corresponding charges.
- Clear information on diagnosis and treatment (therefore clear information on procedures being carried out and when they are carried out).
This feedback also highlights important considerations the NHS needs to take in order to ensure that people have access to services. Service users need to be assured that these services are of good quality, safe and offer timely treatments.
The response also highlighted positive feedback that demonstrated that service user’s value dental care that is personalised to their needs and circumstances (i.e. drop off clinics for the homeless), the efficient management of appointments and follow-up checks, clear information about treatments and prompt access to services. Healthwatch Birmingham therefore suggested that in order for the NHS to commission dental services that are accessible to different groups, safe, offer timely treatment and are personalised, there has to be a strategy for communicating with service users. The NHS will have to develop ways of collecting continual feedback to ensure that services provided by dentists meet their needs and are person-centred.
Birmingham and Solihull CCG’s consultation information can be found here.
Healthwatch Birmingham’s comments focused on:
- The involvement of PPSuCs in developing the proposed options.
- Whether the proposed options are responsive to the individual needs of those accessing services, ensuring that they do not lead to health inequality.
We shared feedback from service users of the three centres which demonstrated that the services were highly valued. We therefore raised concerns about the potential impact relocation might have on the most vulnerable within this community. People on low incomes, the elderly, people living in poverty, and those with caring responsibilities among others could be impacted. We noted that these are some of the groups that might be least able to travel further to access services. We asked that these issues be considered as this proposal has the potential to impact people in terms of access to GP services, continuity and quality of care.
As regards the consultation process, we expressed concern about the following:
- It was not clear how the option (i.e. to relocate) was decided and the extent to which the views of PPSuC and specific users of this service have been taken into consideration when drawing up this option.
- Whilst the CCG offered various methods for people to be involved including over the phone, it was not possible to contact them on the number provided within the consultation document. We therefore requested to read in the consultation report how effective these methods were in hearing from those affected by these proposals.
- The consultation document did not describe how services will look like at the new centre. Whether these will be ‘like for like’ services, with the same staff, or whether there will be some changes?
The CCG’s consultation report can be found here.
The Local Government Association (LGA) consulted on a draft green paper for adult social care and wellbeing. We welcomed that the LGA is leading the discussion on shifting the overall emphasis of our care and health system to focus more on preventative, community-based personalised care, which helps maximise people’s health, wellbeing and independence and alleviates pressure on the NHS.
We shared feedback that highlighted the important role Council’s play in promoting independence for service users and ensuring that care is person centred; and the important role the Council plays in bringing together organisations so as to improve the health and wellbeing of service users. We noted that local Councils are strategically placed and ideally have a good understanding of the determinants of health and wellbeing in their local area. This among other reasons, make local Councils crucial in decisions around adult social care. Their understanding of the population enables them to weigh expenditure against other priorities and spend on areas that are key to local priorities.
The aim of the strategy is to ensure that local people and stakeholders in Birmingham have a say in how health care is organised. Through this response we were able to use the guidelines/principles in Healthwatch Birmingham’s quality standard to guide the development of the strategy. Our comments were focussed on principles for engagement; implementation of the strategy, inclusion of equality and diversity issues, engagement model (response rates, hearing from a diverse group of people and membership of groups such as experts by experience); frequency of evaluation and reviews; budget and resources to achieve the goals of the strategy.
Birmingham City Council consulted the public on planned cuts to various services.
We asked to see a consultation report that demonstrates that the views, needs and experiences of the public have been listened to and how they have informed the final budget.
We also expressed concern that the trajectory of the Council’s plans seem to be on the one hand increasing the amount that the public pays for various services through increased Council tax, introduction of charges for services, and on the other hand reducing the services that the citizens can access. We argued that the proposed plans seem to be at odds with the Council’s key priorities around skills development, reducing social isolation and loneliness; responding to challenges highlighted by regulators within children services among others.
