The Department of Health has published a couple of documents relating to local involvement networks (LINks) across England. I read them to see where Gloucestershire LINk fits in with the rest.
One of the documents looks forward to the future, when LINks are to be abolished in October 2012 and local HealthWatch organizations take over from them. The document summarizes the pathfinder projects that are exploring ways to make the transition.
The other document looks back to the past, analysing LINks’ annual reports for 2010 – 11.
There are 151 LINks in England, as far as I can tell. Neither of the documents reviewed here lists them all. The now defunct NHS National Centre for Involvement listed all the LINk hosts in 2009, though some of the hosts have certainly changed since then, and I think some of the LINks have too.
The National Association of LINks Members (NALM) has a National LINk Directory that is more up to date, although the title page of the September version still says February and glancing through it I quickly found a couple of errors in the data, suggesting that there may be many more. The Finding your LINk search at NHS Choices now seems accurate, but it doesn’t give a simple list as far as I can tell. There doesn’t seem to be any published list that is official, accurate and complete. One of the good things about local HealthWatches when they take over from LINks will be strong national leadership from HealthWatch England, or at least, that’s what’s promised, so perhaps in a year’s time it will be easy to find an authoritative list of all the local HealthWatches.
HealthWatch pathfinders are local authority projects exploring aspects of the local HealthWatch organizations that will take over LINks’ roles from October 2012. Gloucestershire LINk is one of 75 associated with pathfinder projects. The local HealthWatch organizations will be independent bodies, but commissioned by local authorities, so it makes some sense for local authorities to be running the pathfinder projects.
The Department of Health’s Pathfinders document lists all the projects and gives a summary of each. Gloucestershire’s summary is:
Developing a communication pathways and relationships protocol that will enable Local HealthWatch to play its influencing role on the Health and Wellbeing Board. This pathfinder will focus on how Local HealthWatch can work collaboratively with community based member and voluntary organisations in order that they can contribute to the evidence and intelligence that will inform local health and wellbeing arrangements.
Working with the voluntary sector is a popular choice, with around a fifth of the pathfinders including it in their proposal. The curious wording, “member and voluntary organisations”, seems to include member organisations that are not voluntary, like sports clubs, co-operatives and building societies, but I suspect that is just a mistake.
Protocols are a much less popular choice, and indeed it is hard to see how helpful it will be to specify protocols without any experience of how the new arrangements will actually operate. Here, the wording, “enable Local HealthWatch to play its influencing role”, is surely an exaggeration. Influence doesn’t require protocols, and it will be interesting to see whether any work at all will be done by the pathfinder to demonstrate that protocols actually help, rather than hinder, an influencing role.
Not all the work of the pathfinders, however, is the kind of work that you would expect commissioners to do. This makes me wonder whether all the local authorities quite grasp what it will mean to commission an independent statutory body. Devon’s, for example, promises:
This pathfinder will focus on identifying how the new functions for Local HealthWatch will be delivered.
That has quite clearly crossed over to the wrong side of the commissioner/provider divide. It will be for the independent HealthWatch Devon to decide how to deliver what Devon County Council commissions it to deliver.
Not all the proposals are like that. Thurrock’s, for example, is careful to maintain a proper separation between the council’s pathfinder project and the existing LINk:
Developing the remit and function of a Local HealthWatch by working with the Thurrock LINk.
And its proposal for the work of the pathfinder is careful to keep within a commissioner’s proper remit, avoiding the temptation to meddle with service delivery:
This pathfinder will focus on options for governance arrangements on how Local HealthWatch will operate.
Gloucestershire’s proposal, like many others, is closely based on what LINks already do. They already have an influencing role and they already involve the voluntary sector, with nearly a quarter of LINk members nationally being representatives of other organizations. I’m disappointed that only about a third of the pathfinders say they are working on HealthWatch’s important new role in providing the public with advice and information about locally available health and social care services.
More than a dozen of the pathfinders, though, are looking even further into the future and working on the advocacy role that HealthWatch will take on in 2013.
Almost all LINks publish annual reports. It’s odd that not all of them do, as there seems to be a legal requirement to publish one by 30th June each year. The Department of Health’s analysis, LINks Annual Reports 2010-11, is based on 146 of them. The five missing LINks are Barnet, Havering, Northamptonshire, Nottingham City and Salford.
