1. The Engagement Cycle A new way of thinking about Patient and Public Engagement (PPE) in World Class Commissioning April 2009

3. 1. Introduction

5. How the engagement cycle was developed Introduction The engagement cycle has been developed by In Health Associates, on behalf of the Department of Health. It is based on work carried out with Croydon PCT. It has been developed and tested with national stakeholders and the following organisations: NHS Coventry, Dudley PCT, NHS Sheffield, NHS Suffolk, West Sussex PCT. Thanks are also due to all stakeholders who fed back or contributed to thinking about the e-cycle. See final slide.

6. The engagement cycle is a way of approaching Patient and Public Engagement (PPE) in World Class Commissioning. It is a representational model that highlights who needs to do what to engage patients and the public at each stage of the commissioning cycle. It can be used to facilitate improvements in World Class Commissioning, particularly concerning Competency Three - engaging with patients and the public. The engagement cycle is not a toolkit, but a starting point for thinking about PPE in commissioning. It provides checklists for action and will be developed to include links to policy documents, case studies, toolkits and other materials. It has been used so far to undertake assessments of who is doing what at each stage of the cycle, to help develop action plans, identify learning and support needs and as a a basis for PPE strategies and organisational development plans. About the engagement cycle Purpose

8. Primary Care Trusts (PCTs) need to become ‘World Class Commissioners’ , able to shift the NHS towards a more localised, personalised, responsive and accountable system. Competency Three of WCC states: “ PCTs are responsible through the commissioning process for investing public funds on behalf of their patients & communities. In order to make commissioning decisions that reflect the needs, priorities & aspirations of the local population, PCTs will have to engage the public in a variety of ways, openly & honestly. They will need to be proactive in seeking out the views & experience of the public, patients, their carers & other stakeholders, especially those least able to advocate for themselves.” PPE is part of other competencies such as working with community partners (Competency Two) & leading the local NHS (Competency One). PCTs need to fully engage and involve patients & the public as citizens in a dialogue about health needs, strategic planning, service design & decision making & communicate with them to increase understanding & confidence in using local services. Policy context (1) Policy context

9. The NHS Constitution states: You have the right to be involved, directly or through representatives, in the planning of healthcare services, the development and consideration of proposals for changes in the way those services are provided, and in decisions to be made affecting the operation of those services.. Section 242 of the consolidated NHS Act 2006 places a duty on NHS trusts, PCTs & strategic health authorities to make arrangements to involve patients and the public in service planning & operation, & in the development of proposals for changes. Real Involvement: working with people to improve healthcare provides guidance for PCTs and other NHS organisations to identify who they need to involve and what they need to do to deliver better involvement practices, to make sure the NHS is more locally accountable and shaped by the people who use it. World class commissioners will demonstrate their competence through having a coherent strategic plan underpinning their operational plan, Local Area Agreement (LAA), financial plan and workforce development strategy. Policy context (2) Policy context

11. A conceptual framework for PPE Individual My say in decisions about care and treatment Collective Our say in planning, design and delivery of services Information Feedback Influence

12. A conceptual framework for PPE Information Feedback Influence Individual My say in decisions about care and treatment Information to patients about treatments (comms) e.g. PALS, complaints e.g. Expert patient; advocacy Collective Our say in planning, design and delivery of services Information to citizens about services (comms) e.g. patient experience data (surveys, focus groups); consultation; Trends in PALS, complaints data; LINks Representation and involvement in decision making OUTCOMES OUTCOMES OUTCOMES

13. 2. The engagement cycle

14. The Engagement Cycle

15. The Engagement Cycle

16. The Engagement Cycle

17. The key PPE activities - Why & How… The engagement cycle

18. The Engagement Cycle

19. The Engagement Cycle Engaging communities to identify health needs & aspirations Commissioning organisations need to work with partners to engage communities in identifying their health needs and aspirations when developing strategic plans. This includes making sure community perspectives – people’s preferences, felt needs and expectations – are built into the Joint Strategic Needs Assessment (JSNA) and health needs assessments undertaken with particular communities. This means moving beyond a solely data-driven approach to needs assessment to one that is complemented by the views of those in the community. Overview

20. The Engagement Cycle Policy and practice guidance emphasises joint working (e.g. Local Area Agreements) PCTs need to be local leaders of NHS S242 requires involvement in planning and development Contributes to long term area-wide vision and strategies Contributes to enhanced public health programmes Provides new ideas for meeting unmet needs Highlights what services are needed, where and how to better deliver them Promotes joint working – externally and internally Promotes accountability by showing the reasons why actions are being taken Why – Rationale and benefits Engaging communities to identify health needs & aspirations