In our response we expressed concern with the potential impact the closure of this surgery might have on the most vulnerable within this community. People on low incomes, the elderly, people living in poverty, those with a disability, and those with caring responsibilities. These are some of the groups that might be least able to travel further (3.8miles) to access services at the main Summerfield Centre. We believed that the proposal was likely to impact people in terms of access to GP services, continuity and quality of care.
We therefore asked that consideration needs to be taken of the demographics of the surgery’s population group and the corresponding distance they have to travel, and changes to any services that would occur because of the closure. This information would hopefully help the CCG to feed into any impact and equality analysis being carried out and address issues accordingly.
Read the CCG’s consultation report here.
Between 31 October 2016 and 6 January 2017, Birmingham City Council consulted on their Domestic Abuse Prevention Strategy. The consultation focused on three priorities that the Council had identified, namely: Changing attitudes, early identification and early help, and safety and support.
In our response, we shared experiences that Healthwatch Birmingham received from the public around domestic abuse. The feedback highlighted several issues:
- The impact of domestic violence and abuse on health, particularly mental health
- The problems people face when they try to access primary care services, including waiting times, non-responsiveness of services to victims and lack of skills amongst staff to better support domestic violence and abuse victims.
We therefore asked that there be a more central role for health and social care professionals who are often the first point of contact for people facing domestic violence and abuse. We also recommended that the council links the strategy to other strategic priorities including public health agendas that would then promote a change in attitude.
Between 8 December 2016 and 18 January 2017, Birmingham City Council consulted with the public, service users and carers on resource allocations to various services. The proposals in the consultation were organised under five themes: cross-cutting; jobs and skills; homes and neighbourhoods; and children.
Healthwatch Birmingham’s response highlighted the following:
- The impact of proposed cuts to essential services and the possible health inequalities they might cause.
- The long term impact of proposed cuts to health services in the future.
- That the Council had missed an opportunity to take an integrated approach to the budget planning such that cuts were being made to services that are essential to achieving actions planned under Birmingham and Solihull’s Sustainability and Transformation Partnership.
- We expressed concern about the extent of, and the methods for consultation. Considering the scope and breadth of the proposed cuts, having only two public events for 1.1m people was inadequate. In addition, there was an over-reliance on online methods for people to respond or attend a meeting. The public were not given sufficient information and justification for the proposed cuts to enable them to give well informed comments. We therefore emphasised the importance of using service user insight, experience and involvement to ensure that these proposals are shaped by the needs of relevant populations and communities.
In its consultation report, the Council acknowledged Healthwatch Birmingham’s comments and gave further information about how they involved the public and plans to engage with specific groups on the proposals.
Birmingham City Council Consultation Report https://www.birmingham.gov.uk/downloads/file/5837/budget_consultation_report_2017
Between 6 January and 3 February 2017, NICE consulted on a draft quality standard on ‘Oral health in care homes and hospitals’. The three quality statements consulted on were:
- Statement 1 – Adults who move into a care home have their mouth care needs assessed on admission.
- Statement 2 – Adults living in care homes have their mouth care needs recorded in their personal care plan.
- Statement 3 – Adults living in care homes are supported to clean their teeth twice a day or undertake daily oral care for dentures
NICE aimed to find out from the public and stakeholders whether local systems and structures are in place to collect data on proposed measures, and whether these were achievable.
Healthwatch Birmingham agreed that the draft quality standard reflected the key areas for quality improvement needed to address the issue of oral health in care homes. We noted that most care homes have systems and structures in place to be able to implement the proposed quality measures. However, NICE needed to consider the variation in the nature and quality of services provided by different care homes. We shared feedback around some practices in adhering to care plans which have led to service users being unwell. We also highlighted variations in arrangements for assessing service users needs in different care homes, procedures for recording everyday activities which would make auditing difficult and how homes collaborate with dental professionals. We asked NICE to consider these issues and develop a standardised and reliable oral assessment tool that can be used during initial assessments when a service user moves into a care home. This process should ensure that service users are involved in developing oral hygiene plans so that these are person centred.