Even more oddly, many of the annual reports that have been published omit important information:
Around a third of LINks did not provide details of their finances, membership, activities or their effects. The level of reporting on some items was not as good as last year.
The analysis compensates for the missing data by adjusting some of the figures according to population sizes. It’s not clear that this gives valid results. For example, the LINks that failed to report their membership figures might have done that because their membership went down. The figures that were reported showed rising membership. There is no way to tell whether LINk membership really rose overall.
It only adds to the suspicious nature of the adjustments that the method of adjustment is described in such a convoluted way in Appendix A. For example, the LINks covering 74.1% of the population of England reported total membership of 113,275. Membership for the whole population can be estimated simply as 113,275 ÷ 74.1 × 100, which comes to 152,843. But Appendix A explains it like this:
Looking at the membership data item, 110 LINks reported on this figure giving a total number of members as 113,275. The LINks that missed out this data item cover areas containing 13.5 million people (25.9% of the total population of England using mid-2010 population estimates from the ONS). To get the 100% England figure, you can’t simply add 25.9% to 113,275 as the relation is not reflexive (i.e. adding 10% to 10 will equal 11, but taking 10% from 11 does not equal 10). Instead, you find the number ‘x’ so that x-25.9% = 113,275
Huh? Worse, this explanation directly contradicts the explanation given in last year’s analysis, LINks Annual Reports 2009-10, where the explanation was wrong in a different way (but the calculation apparently correct, regardless).
Membership of LINks varies widely by region, from Yorkshire and the Humber where LINks average almost 2,700 members, to the North East where LINks average fewer than 350 members. The South West has the second-lowest LINk memberships, averaging fewer than 400 members. This makes Gloucestershire LINk’s membership of 373 seem OK, only a little less than average for the South West region.
But it’s not clear how these membership numbers relate to population size. The Department of Health’s analysis doesn’t reveal that. From the numbers in Appendix A, I calculated that the 113,275 reported members represent a population of 38.6 million people, which is about 29 LINk members per 10,000 population. Gloucestershire LINk’s 373 members represent a population of 580,000 people, which is about 6½ LINk members per 10,000 population, less than a quarter of the national average.
To take into account regional differences, the average size of the sixteen LINks in the South West is shown in a chart as about 390, which means the total number of LINk members in the South West is around 6,240. The recently defunct NHS South West (now part of the NHS South of England cluster) said it was responsible for a population of 5.1 million people. The populations covered are probably not quite the same, but that gives an average LINk membership in the South West of around 12¼ members per 10,000 population. On that basis, Gloucestershire LINk’s membership is only just over half of the regional average. It’s not as if the people of Gloucestershire just don’t care about health issues, either. The Gloucestershire Hospitals NHS Foundation Trust has nearly 12,000 members, excluding staff members.
The output of LINks’ activities is even more difficult to gauge than the membership. The analysis counted about 3,200 reports and recommendations made by LINks (more than a dozen every working day of the year), of which fewer than a third led to a service change and around a sixth didn’t even lead to a service review. It’s impossible to say how many of those service changes were significant, would have happened anyway, or were temporary. Worse, it’s impossible to say to what extent service managers cut back on pro-active in-house quality management if they think they can leave all that to others like the local LINk.
It is, perhaps, significant that the analysis this year contains no case studies. Last year’s contained ten case studies showing how LINks can make a difference. Follow-up studies showing how those service improvements were sustained and developed would have been useful. Gloucestershire LINk, for example, did follow up its case study on improving the administration of medicines in hospital, and it could no doubt have reported on the matter in some detail (although its annual report only mentioned it in passing).
Participation in LINks is classified inconsistently and described weirdly by the Department of Health:
We can estimate that on average every one active participant engaged a further 17 participants.
That seems a clumsy way of spinning the statistic that only one in eighteen LINk members actually does anything. Gloucestershire LINk’s annual report claims 40 active members, which is about twice the national average considering its size, and which confirms my impression that Gloucestershire LINk is the most active of the four I originally joined.
There is quite a lot of other information in the Department of Health’s analysis, but it is all just as difficult to interpret meaningfully. Taken as a whole there doesn’t seem to be any purpose or strategic goal behind the analysis, except to say that some public money was spent and some people did some things, and that the spending and activity has increased compared to the previous year, except for the reporting of it, which got worse.