21. The Engagement Cycle Work together with all local partners (e.g. statutory partners, MPs, Health Scrutiny, Practice Based Commissioners, potential & current providers, Third Sector) Work with LINks Learn from needs assessment undertaken in specific areas Pool resources and bring together patient experience data trends, needs assessment and aspirations Focus attention on seldom heard groups where needs may be greatest and gaps in data common Work with intermediary organisations Engaging communities to identify health needs & aspirations How (1 of 2)

22. The Engagement Cycle Link with locality groups and neighbourhood management teams Build capacity for effective lay representation on Strategic Boards Adopt community development and participatory appraisal methods Understand customer insight techniques and drivers of behaviour. Utilise social marketing approaches Use public engagement exercises to reveal expectations and aspirations (e.g. Visioning, open-space, future search, whole-systems events, arts-based approaches) Engaging communities to identify health needs & aspirations How (2 of 2)

23. The Engagement Cycle Commissioning organisations need to engage with the public as citizens and taxpayers about the way resources are allocated in order to promote accountability and ensure services are planned fairly. This means having transparent processes by which decisions are made about prioritisation (e.g. what services are funded and what is not, how much is spent on which services), changes in services (i.e. that may require formal consultation) and long term commissioning strategies. Engaging the public in decisions about priorities & strategies Overview

24. The Engagement Cycle Statutory requirement for ongoing engagement Increased need for local accountability requires open and honest dialogue with local residents More robust decision making process can integrate different stakeholder perspectives Commissioning priorities and operational plans better reflect local aspirations Better decisions about what services are needed Contentious decisions based on informed and transparent dialogue Shared understanding of expectations, limitations, areas of consensus and tension Consistent two-way information flow between public and PCT with demonstrable impact of public feedback Improved reputation as local leader of the NHS through increased public confidence in local NHS decision making Engaging the public in decisions about priorities & strategies Why – Rationale and benefits

25. The Engagement Cycle Ensure outcomes from needs assessment and community aspirations work feeds into strategic planning and decisions about priorities Use this stage of the cycle to promote and develop ongoing mechanisms for dialogue with local people Engage with stakeholders (including the media) openly about decision making process and reasons for decisions Work closely with Health Scrutiny and LINks Be clear about the similarities and differences between formal consultation and ongoing or informal engagement Develop criteria and framework for thinking about different types of prioritisation decisions (e.g. evidence-based decisions to fund or not to fund treatment; decisions about commissioning priorities; reconfiguration) Engaging the public in decisions about priorities & strategies How (1 of 2)

26. The Engagement Cycle Do not rely solely on lay representatives on advisory or partnership boards as sources of expertise or to rubberstamp decisions. Learn from good practice in local authorities and other partner agencies Make sure the views of seldom heard groups are incorporated into decision making Consider approaches that ensure a cross-section of local residents are involved Consider deliberative methods (i.e. that allow people to deliberate on complex information and that allow people to rank priorities) Engaging the public in decisions about priorities & strategies How (2 of 2)

27. The Engagement Cycle Engaging patients in service design & improvement Overview Commissioning organisations need to work with partners – including service providers, potential suppliers, clinicians and frontline staff – to engage patients, carers and families in co-designing (or redesigning) services. Much good work in this area is being undertaken. But more needs to be done to build on, and bring together, previous PPE work and patient experience data. It is crucial that outcomes from PPE work at this stage is carried forward into developing standards and outcome indicators within contractual agreements.

28. The Engagement Cycle Why – Rationale and benefits Engaging patients in service design & improvement Improvements in access to, and quality of, services, patient experience, satisfaction and outcomes Better co-ordinated care across health and social care Helps ensure quality is at heart of commissioning Reduced level of complaints and increased positive feedback leads to improved staff morale Service improvements and re-designs accepted and owned by public and patients S242 requires engagement in service planning & design PCTs need to better use patient experience data Patient Reported Outcome Measures (PROMs) will be increasingly important and are in 08/09 operating plans PCT needs to be local leaders – leading service improvement that fully engages patients, carers and families enhances reputation

29. The Engagement Cycle Bring together existing patient experience data to help design services before embarking on new PPE work Ensure project initiation documents and business cases for improvement work include PPE and are resourced Align different initiatives (e.g. primary care redesign & client-specific pathway work). Use PPE as a trigger for breaking down silo working Work with local providers and potential suppliers – but be aware of conflicts of interest and procurement guidance Make sure clinical leaders, clinical and non-clinical staff are engaged in process Draw on good practice from service improvement initiatives Engaging patients in service design & improvement How (1 of 2)

30. The Engagement Cycle Learn from the many national and local examples of good PPE practice in pathway design Engage patients and carers in identifying solutions - not just about what’s going wrong or as subjects of research Engage patients in defining quality measures to be translated into contractual agreements and service standards Consider using a range of approaches - quantitative and qualitative (including stories, real time feedback, web 2.0) Think about how to capture and utilise the ‘1000s of everyday conversations’ at between staff, patients and carers Use one-off initiatives as trigger for sustained engagement Engaging patients in service design & improvement How (2 of 2)

31. The Engagement Cycle Patient centred procurement & contracting Overview Commissioning organisations need to ensure that the learning from service design and pathway improvement work leads to outcomes that can be used to set standards and outcome measures. In turn this can be used within contracts and service level agreements. Patients and the public can be actively involved in developing tenders, helping to scan for innovation, identify potential providers, participating in tender processes and panels and making decisions on resources.

