CS/14/11
16th June 2014
Health and Wellbeing Scrutiny
Health and Wellbeing Scrutiny Committee
People's Scrutiny Committee
Voice of the Vulnerable
Spotlight Review
|
CS/14/11
16th June 2014
Health and Wellbeing Scrutiny
1. Recommendations
The spotlight was established to ask: How can scrutiny be sure that it hears the voice of vulnerable people in Devon? The recommendations support the achievement of this aim and the spotlight review commends them to the Health Scrutiny Committee and Cabinet to endorse and take action.
|
| What does this mean? | How can this be achieved? | Measure |
| Hear | Develop the right conditions to hear vulnerable people. | 1. Members to take ownership of the scrutiny briefing sessions, developing a comprehensive programme of topics and regularly attending, to include training on data. 2. Awareness of who produces what information and when, and what this means. | Briefing session programme and attendance
Develop a clear system of intelligence with information coming from partners and going to them, to help to resolve the barriers identified.
Clear oversight of witnesses invited to speak to scrutiny.
Evaluated by Chairs and Vice Chairs group.
Evidenced in Annual report and action taken by Chairs and Vice Chairs group. |
| Share | Create an environment of trust to enable collaboration with partners whilst still being a critical friend. | 3. Scrutiny Members to improve links with partners including Health Watch, the two CCGs, the CQC, Social Care and Providers. 4. Scrutiny to work with partners to determine what information it receives from whom and when ultimately what insight is needed? | |
| Understand | Monitor, evaluate and review outcomes achieved with a clear evidence base. | 5. Scrutiny to ensure that it receives balanced information, and that it is hearing both sides of the story particularly in task groups. 6. Scrutiny to use data trends to evaluate outcomes for the people of Devon and be informed to ask the right questions. 7. Scrutiny to have input into the Strategic Plan for Devon County Council. | |
| Act | Take responsibility for the health and care of the people of Devon. | 8. Scrutiny to develop arrangements to effectively hold commissioners to account 9. All members to have crib sheet of what to do with complaints or concerns. |
2. Introduction
2.1. Devon County Council scrutiny has been considering the Francis report for many months. In particular it has looked at how to embed the challenges raised. Out of 290 recommendations made, four are specifically aimed at Local Authority Scrutiny (Appendix 1) but it is the intent behind these recommendations that pose the real challenge.
2.2. The consequences of failing to listen to and use the voice of patients and the public were never more forcefully presented than in the Francis report. The failings at the Winterbourne View hospital were in part caused by warning signs not being picked up or acted on by health or local authorities, and the concerns raised by a whistle blower going unheeded. The Keogh review examined the quality of care and treatment provided by hospital trusts with persistently high mortality rates. The views of staff and patients played a central role in the overall review and the individual investigations.
2.3. Taking on board these considerations, the spotlight review gathered councillors from the Health and Wellbeing scrutiny committee and the People's scrutiny committee together with stakeholders including officers, Public Health, NHS Commissioners and Providers, the CQC, Health Watch and third sector organisations. For a complete list of witnesses see section 10. The collective aim of the review has been to ensure that the Council's scrutiny role is robust in hearing the voice of vulnerable people. To do this scrutiny must manage the competing demands of maintaining overview whilst also ensuring accountability.
3. Hear
3.1 The first consideration that came from the discussion was that scrutiny must create the right conditions to be able to hear concerns from the public. There are a number of facets to this, but essentially each committee should consider how it is enabling the right conditions to be able to actively listen.
3.2 The spotlight review came up with some suggestions as to how this might be possible:
Challenge assumptions; 'who does scrutiny need to hear?' this is an interesting element as preconceptions of 'vulnerability' may colour any response to them. The spotlight review did discuss this angle and determined that absolutely anyone can be vulnerable.
Reach further; there are groups that rarely or never engage with our services and their voice is largely invisible. For example older people in residential care homes, children in care, the homeless. All agencies need to get better at considering the voice of the invisible.
