Thursday, July 23, 2009

The make-believe world of consultation

Last weekend I was invited, along with 70 odd other random members of the public, to a consultation event with the local PCT over the priorities for future healthcare in Sheffield. As usual I could not refuse an opportunity to put the world to rights. A free lunch and £50 "expenses" was only icing on the cake.

But what did the PCT get for its, er, your money?

After the introductory speeches and getting-to-know-you gubbins, session 1 was on the subject of improving the patient experience.

On my table, the three main issues raised were i) the difficulty of making appointments ii) access to the latest high-tech medicine and iii) cleanliness. Our discussion had to be distilled into a top three, then a top one bullet point, which would be fed to the factilitators to be further distilled, along with summaries from other tables, and then voted on with radio keypad things.

Our demand, to be able to make appointments at all/reasonably soon/without having to argue with receptionists even when the doctor has told us we will need to make an appointment for such and such a symptom - was thus "distilled" into a demand for Saturday surgeries - that none of us had asked for - but was clearly already on the PCT agenda.

Session 2 was about how to measure patient satisfaction. What sort of surveys should the PCT be sending out to everyone, or should they be listening to complaints instead? Or perhaps clinical follow-up is better. Again our main points - that not everything needs to be measured, and that clinical outcomes are more important than more subjective measures - did not get past distillation. Of course PCT officials know how to interpret a survey whereby a patient reports 'very satisified/satisfied/neither satisfied nor dissatisfied/...' on each aspect of a service. It is something they can do. They don't know how to judge clinical outcomes. They might know how to measure less, but what would that do to the feeling of being in charge of a process you don't understand?

Session 3, after lunch, was probably the worst of the lot with various unrelated issues lumped together under the heading of patient safety! Should we address patient safety with more staff training? (So they don't make mistakes.) Or should we beef up building security? Or put better labels on drugs? Most bizarrely, IT systems were listed as an issue here - because of a potential threat to the safety of patient data - but the IT issue mutated into a rival positive claim for safety dollars.

Positive suggestions from the group: help for people who can't remember whether they've taken their pills or not, and measures to keep infectious swine flu sufferers out of waiting rooms, didn't make it through distillation. Instead we had a pointless debate over whether staff training was more important than properly maintaining the lifts.

The last session was on the criteria for deciding spending priorities. Not, please, anything specific, like mental health, or hip replacements, but general criteria. So we had the usual suggestion that smokers and drug users should be penalised, and that sort of thing. I suggested that clinical effectiveness should be the main criterion, thus cutting funding for chaplains, homoeopathy, ritual circumcisions, etc. I could have but didn't include PCT bureaucracy this time. And I suggested that we probably have too much campaigning for healthy living - that people who haven't got the message by now, probably won't.

This was the most useless distillation of all - it resulted in the following six options, which we then had to vote on:
1. Quality of Life
2. Education/prevention
3. Based on need
4. Improving efficiency
5. The cost of long term care
6. Value for money

What do these mean? Even the facilitator introducing the vote didn't understand quite what a vote for each would mean, although he graciously explained that every £1 spent on education would save £10 later. And so education won 45% of the subsequent vote. Apocryphal as it is, the £1/£10 figure may be right, although it is clearly an average and not a marginal cost - which means that any cuts or increases in education at the edges would have far far less impact.

But frankly every option but education/prevention was so abstract that we had could have no idea quite what would be cut and what would be funded if we supported it. Given one option that seems good, and 5 that don't mean anything concrete, it is not surprising that it scores highly.

The voting on the outcomes of session 2 was also pretty shocking. The idea of measuring less hadn't made it through distillation, and the prime importance of clinical outcomes wasn't offered as a clear option, and instead we had a choice of seven ways of measuring soft outcomes. The faciliator gave a patronising little speech about how you might think this was obvious - if you are treated and get better that is a good outcome - but now you realise there is a lot more to it than that. Next time I will interrupt and demand a vote on hard v soft outcomes.

Not that I'm saying soft outcomes don't matter - they just shouldn't be used to justify much expense or paperwork.

So the session is wound up with speeches telling us how useful this has been. We even voted on whether it was it a good idea to hold this consultation (97% yes) and would you come again (100% yes). We were told by one PCT official that the next time he was in a meeting arguing some corner or other he could say that the people of Sheffield were in agreement with him. Just look at the figures. This is what the PCT gets for your money. Ammunition.