CCGs need to engage the public in the commissioning and not get bogged down with models and processes, says Jonathan Fisher. Foundation trusts provide a useful template
In the last 14 years, a wave of policy reforms has aimed to increase civic engagement in the public sector. Starting with the 1999 and 2000 Local Government Acts that called for increased consultation and public involvement by local authorities, this series of reforms has turned service provision on its head. Whereas once there was only top-down decision making, a collaborative effort is now expected so decisions come to reflect local preferences and choices.
Currently in the crucible are the new clinical commissioning groups, which need to find ways to engage meaningfully with patients, carers and their communities while working to improve performance and efficiency. Luckily for commissioners, there are advantages to being “late adopters” as there are tried and tested engagement models they can look to for guidance. The foundation trust sector provides a particularly instructive example and drawing out the key lessons is the aim of this article.
To begin, it is useful to consider why public organisations should engage. Keeping this front of mind will enable commissioners to remain goal-oriented and help them to separate good practice from bad. With these goals in mind, the FT model can be unpacked and evaluated. These arguments can be summarised as:
- Improving effectiveness By tapping into service users’ insights and taking account of their needs and preferences, public organisations can improve quality and efficiency.
- Fulfilling citizens’ rights Citizens, as the ultimate “owners” of the public sector, have an inherent right to hold providers of public services to account.
- Improving society Public organisations have a role to play in the democratic process and building a cohesive society by creating spaces for public expression and giving a voice to marginalised groups.
At the base of the model is a trust’s “membership”, comprised of patients and/or lay members of the public and staff. Its purpose is to serve as a “citizen’s panel” through which the trust can involve and access the views of the community, its patients and its staff. Above the membership sits the “council of governors”, comprised mainly of representatives elected from and by the trust’s membership, plus a smaller group appointed by key stakeholder organisations.
Its purpose is to represent the interests of stakeholder groups; advise the trust board on its strategic direction; hold the trust to account for its performance in meeting the terms of its authorisation; and to perform various statutory duties, such as appointing or removing the chair and non-executive directors.
‘The difference in engagement comes down to the spirit in which the model is implemented’
This model has several advantages. First, forging ongoing relationships with members lowers costs as trusts do not have to recruit fresh participants for each involvement exercise.
A “ready pool” of interested members is also more likely to be well informed and interested than a random selection of patients, and membership provides opportunities for individuals to arrange themselves into groups focusing on particular issues. Members can also provide comparable feedback on how the trust is progressing towards shared goals over time.
The main advantage of the council of governors is that it enables oversight of the board of directors and enables stakeholder groups to influence decision making at the highest level. As most governors are elected, legitimacy and accountability is added to trust decisions.
Our group of businesses has encountered all kinds of examples of the FT model in practice. We have observed that while most trusts achieve meaningful levels of engagement, some are less successful and, more often than not, the difference comes down to the spirit in which the model is implemented and the degree to which the goals of engagement are kept in focus. The following hypothetical examples illustrate the point:
A “real engagement” foundation trust has fully capitalised on the advantages of the model while remaining true to the ultimate goals of public participation. It makes regular use of its membership, ensuring that members are informed and involved. Involvement is seen as paramount and their approach is to go beyond consulting members on internal decisions, to empower and collaborate with members to develop and decide on alternative courses of action.
The trust does not rely on a “one size fits all” approach. It uses its membership data to identify groups that may have key insights, and develops involvement exercises tailored to each audience and purpose.
For example, the trust might use focus groups, workshops and exercises to understand patient experiences around a specific service and explore users’ proposed solutions to related challenges. The trust also realises that membership should not be a closed circle as it provides just a sample of views. It constantly seeks to identify marginalised groups and bring them to the table.
‘Whatever model commissioners ultimately choose, they should not allow this to become a straightjacket’
The trust views governors as a resource, taking care to involve them frequently and appropriately. The trust facilitates governor interactions with lay members so that they become a true voice for the community; such as by setting up ways for members to “contact a governor”, or by putting governors in hospital wards to recruit members and speak directly to patients about their experiences.
A “tokenistic engagement” foundation trust has lost sight of the goals of participation and has become process-oriented rather than outcomes-focused. It views its end-of-year reporting as the “guiding star” for its membership and focuses its resources on engineering a sizable and representative membership, while neglecting engagement.
When it does “engage”, the trust places more emphasis on informing than involving and, as a result, does not learn or change in response to the needs and priorities of its members.
The trust views governors as a threat rather than a resource and avoids involving them in any activities beyond the minimum requirements. The trust does not facilitate interaction between elected governors and the people they are supposed to represent. Though elected by a democratic process, the council of governors is at odds with democratic principles as this becomes a conduit for the views of the few rather than the many.
A spirit of participation
The FT model provides useful lessons for CCGs, not least is that the groups can usefully consider the use of a membership and elected lay representatives to achieve meaningful engagement. This is a model that works and offers many advantages when properly implemented.
The key lesson, however, is that the model used is of lesser importance than the spirit behind implementation and the degree to which commissioners are guided by the goals of public participation. This in turn calls for enlightened leadership and a critical approach to engaging the public, especially when commissioners are on the lookout for best practice examples to follow.
Whatever model commissioners ultimately choose, they should not allow this to become a straightjacket. They should stay focused primarily on the reasons as to why they are engaging in the first place, rather than on the logistics of the models, processes or practices they adopt.
Jonathan Fisher is associate consultant at Membership Engagement Services, a subsidiary company of Electoral Reform Services