Create the right environment; both in committee and task groups there is a difference between making individuals accountable and conducting an interrogation. If the committee is able to hear bad news it is much more likely to be able to act. This is in stark contrast to a culture where only good news is presented because officers and organisations are reluctant to share negative messages.
Ask the right questions; which sometimes can be the really basic ones why do we do this like this? The Councillor's mandate comes from the ballot box, not schooling in a particular service area. Developing an understanding of how services work is important, but maintaining the independent overview is paramount.
4. Share
4.1 Scrutiny can only be as effective as the intelligence it receives. The process of receiving information however must be an active one. This means that scrutiny and the organisations it is scrutinising must work collaboratively to best analyse and interpret data.
4.2 This process goes far beyond the criticism of Francis that councillors were passively receiving reports in committee and instead conceptualises dual responsibility for meaningful information both at the feet of the committee as well as providers and commissioners. In practice this means that scrutineers should be actively seeking out information more regularly than receipt of quarterly performance reports at committee. Some work has already been done on this with enabling access and providing member training on the Council's performance system spar net. Informal evidence gathering through conversations, monitoring of trends, following press reports all contribute to building a picture of the landscape.
4.3 This spotlight review should be one step on the journey to the meaningful interpretation of information for scrutiny. The review discussed at length the significant amount of information that is already collected; the issue is not about creating different channels of collection, but about how data can become insight. To begin this process the spotlight review asked partners in the room to catalogue what information is currently collected.
What data exists?
4.4 The spotlight review gathered a fairly comprehensive list of channels of information flow and collected them by agency:
| CCG | Safeguarding information |
|
| Incident information |
|
| Audits |
|
| Monthly assurance meetings with providers, KPIS dashboard |
|
| Daily safeguarding reports |
|
| Month sats |
|
| PALS |
|
| 'live chat' on web |
| DCC | Patient Participation Groups (PPGs in GP surgeries) |
|
| Complaints |
|
| Annual social care surveys |
|
| Safeguarding referral data/ data flow to from NHS |
|
| Education |
|
| consultation |
| Health Watch | 'speak outs' |
|
| Tailored information gathering |
|
| Consumer champion |
|
| National reporting systems data sets |
| CQC | Care home sector concerns |
|
| Hospital reviews |
Is this the right data?
4.5 Having established the breadth of information collected by partners in the room the spotlight review then discussed whether this was the right data and what considerations should be applied to it. The challenge for scrutiny is to receive intelligence to enable the function to accurately hold to account the Cabinet and the NHS. Barriers to the effective use of data block this from happening and inhibit scrutiny's ability to be as effective as possible. Access to information is the first challenge, whilst identifying that there is a wealth of data collected, this needs to be accessible in order for it to have meaning.
4.6 There are of course organisations who were absent from the room who scrutiny may wish to analyse data from, for example Ofsted.
4.7 When considering data there is usually a predilection for numbers based information with the inference that large numbers equal reliable data. However qualitative information can be just as meaningful and at times more useful to scrutiny recommendations. It is paramount that individual experiences are not dismissed as anecdotal, whilst being clear that scrutiny has no mechanism to resolve or examine complaints. The spotlight review thought that it would be useful to issue guidance to all members on the correct agency to go to when concerns were raised.
4.8 The most important point is that data needs to be turned into intelligence. The information needs to tell a story about whether the action carried out is effective or not. The spotlight review did not go into detail mapping the pathway of data collection, analysis and dissemination. There was consensus on the need to ensure accurate data collection with a focus on outcomes. We need to be measuring the impact and the change created by our initiatives rather than whether the initiatives have been carried out.
4.9 The risk register on performance reports can really help highlight not only attainment against a particular project or initiative, but how high the level of risk of not doing it is. This type of intelligence is particularly insightful to enable scrutiny to monitor Council wide initiatives as well as to determine where further investigation can add most value.
