Lighthouse Medical Practice, Eastbourne, East Sussex
Amanda joined the NHS in 2004 after more than 15 years in international retailing. She is now Business Partner for the Lighthouse Medical Practice, a 15,000-patient GP practice in Eastbourne. Amanda is also a Business Management Lead for the Eastbourne Central Commissioning Consortium, and works in partnership with her local PCT to set up extensive patient networks. She has worked closely with the NAPP and has been a member of the NHS Alliance Practice Managers' Steering Group. Her extended portfolio includes public speaking at conferences on a variety of subjects, including patient and public involvement, leadership and business management
Retail industries spend millions of pounds every year in order to find out what their customers want, need and aspire to. They do this to increase their market share, retain a loyal customer base and thus achieve profit.
This is attained through an involved and costly process of market research, customer focus groups and talking directly to customers/service users. As Steven Ballmer, the chief executive officer of Microsoft Corporation since 2000, has said:
"We can believe that we know where the world should go. But unless we're in touch with our customers, our model of the world can diverge from reality. There's no substitute for innovation, of course, but innovation is no substitute for being in touch, either."
So, why is it that with more than 10,000 GP practices in the UK, the National Association for Patient Participation (NAPP) has in the region of 400 members? As practices in a modern NHS, we now need to sit up and take action and realise that "society is changing; we now live in a post-modern, consumerist world. Patient consumerism is endorsed by current political attitudes, which support immediate access to healthcare."(1)
The view from the top
Since the 2000 NHS Plan, the government has been committed to a health service designed around the patient.2 Indeed, in all the Labour government's key publications, the views of patients have been cited as the key to reform and service redesign.
The Plan says: "Patients are the most important people in the health service. It doesn't always appear that way. Too many patients feel talked at, rather than listened to. This has to change … patients must have more say in their own treatment and more influence over the way the NHS works."(2)
Further documents, including the 2006 white paper Our Health, Our Care, Our Say, emphasised the need to give people greater choice and control over the services they use: "When people get involved and use their voice, they can shape improvements in provision and contribute to greater fairness in service use."(3)
In 2003, a duty was placed on local authorities to involve and consult people when it comes to making changes to services. The changes to the law introduced by the Local Government and Public Involvement in Health Act 2007 made this clearer, and a strengthened "duty to involve" came into force on 3 November 2008.(4) This requires NHS trusts, primary care trusts (PCTs) and local authorities to involve service users in:
Under the updated law, organisations must also have regard to any government guidance that explains how they should discharge the involvement duty. A 2008 Department of Health (DH) guidance document focused on supporting local discussion and raised awareness about the NHS duty to involve patients in commissioning.(5)
Last year, the 2009 NHS Constitution made it clear that patients have a right to be involved in planning and developing services provided by the NHS.(6) There is no doubt that the time is right for practice managers and patients to work together.
The key to successful PPG engagement
All successful businesses have key elements that work together to provide a quality responsive service. General practice is no different to any other business and these key elements are:
With these three elements working together, it becomes possible to make sound and informed decisions. But these decisions cannot be effectively made without the support of patients.
Why aren't PPGs in every practice?
Why does NAPP have just over 400 members? While innovation and dedication to patient participation do exist in pockets of surgeries around the country, and not all practices with patient participation groups (PPGs) will necessarily be members of NAPP, it is obvious that patient involvement in GP practices is not as widespread as it should be. We should be asking ourselves why frontline surgery staff are so frightened of engaging in meaningful dialogue with patients.
Is it because a culture of criticism and blame has developed in the NHS and been built up by the media, leaving frontline staff feeling vulnerable? Another possible explanation is that it is not uncommon for organisations to struggle with the concept of involving users (in this case the patients) when there is no financial incentive to do so. Unlike commercial organisations that are constantly vying for market share, GP practices have ready-made customers lists.
Furthermore, practice managers, or their employers, may not see helping to establish and sustain a PPG as a priority in the target-driven, everyday business of managing a practice, where the Quality and Outcomes Framework, annual reviews, enhanced services, staff, employment law, health and safety and premises are just a few of the many daily priorities. To review practice culture and rethink the way a practice works requires a change of priority and a change of culture, as well as financial support from the partners.