Our comments were included in NICE’s consultation report and have been taken into account in the final Quality Standard published in June, 2017.
NHS England consulted on service specifications for Tier 4 Child and Adolescent Mental Health Services (Tier 4 CAMHS) between 1 December 2016 and 28 February 2017. Healthwatch Birmingham recognised the need to develop highly specialised mental health services for children and young people that ensure personalised and joined-up care. Thus removing complicated service pathways and developing services that are more closely aligned with health, education, and local authority services. Responding to this consultation was important as 46% of Birmingham residents are under 30 years of age with 250,000 of those under 15 years and 28,000 children and young people in Birmingham aged between 5 and 16 years have a clinically diagnosed mental disorder.
We shared feedback received by Healthwatch Birmingham from patients, service users and the public to highlight some of the issues they face in accessing CAMH services. We also shared Healthwatch Birmingham’s report into care plans to highlight poor implementation of policy around care plans for those suffering from mental health. We also shared a report on young people’s experiences of accessing primary care services.
Birmingham City Council consulted on its proposals to help manage and control on-street parking activity in Digbeth between 10 February and 13 March 2017. We commended the Council for providing various methods for the public to respond to the consultation including over the phone, through email, both paper and online forms and drop-in sessions. In our response, we asked the Council to consider the following before implementing the proposals:
- To carry out an impact/equality analysis to identify the population groups that might be affected by the proposals. We argued that an equality analysis would help them understand the potential impact on those that access health and social care services in this location.
- We expressed concern that for those able to pay for parking, parking was not guaranteed despite buying a permit.
In April 2016 BCC and BSC CCGs carried out an impact assessment to support their plans to redesign the local urgent care system. The CCGs were working together to create a simplified, integrated urgent care system including the establishment of urgent care centres for non-emergencies. This pre-consultation engagement aimed to capture the potential negative and positive impacts of the different urgent care reconfiguration scenarios. These are outlined in the document here.
We shared with the CCGs feedback Healthwatch Birmingham received from service users and the public on their experiences of accessing urgent care services in Birmingham. The feedback highlighted that patients valued urgent care centres and that these centres reduce access to A & E departments and are at times useful when people cannot get a GP appointment. We asked the CCGS to consider the following when deciding the scenario to implement:
- That it captures the diversity of Birmingham and takes into consideration that the impact of proposed changes will be varied for different groups.
- The potential impact of proposals on health inequality should the CCGs close urgent care centres or limit services.
- The inconsistencies within urgent care centres that lead to variability in the services patients’ access. For instance, some centres are only manned by nurses or non-nursing staff at particular times of the day. Others are led by a nurse and others by a GP
- To ensure better information sharing between urgent care centres, GPs and hospitals.
- The importance of centres to some groups such as homeless people, travellers, and refugees.
Between 12 June and 8 August 2017, the Care Quality Commission consulted with stakeholders and the public on how it will:
- Register, monitor, inspect and rate new models of care and large or complex providers.
- Use its unique knowledge and capability to encourage improvements in the quality of care in local areas.
- Regulate primary medical care services and adult social care services.
- Carry out its role in relation to the fit and proper person’s requirement.
In our response, we observed that there was insufficient focus on the need to engage with service users and the public in identifying and understanding how the services provided by health and social care organisations impact on their health and wellbeing. We suggested that one of the principles should be to ‘always ensure that patient and public insight, experience, engagement and involvement informs all regulation activities’.
Healthwatch Birmingham also shared feedback with the CQC around service user experiences on discharge and coordination of care post-discharge. This was to highlight issues that lead to poor integration between services. We also supported the inclusion of ‘determining whether there is learning from investigations, event analyses or reviews by organisations’ to the CQC’s Key Lines of Enquiry. We asked the CQC to ensure that in determining the extent of learning during its inspections, they should also determine the extent to which families and patients are included in investigations and demonstrate how lessons will be learned as a result of clinical incidents. Our comments were taken into account by the CQC and were included in their final report here.