Culture
4.10 The culture of collaborative working between councillors, officers and other organisations is very important for the successful identification of trends and issues, but relies on 'open reporting' within each organisation. This means areas that are reporting to scrutiny being completely transparent and not seeking to 'put the best foot forward' particularly in public meetings.
4.11 The spotlight review also identified the need for more robust mechanisms to register concerns or complaints. In the NHS setting both patients and staff can be inhibited from sharing their poor experiences for fear of reprisals. As a cultural issue transparency can only be achieved if organisations welcome what users and staff have to say.
4.12 Scrutiny needs to have confidence that it is seeing the right things, it is suggested that the best approach to achieve this is triangulation of data. For example, scrutiny gathering information from the CQC and Health watch on a specific issue should help to identify if there is a concern with a service area. Trend analysis can also be monitored and pulled together where there concerns have been identified. The spotlight review suggested that the CQC five questions might help consideration:
Is it safe?
Is it effective?
Is it caring?
Is it responsive to people's needs?
Is it well-led?
4.13 The ideal situation to reach is a desire to find joint solutions to the challenges that affect the public sector. This does not always happen, but a good example where an evidenced-based investigation has then been embedded into NHS policy is the work undertaken by the Community Hospitals Task Group.
4.14 The conclusion from this section is then that there needs to be a systematic mechanism for knowledge transfer and sharing of information between and within organisations. Scrutiny needs to be assured that they can trust the interpretation of the information in a meaningful way to gain a balance of data overload and effective overview.
5. Understand
5.1 Having created the right conditions, pathways and relationships to receive information, scrutiny then needs to ensure that it is drawing the right conclusions from the intelligence. This is more likely to be meaningful if the data is based on the achievement of outcomes. Scrutiny can then contribute to policy development rather than a reactionary interrogation of why initiatives have not happened.
5.2 Information can be factually accurate but be misleading. For example, the spotlight review heard of a sexual health clinic in Devon reporting a 300% rise in gonorrhoea in one year. In fact the previous year there had been no diagnoses and in the year measured there were 3 people diagnosed. However looking at the accurate percentages this could give a very different conclusion.
5.3 Understanding the meaning behind data and experiences is essential for the committee to build up a clear picture of the service and situation. Part of this understanding must be a triangulation of qualitative and quantitative data.
5.4 Collection of data should not be a tick box exercise but this depends what we are measuring. We should be looking at impact and outcomes from intervention or services. Data should not just be looking at whether or not we have done a specific action. Public Health has made significant progress in this area as they have a tradition of working in an evidence-based way.
5.5 Whilst scrutiny does consider information and trends in the committee setting, for the most complex issues other avenues can be utilised.
Briefings
5.6 All scrutiny committees now have briefing sessions in the morning before having a committee meeting in the afternoon. This relatively new initiative aims to enable Members to gain in depth insight into service areas or skills that they would not otherwise have done. The committee meetings remain active places for scrutiny.
Task Groups
5.7 Task groups or spotlight reviews remain the primary way in which scrutiny will be able to hear the voice of the vulnerable. The task group consideration of different types of evidence might look something like this:
5.8 The spotlight review was particularly interested in the work of the performance team in developing interactive programmes to aid members in the analysis and prioritisation of intelligence and awaits the outcomes of this work with interest.
6. Act
6.1 Having created the right conditions to be able to know what the issues are the responsibility then lies with the Councillors to take action. Measuring performance or data in isolation has no impact on improving services. What is done with the data might have. Scrutiny committees being actively empowered to use information to identify issues and then conduct more in-depth investigations is one route. Another is making recommendations to Cabinet or partners to take action, and demonstrate public accountability.
6.2 The best practice model of scrutiny involvement would be maintaining an overview of the strategic issues, with a clear awareness of areas of good practice and those where the service needs to improve. This enables local Councillors to conduct task group investigations to support the improvement of services, listening to service users as well as professionals. Local authority scrutiny has limited powers to intervene in services; however agenda setting and policy direction are within its compass.
