Patients' big chance to call the shots

Vivienne Nathanson, director of professional activities at the British Medical Association. This article is based on her presentation at a Centre for Public Scrutiny debate on 1 February.

Involvement has never been more important. At a time when reconfigurations are rife and local services face crucial commissioning decisions, both deliverers and receivers of care have a right to be engaged in design and development.

Far from the image of an angry public clashing with health professionals over the latest local closure, if both parties work together they are more likely to move towards excellence in care.

Frontline professionals have clinical and scientific expertise, as well as years of direct experience with patients, collecting evidence of what works best. Meanwhile the public's taxes fund the NHS and they best understand what it feels like to be a patient. These complementary perspectives on clinical excellence and the patient journey can be powerfully combined in decision making, to produce more accountable and responsive services. There is greater understanding, as professionals inform the public about the clinical world and how best to meet patient expectations within the reality of delivery constraints.

Involving patients also improves health outcomes. Patients are more likely to comply with treatment if fully involved with professional decisions. On a wider scale, patient involvement can help reduce health inequalities, by informing patients and lifting some communities out of the 'poverty of expectation' they have of their health and healthcare.

So how do current systems live up to this ideal? There has been progress. Modern concepts of professionalism have contributed to high levels of trust between the public and clinicians. More recently, professional bodies have innovated with schemes such as patient focus accreditation and information kite-marking, to ensure the public is empowered in healthcare decisions.

However, despite the effort put into public engagement over the last 15 years, surveys still show that patients feel a disappointing lack of opportunity to work alongside professionals in guiding healthcare decisions.

Local and national consultations may seek views - but then ignore them. 'Patient choice' policies have had limited value for public involvement and accountability - and have often worsened inequalities as wealthy and educated people become the main beneficiaries. There is a lack of evidence to show foundation trusts are working as originally envisaged.

Local government overview and scrutiny committees (OSCs) can, as democratically legitimate representatives acting in the public interest, help balance differing public and professional opinions about healthcare provision. However, they have few formal powers to enforce recommendations, and some members' lack of health expertise can be seen as a disadvantage as well as an advantage.

However, we may have reached a watershed, with the Local Government and Public Involvement in Health Bill now before Parliament. It seeks to establish local involvement networks (LINks) and formalise their relationship with OSCs. There will be one LINk per social services authority area, replacing the current patient and public involvement forums. These LINks will be able to inform the NHS, social services departments and OSCs on public and user views on health and social care services.

This provides a concrete way for an informed public to show professionals what the patient journey feels like across organisational boundaries.

The bill also requires primary care trusts to show how they have responded to the views of those they consult. If this were replicated across the healthcare system, engaging the public and healthcare professionals would become more than a tick-box exercise.

However, LINks' contribution to such a system will be limited if key issues around representation, capacity and resources are not resolved. The task of collecting real opinions can be complex and time-consuming, especially if traditionally excluded communities are to be reached. Representation should also be genuinely democratic and not limited to the usual suspects.

Most of all, LINks must be given the time and capacity to become properly effective and not be
under-resourced or interfered with.

Equally, health professionals must try to ensure they make patients equal partners in care. They should think carefully about the information the public needs and how to communicate this. They should inform themselves better on how services appear to the patient, for example by understanding what other clinicians on their team do and how they can work better together to enhance the patient journey.

Finally, they should react flexibly to the patient voice. If professionals cannot persuade the public that a change is beneficial, they need to think again about their argument and how they are communicating it.

Perhaps the greatest challenge is for professionals to acknowledge - and meet - their duty to engage with and listen to those who are neutral. In terms of achieving the right outcome for patients and clinical excellence, this could pay the greatest dividends.

Jessica Crowe, executive director of the Centre for Public Scrutiny (www.cfps.org.uk).

You are a director of public health. You have been advised that putting fluoride into local water supplies will be a powerful tool against child tooth decay. Yet only under-18s will benefit and, while evidence suggests older people will not be harmed, there is loud protest from some sections of the community.

Balancing conflicting demands like these will be crucial as the public health environment becomes further characterised by preventive care, joined-up services and a stronger public voice. So who can help you to balance professional and public accountability and ensure services are geared to provide the best public health outcomes?

Overview and scrutiny committees (OSCs) are showing great potential as an 'honest broker' between such interests. They may have been put on the map by their powers to refer controversial reconfigurations to the health secretary, but can also add real value during difficult service developments. By bringing together patients, the public and professionals, OSCs can gather evidence from these equal but different perspectives and weigh up the merits of various approaches.

This is a difficult task - the old cliche of 'comparing apples with pears' applies when considering how an OSC can compare statistical data from clinical trials with the passionate plea of a patient for better local facilities.

However, OSCs are ideally placed to do so, given that their elected status lends them legitimacy, while their 'non-executive' status frees them from the politics of decision-making.

This gives them a unique ability to be genuinely public-minded, taking an overarching look at how public health is affected by services, and how professionals can work together to improve them.

Vivienne Nathanson discusses the need for greater public engagement. OSCs are increasingly facilitating this by gaining a high profile in public and in the press. They are using innovative mechanisms to ensure both the marginalised and neutral are heard and alerted to public health issues. One OSC held a workshop for patients with dementia, using a theatre company to creatively consult with them on ongoing service developments.

Other OSCs have joined with PCTs to hold awareness days on issues such as breastfeeding
and smoking. Such activities can ensure greater access to accountability mechanisms. Mrs Patel, waiting in the rain to see her practice nurse in inner-city Leicester, needs to know how to influence the local system.

Additionally, OSCs' cross-cutting nature can ensure each public health issue is increasingly examined in terms of its entire impact on patients. Professionals may know how to ensure the care they offer is gold standard, but what if patients cannot reach their hospital, due to poor rural transport links or expensive car parking?

Health and well-being is affected by services such as housing, transport and leisure facilities, to name but a few. With their knowledge of such wider local services, OSCs can ensure clinicians are aware of the diverse realities of patients' lives.

With these issues being increasingly brought together under local area agreements, and OSCs able to hold diverse bodies to account, it will be necessary to ensure that the committees have the skills, information and capacity to give a meaningful voice to all involved.

However, if done well, this enhanced system can help both patients and professionals find their way through the new local service landscape and ensure both are responding to each others' needs.