NHS Citizen Reports

Categoty: NHS citizenThe NHS Citizen project recently published two reports that sum up what took place at public meetings in London and Birmingham. The London meeting on September 18th was a test of the NHS Citizens’ Assembly with the NHS England Board, and the Birmingham meeting on October 2nd and 3rd was a design workshop focussed on the interaction between NHS Citizen and local issues.

I was away when the reports were published, and it has taken me a little while to catch up with things.

Accessing the reports

I could have read the reports while I was away, had there not been some technical problems with the way the reports were provided online. I only had an iPad with me, and none of the apps on it could handle the zipped PDF format of the reports. Why were they only provided as zipped PDFs? I examined the internals of the Assembly report to find out.

The report was created from a Microsoft Word document, made to look nice by including a little decorative image at the top left of each page:

And a slightly larger decorative image along the bottom of each page:

The two image files you see here in this blog total about 10 KB in size.

But the image files in the report aren’t just 10 KB. Instead, each page has a huge background image covering the entire page. Of course, it’s mostly white except for the two decorative images shown here. Using JPEG compression at about 25% the huge background image is compressed down from about 11.5 MB in memory to just 67 KB in the PDF file.

Now, PDF files have a clever internal structure that allows components of pages to be reused. For example, if every page has the same background image, then the image data only needs to be included once in the file. But the report doesn’t make use of this structure. Instead, the huge background image is included over and over again in the file — once for each of the 20 pages. The total comes to 1.3 MB, just for those little decorative header and footer images.

I don’t know whether this is just the result of Microsoft Word weirdness, or whether someone actually decided to do things this way. I don’t have Word, so I made a test PDF in my usual word-processor, LibreOffice Writer, putting those same images in the header and footer on each page, and each image ended up stored in the PDF just once, reused on every page. There was no huge background image, and the image data inside the PDF occupied only the original 10 KB.

Anyway, the NHS Citizen PDF file is more than twice the size it needs to be. So, to make it smaller the whole file was compressed again and uploaded to the server as a ZIP file. This means that when you click on the link in your web browser, your browser doesn’t get a PDF, it gets a ZIP. And your browser probably can’t directly display a ZIP. Mine couldn’t.

The need to compress Internet data is a well-known problem, and it has a well-known solution. Browsers that know how to handle compressed data notify web servers of their capabilities so that the web servers can compress the data for transmission over the Internet. Web servers, in turn, notify browsers when they are sending compressed data so that the browser can automatically decompress it.

For example, the Safari browser in my iPad knows how to handle data compressed by web servers using gzip or deflate compression. The report could have been uploaded as an ordinary PDF file, and the Apache web server could have been configured to compress it using gzip for any browsers capable of handling gzipped data. Then the server would have notified Safari that the data was gzipped. Safari would have ungzipped it to obtain the ordinary PDF, and it would have been able to display the report directly. But this well-known solution wasn’t used.

The Assembly meeting

The Assembly meeting was the one I wrote about here: NHS Citizen Assembly

The official report has a different point of view from mine, however. A key difference is that the report emphasizes lack of time as a significant constraint. From near the start:

“Given the time constraints of this first test of the NHS Citizen Assembly Meeting…not all groups were able to reach the stage of solutions…”

And again near the end:

“Although all conversations were rich and constructive, the limited time and wide scope of the issues meant that the groups struggled to work together towards defining clear solutions.”

My view of this is that there would have been ample time for the discussions to reach firm conclusions if the topics had been better chosen with this in mind, and if the facilitators had been more proactive and focussed.

I don’t agree that the purpose of an Assembly meeting should be to come up with solutions. My understanding is that it’s not meant to be a problem-solving workshop. So I find it strange and a little disappointing to see the report worded in terms of solutions. This may have been another side effect of poor facilitation.

Another key difference in point of view is the report’s emphasis on “co-production”. From near the start:

“For NHS Citizen to function effectively, culture change among citizens and professionals is crucial. Facilitating co-production of services and a more collaborative approach is therefore an essential part of NHS Citizen’s work.”

But I have no idea where these statements come from. I don’t remember them from the day. In the report they are tacked on to the end of a  paragraph describing a short film that was shown at the start of the meeting, but I watched the film again as I was writing this, just to be sure, and the statements certainly don’t come from the film.

Again, near the end, in a paragraph reporting on Sir Bruce Keogh’s summing up of the discussion about mental health that he had participated in, he is reported as:

“…recognising the opportunities of co-production and peer support…”

Having no memory of his mentioning co-production on the day, I watched that webcast again, too, and sure enough he never mentioned co-production.

OK, this meeting was just a test. It’s not really a big deal that the reporting was not as meticulous as it might have been. But in future when there are Assembly meetings for real, they will be dealing with things that really matter, and whether or not the summary report is an accurate reflection of what was really said will matter, too.