32. The Engagement Cycle PCTs need to manage market and identify wider array of potential providers Service Level Agreements (SLAs) better reflect patient-centred indicators Focuses minds on identifying providers who can better meet needs of patients Performance metrics need to include more patient experience indicators Improved monitoring and performance monitoring flows from being able to specify outcomes that matter to patients Patient representation on tender evaluation panels leads to increased public confidence around providers Patient centred procurement & contracting Why – Rationale and benefits

33. The Engagement Cycle Ensure evidence of what matters to patients derived from service redesign work is part of standards, outcome indicators and specifications within contracts Engage patients and the public in identifying providers who can deliver innovative solutions (e.g. voluntary sector, social entrepreneurs, social enterprises) Engage voluntary sector networks in identifying social innovation Engage and support patients and public in procurement processes – in developing tenders and as part of procurement panels Patient centred procurement & contracting How (1 of 2)

34. The Engagement Cycle Make sure there is clarity about patient representation on panels - their role, terms of reference and training Consider creative methods (e.g. Dragon’s Den) in procurement decisions Consider participatory budgeting approaches that allow enhanced public decision making over resources Involve people in the appointment of staff Hold briefing events so that the wider public find out what is going on and about proposals being developed Patient centred procurement & contracting How (2 of 2)

35. The Engagement Cycle PCTs need to work with local providers to gather and use patient-derived data concerning outcomes and experience in order to monitor and performance manage providers. This means ensuring that contracts and SLAs that specify outcomes and quality are followed up by systematic methods to gather and use patient experience data and patient-recorded outcome measures (PROMs). Patients themselves can also be supported to monitor services and undertake review visits. Patient centred monitoring & performance management Overview

36. The Engagement Cycle Identifies what’s working and what’s not in terms of quality of, and access to services Ongoing patient-centred monitoring promotes learning for improvement Increasing emphasis on commissioning for quality and outcomes Generates better quality data to augment needs assessment and aspirations work Patient Reported Outcome Measures (PROMs) are included in this year’s Operating Framework Leads to more efficient monitoring and performance management Provides increased opportunities to improve services (e.g. though incentivising quality) Patient centred monitoring & performance management Why – Rationale and benefits

37. The Engagement Cycle Complement monitoring activity with regular meetings to discuss quality and outcomes Value and use patient-derived data (quantitative and qualitative) as much as routine data about activity Find ways to get timely patient experience data to those monitoring contracts Consider having patient representatives as part of regular monitoring meetings with providers Be clear about roles and responsibilities of commissioners and providers concerning who gathers, reports and uses patient experience data Adopt patient-centred methods for monitoring as well as patient-centred measures (e.g. Patient/user focused monitoring; Mystery shopping) Patient centred monitoring & performance management How (1 of 2)

38. The Engagement Cycle Work with LINks to ensure that data they have from visits to providers are incorporated into monitoring processes Develop ways to reward improvements in quality Consider real-time engagement via the use of hand-held patient experience equipment Utilise methods of online dialogue Find ways to empower clinical and non-clinical staff to gather and use data from everyday staff-patient contact Ensure that patient experience data gathered for monitoring processes are available to others (e.g. those planning needs assessments, priority setting, service redesign, etc). Patient centred monitoring & performance management How (2 of 2)

39. Customer insight The engagement cycle

40. Customer insight

42. Customer insight Customer Insight Vital Signs within Operating Framework require better capture and use of patient experience data Commissioners need to develop methods to incentivise quality improvement. Better use of patient experience data may save resources otherwise spent on duplicating PPE efforts Boards require an overview of what matters to patients and where improvements are needed to aid strategic planning, better governance and quality assurance Performance managers require timely data about quality for monitoring purposes Commissioning organisations need to be able to report back to patients and the public about what happened as a result of PPE – to adopt a ‘you said, we did’ communications culture Why – Rationale and Benefits

47. A framework for thinking about patient experience What matters to patients Outcome Quality / safety Humanity Involvemt Support Envnmt Access (2) Place Access (1) Time Contin. After care Routine data Mortality Infection rates Waiting times Patient-derived data Patient-reported outcomes data (PROMS) Data from patient surveys?

48. Engagement culture and systems The engagement cycle

49. The Engagement Cycle Engagement culture & systems Turning PPE into everyday practice relies on a culture and systems that value and embed PPE throughout the organisation. The engagement culture and systems is the hub of the engagement cycle and drives PPE activity at, and between, each PPE stage. Overview

52. The end