6.3 Health scrutiny should also be informed of any substantial variation in services and has maintained the power to refer issues to the Secretary of State on issues of process when local resolution has not produced successful outcomes.
7. Conclusions
7.1 The Francis review provoked a significant challenge to public organisations involved in providing, commissioning, evaluating and improving health care throughout the country. Local Authority scrutiny was specifically criticised for a lack of oversight and rigor in holding NHS organisations to account.
7.2 This spotlight review is the culmination of two scrutiny committees' consideration of how they can hear the voice of vulnerable people and maintain an active challenge to themselves. In order to ensure that the work of scrutiny is as effective as it possibly can be. This review has demonstrated that if scrutiny is only there to act as a backstop when other agencies have failed then there is a significant problem. For it is only by working with other agencies and sharing information that scrutiny can identify and work in partnership to improve areas that are underperforming.
7.3 The review does not present a conclusion to this work but challenges members, scrutiny committees and the chairs and vice chairs group to continue to actively take responsibility for listening to vulnerable people and taking action accordingly. The challenge is also laid at the door of the County Council the NHS and other partners to work with the mechanisms of democracy to help develop services from a person centred perspective.
7.4 This review raises significant questions about what good scrutiny looks like, and how other agencies might judge it as effective.
8. Membership
The spotlight review was jointly chaired by Councillor Sara Randall Johnson, Chair of the People's Scrutiny Committee and Councillor Richard Westlake, Chair of the Health and Wellbeing Scrutiny Committee, there was an open invitation to all members of the Council and the following members were in attendance:
| Councillor Roy Hill |
| Councillor John Berry |
| Councillor Alan Connet |
| Councillor John Hone |
| Councillor Julian Brazil |
| Councillor Alistair Dewhurst |
| Councillor Debo Sellis |
| Councillor Andy Hannan |
| Councillor Olwen Foggin |
| Councillor Gaston Dezart |
9. Contact
For comments or further information regarding this report please contact
Camilla de Bernhardt, Scrutiny Officer
Camilla.de.bernhardt@devon.gov.uk
01392 38314
10. Sources of evidence
Expert Witnesses
The spotlight review heard testimony from a number of people and would like to express sincere thanks to the following for their involvement and the information that they have shared as well as to express a desire of continuation of joint work towards the fulfilment of the recommendations in this document.
|
|
|
|
|
|
| Ed Coutts | Be Involved Devon |
| Marjorie O'Sullivan | CQC |
| Keith Bowden | DCC Improvement Officer |
| Paul Giblin | DCC Involvement Manager / Senior Involvement Officer (Social Care) |
| Lucy Knight | DCC Performance & Strategy Project Manager |
| Simon Chant | DCC Public Health Specialist (Intelligence) |
| Elli Pang | Devon Health & Social Care Forum |
| Maria Kasprzyk | Devon Partnership NHS Trust |
| Revd Peter Brain | Health & Social Care Forum |
| John Rom | Healthwatch Trustee |
| Lorna Collingwood Burke | NEW Devon CCG |
| Martin Cordy | Safeguarding lead NEW Devon CCG |
Documents/Links
http://www.devon.gov.uk/loadtrimdocument?url= ilename=CS/13/37.CMR&rn=13/WD1182&dg=Public
Appendix 1: Specific recommendations for council scrutiny
The recommendations can be found in Chapter 6 of Volume 1 of the Francis Report (page 481)
43 - Those charged with oversight and regulatory roles in healthcare should monitor media reports about the organisations for which they have responsibility.
147 - Guidance should be given to promote the co-ordination and co-operation between local Healthwatch, Health and Wellbeing Boards, and local government scrutiny committees.
149 - Scrutiny committees should be provided with appropriate support to enable them to carry out their scrutiny role, including easily accessible guidance and benchmarks.
150 - Scrutiny committees should have powers to inspect providers rather than relying on local patient involvement structures to carry out this role, or should actively work with those structures to trigger and follow up inspections where appropriate rather than receiving reports without comment or suggestion for action.