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Case study: Patient and public involvement (PPI)

Dr Brian Fisher explains how co-production could create full patient and public engagement in commissioning decisions.

Dr Brian Fisher explains how co-production could create full patient and public engagement in commissioning decisions.

WHAT FULL ENGAGEMENT COULD LOOK LIKE – CO-PRODUCTION THROUGHOUT THE NHS

Co-production is the model by which public services can begin to prevent, address and provide solutions to social problems like crime and ill-health, understanding that this is only possible by providing a catalyst for citizens to broaden the range of what they already do or can do in the future. It means public services building mutual support systems that can tackle problems before they become acute. It means encouraging behaviour that will prevent these problems happening in the first place, and building the social networks that can make this possible. It means public services reshaping themselves to build the supportive relationships that can help people or families in crisis carry on coping when they no longer qualify for all-round professional support.

Increasingly looking outwards to local neighbourhoods to create supportive social networks, seeking out local energy where it exists to help deliver and broaden services, and seeing clients for what they can do, not just what they need.

This is how Dr Abby Letcher describes the impact on mainstream practice that the Community Exchange had on her own health centre outside Philadelphia:

"It is a fairly radical change, and it does challenge people's ethical and professional sense. But it has transformed the way we practise medicine. It has stopped us seeing our patients in terms of us and them, as if we were just service providers to people who are classed as ‘needy'. We are no longer looking at them as bundles of need, but recognising that they can contribute, and when you see people light up when you ask them to do so, it changes your relationship with them. The culture has changed. The relationships are different, deeper and more therapeutic than they are in the usual doctor's office.[1]"

Here is a picture of what such a system might look like. Most of these activities and relationships already take place somewhere in the NHS. They are scattered and sporadic, and they need to be systematised so that they become an integral part of the way the NHS does business.

Keeping people well

Practices would see linking with voluntary groups in their patch to be just as important as keeping up with their colleagues in the PBC group or reading the British Medical Journal. They would offer support to the residents group on their estate in their fight against damp, they would be in regular touch with the diabetes group and the Chronic Obstructive Pulmonary Disease group and the MIND group – listening to their ideas for improving services and in dialogue with them about ways in which patients could be encouraged and supported to follow best practice in treatment. Practices would see these as efficient ways of supporting self-care as well as places where feedback on services could be received and discussed.

The elderly will be looked after by a network of milkmen, neighbours, home hairdressers as well as community services and Age Concern. There will be outreach into communities to prevent falls, identify hypertension, and discuss hypertensive treatment with BME groups, for instance.

Local community development workers, jointly funded by the PCT and the local authority, would support existing and develop new groups as they became necessary. There may be allotment groups, arts-based groups, groups to prevent falls and engage the local community in raising awareness of cancer, all bringing a wide range of people together. They should use the PPGs as their hubs.

Public Health will be linked into this busy network of local support. They will be commissioned by the LA and will harness the expertise of the local Chamber of Commerce as well as the 3rd sector. The council will be using their approach to local democracy to ensure that all this participatory activity is brought together to bear on local issues.

Managing illness better

GPs will be using all this activity as referral points. Interventions are as likely to be referring to the diabetes group as to altering treatment. GPs will be referring people to Time Banks, they will be using social prescriptions.

All patients will have online access to their full GP record which will link them to a range of self-care facilities that are tailored to their needs and expertise. They and their families will understand what has already happened and what is planned for their care, they will be able to share that with anyone they wish and applications linked to the record will help them manage their own and their families' health better. They will be able to add (but not subtract) from the record which becomes co-produced.

Local groups would help the practice run group appointments where patients would be supported in taking more evidence-based decisions about their care, but also sharing ways of solving problems in their management of their own care.

Managing local services together – listening and responding

The practice based commissioning group would be run by a committee of professionals and elected patients. They, together with local PPGs and other members of the PBC group and Public Health, would help plan the needs-based health and disease plans for the coming 5 years. There might be infrequent meetings with local people to check that these plans continued to meet the needs of the area.

Each practice would have access to a community development worker whose job it would be to maintain, develop and liaise with the community and 3rd sector groups relevant to the area and the disease prevalence of that patch. The CD workers would also be listening to issues raised by the community, transmitting these ideas and recommendations to practices and the PCT (or whatever will be commissioning or planning services). In addition, CD workers, where these ideas are widespread and backed by evidence, would be pressing, with the LINK, to get changes in services. CD workers will be seeing where they can work with the local community to increase the groups available to link people up.

Participatory budgeting will be commonplace across both Health and the Local Authority. Local people will be sharing in budgetary decisions.

Responding to the local community is complex. Issues are not bundled neatly into health, housing, social integration, immigration, crime, but are seen as linked. Responding to issues of crime raised by residents of an estate may benefit health, as people become more confident and able to tackle other problems themselves.

Increasingly, the design of services and their provision become co-produced.

Acute trusts

Hospitals, perhaps in conjunction with their Health Science Centres, would be also reaching out into the community supporting these groups with expertise and personnel because they know that such outreach offers health protection. Payment by Results will have been suspended, so all parts of the system can collaborate on prevention as well as treatment.

Dr Brian Fisher is a GP in Lewisham, south-east London, and NHS Alliance PPI Lead

Dr Brian Fisher

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