Between April and December 2016 NHS England consulted stakeholders and the public on a framework for involving patients and the public in primary care commissioning. Healthwatch Birmingham’s comments centred on the extent to which the draft framework brings together the two statutory duties of patient and public participation and addressing health inequalities. Also highlighted was Healthwatch Birmingham’s quality standard and how it brings these two duties together. NHS England has requested a link to Healthwatch Birmingham’s quality standard to include in their final report.
Healthwatch Birmingham commented on Birmingham City Council’s consultation on their new strategy for home support, supported living and residential care. The consultation took place between 5 April and 5 July, 2017. Our comments focused on the elements of the framework that related to service user feedback:
- How providers listen to service users
- Service user and relative’s views on engagement
- How providers act on the feedback they hear
- Whether service users feel they are treated with dignity and respect
- Service users and complaints
Service user and carers’ experiences were collected through Enter and View visits conducted by Healthwatch Birmingham staff and volunteers. This feedback was used to comment on proposals by Birmingham City Council to use service user feedback in their rating system for providers. The aim was to provide the Council with further insight regarding:
- The obstacles that may need to be overcome when they think through the details how patient feedback is to be heard and acted on by providers, and by the Council.
- The good practice that is already in place, and can be built on, in some residential and nursing homes with regard to listening to service users and relatives, and using that feedback to improve the care and wellbeing of their residents.
Our response to the consultation has helped improve the process for Birmingham City Council and Birmingham City Council funded providers to hear the views of service users, their relatives and carers. We have been provided with opportunities to increase the number of providers using Healthwatch Birmingham online feedback centre. In addition, we will run workshops with providers on Healthwatch Birmingham’s Patient and Public Involvement Quality Standard.
Healthwatch Birmingham responded to Birmingham City Council’s consultation on changes to the way children’s centres, health visiting and parenting support services are delivered in Birmingham. The consultation took place between 19 June 2017 and 17 August, 2017. Our response focused on the potential impact the closure of some services (i.e. children’s centres, health visiting and parenting support) might have on access and health outcomes. The response highlighted the absence of an equality analysis in the consultation process that would have helped the Council identify groups that would be affected by proposed plans.
The Early year’s mobilisation team acknowledged receipt of our comments. They are due to use the views from the public to make recommendations to the Cabinet in September 2018.
Between 22 August and 3 of October, 2017, NICE consulted on a draft guidance on improving the experience of care and support for people using adult social care services. We welcomed NICE’s inclusion of the following as a recommendation in the proposed guideline:
- involving people in service design and improvement
- using people’s views to improve services.
However, we expressed concern that the ‘involving people in service design and improvement’ recommendation states only that its main purpose is to:
- Involve people in decisions about the way services are commissioned, run and are governed; and
- Checking that the service is delivering quality care.
We therefore suggested that the proposed guideline could be strengthened by a clearer link between the two public sector legislative duties. Namely legislation requiring public sector organisations to:
- Engage/involve the public and patients; and
- Reduce health inequality and improve health outcomes.
Through this consultation we were able to share our findings from the Enter and View study carried out in May/June 2017. We were also able to share raw feedback from service users that we gathered during these visits. The final guideline has now been published on the NICE website. Stakeholder comments and NICE responses to these have also been published.
Healthwatch Birmingham’s contribution can be accessed here from page 15.
Sandwell and West Birmingham CCG consulted on proposals to change the way GPs prescribe medicines for short-term, minor conditions or where there is no clear health benefit for patients. The consultation took place between 23 March and 13 July, 2017. Healthwatch Birmingham comments focused on:
- The involvement of patients, the public, service users and carers (PPSuCs) in developing the proposed changes.
- Whether proposed changes are responsive to the individual needs of those accessing services, ensuring that they do not lead to health inequality.