It is understandable then that some practice managers may simply be overwhelmed and not know where to start. However, managers should appreciate the added value that working with a PPG can bring to the business. Patients will have skills, knowledge and talents that can be used constructively for the benefit of the practice and its patient population, and this will vastly improve the quality of services and may even reduce workload for staff.
What can a PPG do?
A successful PPG is about regular and meaningful communication between practice staff and patients. This will provide an opportunity for the practice to explain to patients the reasons why services have been set up in a particular way and why certain procedures are carried out, as well as to listen to the views of patients. Once all views are heard and understood, a mature discussion can take place with the opportunity to change practice and procedure.
A PPG could look at:
Who do you need in your PPG?
In a responsive PPG, patient members can become involved in the wider health community by becoming members of PCT and strategic health authority committees, as well as play a role in commissioning.
Developing your PPG
A proactive practice should gradually allow the PPG to develop. The ultimate aim is for the PPG, not the practice, to lead and for the PPG to be involved at the instigation and planning stages of systems and services, rather than solely feeding back once plans are in place.
This requires careful planning to ensure that while letting go, the practice still maintains an active interest, with representatives attending PPG meetings and remaining active partners. For this to happen there needs to be mutual trust and respect.
So what can PPGs achieve?
In Eastbourne, the formation of a PPG at the Lighthouse Medical Practice has brought about a huge cultural shift from an "us and them" scenario to a united team of patients and practice staff working towards a single vision. They exist as one and the same and are there to help and support one another. Our PPG has developed into a living, breathing part of what makes the practice work, and is an integral part of daily practice life. Our PPG members:
The PPG is financed by the surgery, but the total cost has been no more than a couple of hundred pounds over the past three years for things like hire of halls and printing of leaflets. However, the PPG is looking at fundraising as a way to have more money available in the future.
The PPG is a precious resource for the whole practice team. Members have not only taken day-to-day tasks off busy staff, but have also filled the gap between what the practice perceives patients need and the reality of their actual needs.
Working in partnership with patients
Working in partnership with the people who use your services also offers potential to bring about significant change in the relationship between doctors, staff and patients, and in the redesign of services for the benefit of patients.
Practice managers can use both the GP Patient Survey and the forthcoming revalidation of all doctors to take back control. While practice managers can't influence the contents of the Patient Survey, they can influence the results by working with their patients.
Revalidation will require practice managers to encourage GPs to continue with patient surveys, so that evidence-gathering continues and that a proper reflection of the results is embodied in the annual appraisal.
Problems with PPGs
Of course, not all PPGs are successful and it is important to acknowledge why this is and what managers can do to try and avoid the failure of a group. Table 1 sets out real examples of why some PPGs have failed, together with possible solutions to these problems.
Future challenges for practice managers
The role of the practice manager is becoming increasingly challenging as a result of national policies to promote choice and competition within primary care. Demographic changes are occurring in many areas of the country, with increasing numbers of older people and those with long-term conditions, as well as greater ethnic and linguistic diversity. Added to this, of course, remain major public health challenges such as obesity and drug and alcohol misuse. Effective practice management now needs to be able to see the bigger picture.
From 2011, practices will have to meet 16 essential standards of quality, safety and registration with the Care Quality Commission. How can a practice manager successfully achieve accreditation without the support of a PPG?
Practice managers are achieving excellent work in forging strong links between practices, patients and even the wider community. But now is the time to spread this to every surgery in every town. The benefits of PPGs will take time to filter through. However, with the foundations in place, practice managers, their surgeries and patients will see significant changes and improvements.
PPGs can help forge links with the wider community, promote healthier living and greater health awareness, recognise the needs of carers and manage change in a way that generates confidence among both staff and patients. Services may come and go, change and adapt, but practices will always have patients. Invest in the future of primary care and in a patient-led NHS.
1. Section 242, Health and Social Care Act 2006.
2. Department of Health. The NHS Plan: a plan for investment, a plan for reform. London: DH; 2000.
3. Department of Health. Our Health, Our Care, Our Say: a new direction for community services. London: DH: 2006.
4. OPSI. Local Government and Public Involvement in Health Act. Available from: http://www.opsi.gov.uk/acts/acts2007/ukpga_20070028_en_1
5. Department of Health. Real involvement: working with people to improve services. London: DH;
6. Department of Health. The NHS Constitution for England. London: DH; 2010.