Our full submission (available by clicking here) to the NHS White Paper consultation is a set of issues to consider, and a set of questions to act as prompts, for actions at national level which may both liberate the NHS and transform its relationship with the public it serves, without losing sight of the core values on which it is based and which are held dear by the public and the electorate.

Here we present the issues we believe the Government must address.  We blogged the questions earlier this week (and available here).

Our submission starts from a fundamental proposal: that the key goal of the next stage of NHS reform could and should be to achieve a new psychological and social contract between the public and public service, to generate the 'fully engaged' scenario, liberating both the NHS and the skills, energies, knowledge, wisdom and time of local people. 

We believe the benefits of full-scale involvement are attainable from our current position, yet also that the White Paper fails to secure that future.

Key areas for the Secretary of State and the Government to address

We believe the NHS, especially the NHS, should not be exempt from the new deal required for Public Services at this time.  There is a curious absence of real active citizenry-based approaches advocated within the White Paper, a gap which is made still more curious by the emphasis on new forms of accountability, and gives rise to the potential for these to be confused in the delivery of the White Paper.  Generating an active citizenry dimension to healthcare delivery and to Health improvement, will generate better, higher quality, more effective and more efficient solutions in both delivery of care and improvements to health.  Indeed because the causes of so many health issues lie in the fabric of society and in way services are currently structured to meet supposed needs, often narrowly defined, it is only a wide-ranging and holistic approach that can achieve fundamental change.  And because so many health issues lie at the interface between collective and individual action any approach to the NHS which fails to address collective and personal motivations, collective and personal responsibilities, collective and personal actions will inevitably miss the full potential for change.

This approach requires existing providers and future commissioners of service to think and act very differently.  It requires them to enable and support others, even to promote and inspire, to seek the added value from very different relationships with their clientele, their patients, their public, not to provide services directly.  This is an approach which is largely outside current mindsets.  It would be difficult to overstate the scale of this challenge, as it requires a move away from centralised control processes and the current task focus, toward a much more dynamic yet enabling and enabled approach.  This will require both constant disruptors to existing patterns of behaviour, and a real emphasis on making change happen in the service and gearing up the skills and capabilities of local communities and local people to act proactively in the new environment.

Generating the ability of existing health providers (and commissioners) to operate in the context of the Big Society-driven  approaches of other public services and other types of service provider will be a critical step.  Generating the ability to respond with the agility and sensitivity this requires will be dependent on a shift in mindsets beyond what is currently envisaged by those who currently lead.  It is not simply an extension of incremental approaches to PPI. It will require health providers and commissioners to have sourced a significant proportion of their solutions through 'external' providers (and probably to have been required to do so by the Secretary of State).  It cannot be assumed, but it appears tacitly to have been so, that the public will automatically and naturally fill the gap left by state solutions.  To do so will require an emphasis on plurality of delivery mechanisms and vehicles, which can be summarised as a plurality of organisational forms and governance types, for example emphasising the potential of co-operative and socially-owned solutions (as distinct from Staff-led enterprises, which, while having a place, are themselves potentially an un-ambitious  cul-de-sac, so a diversion), alongside real investment in social value-driven SMEs and Social Enterprises.

This approach will require both local NHS providers and national bodies to have worked hard at generating sufficient capacity in third sector and other providers, to meet the potential shift in demand.  This is counter-intuitive for existing providers and commissioners, and as a result existing 'external' providers are often most at risk from public sector cuts in the short term.

Early progress to such approaches will depend on trusting and productive relationships, from the outset.  We believe the Secretary of State (not DH per se) has a crucial role in ensuring the response of the service meets this challenge.  Merely requiring the service, the DH or the National Commissioning Board to deliver on this agenda and enforcing the same through traditional performance management of the system will not achieve this change.

We are concerned the White Paper is primarily addressed to the professional groups seen as traditional power brokers in the NHS. We believe there is another approach which adds an exciting  and potentially transformative new voice to the equation, without which that equation will not deliver real change.  It is the voice of the public as engaged and involved citizens, tied deeply into the fabric of decision-making in the service, achieving a level of involvement in decision-making that generates co-designed and co-owned solutions - the new deal we have referred to before.  For the NHS is to be 'Liberated' requires the public and the patient to each be liberated and enabled to act differently too.  The Secretary of State can uniquely (as opposed to the DH or Commissioning Board) enable this approach for the public as well as ensure it is a driver for change (not a command) within the service too.  Not to do so would display an alarming lack of ambition and foresight about the troubles ahead for the rest of his programme.

On the questions of accountability - there is an opportunity to ensure the right people  are held to account publicly and transparently by local people (and we don't mean local functionaries of the new NHS infrastructure).  The White Paper proposals create some interesting potentials and some new dynamics, yet there is a lack of real balance and follow-through, ie a concern that the new arrangements do not go far enough in generating a sense of local accountability to local people, rather than to local government and local officialdom.  However addressing this issue requires that the public are present as a real force in public audit, that the public can be re-assured of the benefit of these new systems.  A similar requirement (of re-assuring the public) also applies to the new systems of plural delivery, ie ensuring confidence in the public benefit of private sector delivery.

Healthwatch seems an inadequate and confused vehicle - even its name indicates a passive and constrained role.  It also appears vulnerable to being regarded as the sole or principal means of delivery of involved or Big Society solutions, having the effect of passing responsibility from those with operational and strategic management responsibilities to a separate group, much as 'Quality' was initially managed in the NHS.  Greater clarity is required about the requirements on the whole service to deliver this responsibility.