- The extent to which proposed changes align with policy and national plans.
Patient, the public and service user experiences were used to highlight the impact the proposed changes would potentially have. This included the impact on people from different socio-economic backgrounds and the impact on GP-patient relationship, should GPs be expected to make decisions on eligibility for free prescriptions. We asked the CCG to consider:
- The wider impact these proposed changes may have on the NHS.
- The impact of proposed changes on people from different socio-economic backgrounds considering the levels of deprivation in Sandwell and Birmingham.
- How GPs will take into account socio-economic issues should they be required to make decisions on who can get a free prescription and who cannot. In addition, how the CCG will mitigate against unfair discrimination should prescribing be based on socio-economic status.
Sandwell and West Birmingham CCG welcomed our comments and said: “You raise some very interesting points on the consultation and our approach which we are considering. The consultation period has now closed and we are currently collating all the feedback that we have received. The results and feedback on the consultation will then be taken to our Governing Body for a decision to be made on how we take the proposals forward. We will contact you again to inform you of our decision and give you some feedback on your comments.”
Between 22 September and 21 November 2017 Birmingham City Council consulted on the needs for pharmaceutical services of Birmingham. Healthwatch Birmingham agreed that, based on the assessment document provided:
- Opening hours and locations for pharmaceutical services are well-spread across Birmingham. However, this will only remain true if there are no closures or downgrades to services during the life of this PNA.
- The Health and Wellbeing Board should consider upgrading MUR (Medicine Use Review service) and MAS (Minor Ailment Service) services to ‘essential services’. This will align with National Policy and the subsequent changes at the local level. For instance, plans under the NHS Five Year Forward View to integrate Pharmacists into the healthcare system and ensure that pharmacists have a significant role in clinical care. As well as the review of the Urgent Care System which will have implications for pharmacists and their role in managing urgent care demands.
- Patient, public and service user experience and views should inform local commissioning decisions on pharmaceutical services. Therefore, agreed with plans by the PNA to develop a strategic approach for patient and public engagement.
However, we also expressed the following concerns:
- that some areas in Selly Oak and Edgbaston, have lower per capita access than the Birmingham and West Midlands average. We therefore agree that any pharmacy closures in these areas should be reviewed by the Health and Wellbeing Board, should this occur before the next PNA. In addition, that such a review should involve the public and service users.
- that services providing Dermatology Dispensing and advice to care homes have been decommissioned. This is despite the 2015 PNA considering these to be ‘adequate provision’ and ‘to be developed further’ respectively. We look forward to reading more as to why these were decommissioned, a consideration of the impact this may have on service users and the planned actions to address this.
- that the provision for Appliance Use Review (AUR) in Birmingham is lower than the England and West Midlands average. In addition, there is no data on how well the public and service users are informed about the current services and the demand for such services. We ask that monitoring of the demand and whether the service is reaching those that could benefit from it, should be carried out during the life of this PNA.
- that Birmingham performs slightly worse compared to the national average for the New Medicines Service (NMS). This is more concerning as Birmingham appears to have the capacity to offer NMS services more widely and offer more NMS consultations each month. We therefore ask commissioners to take heed of the advice in the PNA to use data regarding geographical distribution of the NMS service to support assessment of equity of provision.
- that there are gaps in the provision of the Minor Ailment Scheme and Pharmacy Palliative Care services. We hope to read in the final report plans to address these gaps.
Responding to this consultation has opened up dialogue with Birmingham Public Health on how we can improve the use of patient, service user and public experiences in future PNAs.
NHS Improvement (NHSI) and the Care Quality Commission carried out a consultation on reflecting NHSI’s assessment of trusts use of resources in published CQC inspection reports and trust-level ratings. The consultation took place between 10 November 2017 and 10 January 2018. We focused our comments on whether the proposed changes will help ensure that services provided by Trusts are responsive to the needs of those accessing services, are of good quality and do not lead to health inequality.