I’m particularly interested in mental health, of course, and I was particularly interested to read the report on the mental health discussion because on the day I participated in a different discussion online. The report is disappointing, though. The discussion seems to have been nothing but a rehash of ideas widely bandied about elsewhere. Co-production is highlighted in bold, naturally:

“There was broad agreement in the group that people should be given more control over their care. This means co-producing services with service users and learning from good practice.”

Overall, I’m none the wiser about how NHS Citizen can help the NHS to improve mental health care. If more of what hasn’t worked so far is going to be the plan, I’m underwhelmed.

In a section headed Final reflections, the report lists seven “crosscutting themes” that it claims emerged from the meeting’s working groups. These are to do with overall NHS funding, patient-centred and joined-up care, staff training, inequality, empowerment, co-production (yet again), and tangible results — a big useless heap of stale buzz-words. I’m firmly convinced that there was more significance to the Assembly meeting than that, and that in summing it up like this the report misrepresents it.

The design workshop

The design workshop initially seemed to be of interest because it was intended to explore how NHS Citizen can be useful in addressing local issues. I couldn’t participate, and I haven’t had time to review the recordings, so at the time of writing I have only the report to go on (and I’m not certain how much to trust the report).

The report gives the impression that few local issues were actually discussed during the workshop. There were discussion groups based on six issues that all seemed to me to be national.

For example, there was a discussion about reconfiguration of hospital services, which is happening nationally. It’s true that the details differ from place to place, often causing local concern, which indeed it has here in Gloucestershire, but the report doesn’t suggest any definite way in which NHS Citizen could help.

It’s not even clear what the goal is. In an ideal world, would it be easily possible to reconfigure hospital services to meet the changing needs of the population without causing an enormous fuss? Or in an ideal world would it be quite impossible to reconfigure hospital services no matter how badly they meet the population’s needs, because it would cause such an enormous fuss? Is NHS Citizen going to be a way to get us closer to the latter ideal? I hope not.

Overall, I’m none the wiser about how NHS Citizen can work for local issues.

It’s exactly a year since I first wrote about NHS Citizen here, and back then it seemed exciting to be present at the very start of something important, taking part in wide-ranging discussions about open-ended possibilities. A year later, however, I’m still hearing wide-ranging discussions about open-ended possibilities. I feel I should by now be hearing what NHS Citizen definitely is and definitely isn’t. Instead, in these two reports there seems to be a pervasive vagueness, an aversion to getting down to brass tacks or risking fresh approaches, and a slight suspicion that sounding good may sometimes have got the better of accuracy.



About Rod

Chairman of the Gloucestershire charity Suicide Crisis, Vice Chair of Relate Gloucestershire & Swindon, and an enthusiast for public involvement in the NHS.
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3 Responses to NHS Citizen Reports

  1. Andrew Brightwell says:

    Hi Rod, thanks so much for this very helpful note. On the issue with the PDFs they were created in Word – and I’m looking at different ways to make them smaller. However, the original problem was caused by WordPress only permitting up to a 2mb size for uploads. This is now resolved and the PDFs are up in their glory. They’re still too big – but as I say we’re looking at this now. Thanks again for your help!

  2. Hi Rod

    Thank you for taking the time to blog about the NHS Citizen work – we really value the input. I wanted to comment properly here – but some of what I am saying will also appear on the NHS Citizen website as its part of the work in progress. There were three main points I wanted to specifically comment on:

    1. PDF Files: Thanks for pointing out an issue with the template, which has now been reduced in size. As Andrew pointed out, there was a problem with uploading files to our website, which has also now been resolved – and we’re going to try to ensure the pictures that go into reports are also a little smaller, too.

    2. Assembly test: One of our observations – based on your feedback and other comments – is that we need to be better at making it clear what we are trying to achieve with these reports. I think both of Birmingham and the Assembly reports blurred the lines between simply reporting what happened and exploring the implications for the design. That isn’t the fault of the authors – but the result of not creating a firm brief for what we wanted them to achieve beforehand. We want to be better at streamlining the ‘reportage’ so that we can spend more time on the analysis work and you should see this happening in the future – please tell us if you don’t. In terms of the detail of what you are saying I think the real issue was less with time but more a combination of two things: firstly the gather process that we used to develop the issues for the assembly didn’t have long enough to run and ended up providing very open ended agenda items; secondly that those discussions were more repeated than built on at the actual Assembly meeting. We want to address both of these points in the next test (no date for that yet).

    3. Design workshop: I actually disagree with you on this one – while we did expect to discuss local issues in the planning of the event what we actually ended up with was a much richer discussion around how NHS Citizen could create the conditions for a social movement and also a clear steer that the way in which we had framed the local/national dynamic was not quite right – very useful feedback if not what we expected when we planned the event! What it does mean however is that we will need to do more work on the local/national question and we are planning the next phase of work to do that.

    Reading your comments really emphasises the need for us to be concentrating on this kind of reflection and analysis after the events, rather than on reportage – we will try and improve on this.

    Thanks again for taking time to comment – hope to meet you in person or virtually soon

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