We used feedback we have received from patients to highlight what they consider important when accessing health and social care services. These experiences were used to argue that the underlying principle of any rating system for health and social care should be the quality of services. Therefore, that plans to rate trusts use of resources do not supersede quality concerns. We therefore expressed concerns about the following:
- The impact the use of resources rating will have on trusts services and service users. Delivering better financial performance could be at the expense of quality or by restricting access to services. There are already examples in Birmingham where services are no longer being delivered because they are no longer considered financially viable. For instance, the closure of oncology services at Sandwell and West Birmingham Trust.
- Consequently, delivering better financial performance might be negative for patients as it might mean restricted access to drug treatments, procedures, surgery for certain groups, or rising waiting times. Therefore, there is need to consider the balance between finance and quality in CQCs assessments.
- The impact of national policy on spending decisions. How does the use of resources assessment factor in issues around financial pressures? If the Trusts budget does not adequately cover demand and therefore overspends by drawing on reserves or running a deficit, how will this be taken into consideration?
- Equally, how will the use of resources process capture the impact of performance by other bodies? For instance, some of the metrics to be used in the assessment, such as delayed transfers of care, are dependent on Councils having a bed available in social care. There has to be a clear process for assessing the extent to which a Trust has control over delayed transfers of care. Other issues which Trusts might not have control over could be workforce supply and expenditure on some specialised medicines. We hope that the qualitative aspect of the assessment will capture the factors in a Trusts environment that would impact its use of resources.
Between 30 November 2017 and 18 January 2018, Parliament run an inquiry into the effectiveness of Sustainability and Transformation Partnerships. Our response focused on aspects of the inquiry that related to:
- The involvement of patients, the public, service users (PPSuCs) in developing the STPs; and
- Whether proposed changes have improved the quality of care and led to services that are responsive to the needs of patients and service users.
We expressed concerns over the lack of public engagement by the Birmingham and Solihull STP. Thus raising concerns about the extent to which the plans are locally driven. We noted that despite NHS England’s guidance recommending that the public should be engaged throughout the STP process (from problem identification, designing of solutions, implementation and review) this has not been the case in Birmingham.
We used feedback from patients, service users and the public to demonstrate the concerns they have with integration and joined-up care.
Our response has been published alongside other responses here.
Between 12 December 2017 and 15 January 2018, Birmingham City Council consulted on the 2018+ Budget plans. The Council set out in the how they planned to tackle the challenges facing the council. Healthwatch Birmingham expressed concerns that the Council had failed to consider the concerns we raised in the 2017+ budget consultation response. These issues were restated:
- The majority of the methods employed by the Council for involving the public are online, and this has the potential to exclude some groups from contributing to the consultation.
- The timing of the consultation (over the Christmas period) does not give the public adequate time to consider and respond to proposals.
- The consultation documents do not provide adequate information on proposed cuts to enable the public to comment appropriately. No impact and equality assessments have been carried out in order to identify the potential impact of proposals on different groups.
We also expressed concern that the majority of the cuts are in adult social care and health. We shared feedback from patients and service users to highlight their experiences and how some proposals will further worsen their quality of life. Generally, we expressed concern that proposals offer blanket solutions for people with different needs. Similarly, that the Council has not assessed the potential consequences of withdrawing some service from the community, such as children’s nurseries, young person’s homeless hub and re-directing discretionary aspects of the public health allocation into prevention and early intervention.
Between 5 February and 19 March 2018, Sandwell and West Birmingham CCG held a consultation on changes to three GP Practices in the area. Our comments focused on Summerfield Practice which is within Healthwatch Birmingham’s remit. The GP contract for Summerfield Practice is coming to an end in March 2019 and the consultation responses were to feed into plans to close or restructure the practice. Healthwatch Birmingham commended the CCG’s foresight in using this critical juncture to gather views from service users and members of the public on how services can be improved or restructured.
However, we expressed concern about the impact the proposed changes (in particular Option 2 – to close the practice and move patients to other local practices) might have on the most vulnerable within this community. Such as the people on low incomes, the elderly, people living in poverty, and those with caring responsibilities among others. We asked the CCG to consider the impact of these plans on access to GP services; continuity of care; and quality of care. We shared with the CCG service user feedback that demonstrated the difficulties individuals face in registering with a GP in Birmingham. Thus highlighting the difficulties the CCG would have in re-registering 5000 people at the same time. Including, the capacity of neighbouring practices in taking on these patients.
In our response, we also shared with the CCG insights from service user experiences of accessing GP services in Birmingham on what they consider to be best practice. This included areas where GP services could improve. In our response, we also commented on how the CCG had involved service users and the public in developing the options under consultation. We expressed concern about the lack of an impact assessment of the options under consultation. We noted that without an impact assessment, it was unclear how the CCG has identified those that will be affected most by the proposals and how this has informed the CCGs involvement approach.
Between 6 April and 8 June 2018, the Department of Health and Social Care ran a consultation on proposals to extend legal rights to have personal health budgets and integrated personal budgets. We welcomed the proposal to extend legal rights to more groups other than only those receiving NHS continuing healthcare or children continuing care. We highlighted that the premise that underpins personal health budgets is good as it offers choice to people and gives them control over their life. However, the effectiveness of personal budgets depends on how they are implemented and the principles that govern their implementation. As such it is important to consider the following issues:
- Are personal budgets/direct payments better suited to conditions that are stable and predictable rather than more complex conditions where needs change regularly.
- Will direct payments offer new groups the flexibility to choose or will it limit choice;
- Will all individuals be able to successfully use personal budgets/direct payments and how will the government ensure that they still have access to much needed services such as day centres etc.
- What support will be in place to ensure that personal budgets/direct payments do not transfer burdens to individuals and their families?
In our response, we shared with the Department of Health and Social Care findings from our investigation into people’s experiences of using direct payments and prepayments cards in Birmingham. In summary, we shared the following feedback about accessing and managing direct payments:
- Many people, including service providers, have not heard about or do not understand direct payments.
- It is difficult to access social workers to obtain timely assessments and other advice.
- There is a lack of informed, shared decision-making.
- In some cases, direct payments burden families and carers with extra responsibilities.
- Direct payments cannot be used for all services such as DBS checks and untimely payments lead to loss of support for individuals.
We asked the Department to consider the findings of Healthwatch Birmingham’s investigation as plans to roll out personal budgets to new groups take shape.
NHS England consulted on reducing prescribing of over the counter medicines for 33 minor, short term health concern between 20 December 2017 and 14 March 2018. – Healthwatch Birmingham’s comments focused on:
- The involvement of PPSuCs in developing the proposed changes, future updates to the prescription list and the guidance review.
- Whether proposed changes are responsive to the individual needs of those accessing services, ensuring that they do not lead to health inequality.
Using patient, the public and service user experiences we expressed concern about the impact the proposed changes will have on:
- The most vulnerable in our society such as the homeless, people on low incomes, people living in poverty, people who are geographically isolated, and those with caring responsibilities;
- People who are entitled to free medication on the NHS and would therefore not afford to pay for over the counter medication; and
- People suffering from conditions that necessitate the use of these prescriptions
We asked NHS England to demonstrate in its consultation report, how it has taken into consideration the following issues:
- The wider impact these proposed changes may have on NHS finances. For instance, the unintended consequences that might lead to prescribing more expensive items. Equally, the potential market changes that might lead to an increase in prices for over the counter items making access difficult for PPSuCs.
- The impact of proposed changes on people from different socio-economic backgrounds considering the variable levels of deprivation across the UK.
- How GPs will take into account socio-economic issues should they be required to make decisions on who can get a free prescription and who cannot? In addition, how the CCG will mitigate against unfair discrimination should prescribing be based on socio-economic status.
- The legal implications of this guidance being a statutory document and therefore make clear areas where CCGs obligations precede this guidance. For instance, when due regard to local circumstances and their own impact assessment is taken into consideration in decision-making on prescribing items.
- How CCGs will communicate changes to the public and individual patients who are affected by changes. Communication will be even more important for patients whose medication is changing to a cheaper one. Patients need to be reassured of the clinical effectiveness of new items and that principles of best practice on clinical prescribing are being adhered to. This can only be done if changes are discussed with patients and their carers.
NHS England welcomed our comments and in a follow up consultation on the same subject seems to have addressed some of these issues and NHS England has included a list of groups that should still receive the medicines under discussion such as children, vulnerable people, people with complex and long term health needs etc.
Between 21 July and 21 October 2017, NHS England consulted on proposals to reduce the prescribing of 18 products considered of low clinical value, clinically ineffective and of low priority for NHS funding. Whilst our comments on this proposed guidance were made cognizance of the negative impact poor prescribing has on patients and on NHS finances, we argued that the needs of patients, the public and service users (PPSuCs) should be central to any changes to prescribing. Therefore, NHS England should use the views and experiences of PPSuCs to better understand the unintended consequences of this commissioning decision. We asked NHS England to consider the short and long-term impact of these proposals and the inequalities these proposals might cause. We shared with NHS England feedback we had received about people’s experiences concerning changes to prescriptions for cheaper drugs; negative effects of cheaper medicines on patient’s health; and lack of accountability of changes made to prescriptions.
We note that once approved, the guidance will be reviewed annually and items may either be retained, retired or added to the current guidance. We also note that the joint clinical working group will prioritise items based on five criteria. We ask NHS England to consider making ‘patient feedback’ a standalone criteria rather than an alternative to strong clinician feedback. Healthwatch Birmingham believes that NHS England should use patient feedback to:
- Identify and understand the impact of proposals on health inequalities and barriers to improved health outcomes; and
- Use patient feedback to inform the development of possible solutions, decisions made and actions taken in order to address health inequalities and drive improvements in health outcomes.
We urged NHS England to ensure that any future reviews of this guidance reaches a wide variety of people, uses varied methods for engagement, provides the necessary information including an equality impact assessment, and that the appropriate length of time is given for people to comment.
Between 14 May and 22 June 2018, Sandwell and West Birmingham CCG and Birmingham and Solihull CCG run a consultation on proposed changes to 21 treatments and procedures and their accompanying policies. Healthwatch Birmingham stated that the premise (that policies incorporate the most up-to-date published clinical evidence, stop variation in accessing NHS-funded services across Birmingham and ensure that access is equal and fair) that underpin the proposed changes is good. However, we argued that the effectiveness of these policies in meeting the needs of Birmingham residents will depend on how they are implemented and the principles that govern their implementation. In particular, should financial considerations become the overriding principle, then there is the potential for patient’s wellbeing being considered second best. We therefore asked the CCGs to consider the following when implementing the proposals:
- whether the proposals will improve the quality of care and lead to services that are responsive to the needs of patients and service users
- Whether proposed changes may address or lead to health inequality
Between 15 January and 18 February 2018, NHS England consulted on the Equality Delivery System Grading tool. The survey asked for information on our views of how well NHS England is doing in allowing for the needs of people from different backgrounds. Healthwatch Birmingham commended NHS England’s efforts to address equality issues and promote diversity and equality. We highlighted the work being done by local CCGs in implementing the EDS2 tool and noted that evidence exists for each outcome. This demonstrates that work is been done to address equality issues for both staff and patients.
However, we expressed concern that EDS2 reports do not tell us the impact various activities have had on improving the experience of different groups. Failure to collect demographic data means that CCGs are unable to determine the extent to which they are meeting the needs of different groups. We shared the key themes that we hear from individuals and groups with the protected characteristics as highlighted under the Equality Act.