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Interim Report on the Evaluation of Polysystems in London 12 Jan 2011 V3

Evaluation of London PolysystemsFirst interim report: The development and commissioning of polysystems: early lessons from the patient and public experience

12 Jan 2011 V3

Picker Institute Europe: Dianna McDonald Amanda Attwood

Louise Harris

NOTE: This document forms part of the first interim report, The development and commissioning of polysystems: early lessons, (submitted separately) and should be read in conjunction with that report. This component covers patient and public engagement (one of four criteria selected for the evaluation exercise), and should be read in context with findings related to the other evaluation criteria.

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Contents

Executive Summary 3

1. Introduction 7

2. Methodology 8

3. Case Studies3.1 Hammersmith Centre for Health and Fulham Centre for Health 113.2 Alexandra Avenue Health and Social Care Centre 163.3 Gracefield Gardens Health and Social Care Centre 213.4 Loxford Polyclinic 26

4. Key Lessons 32

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Executive Summary

This is a supplementary report to the full phase one report from the Commissioning Support for London (CSL) evaluation of the first Early Implementer polysystems in NHS Hammersmith and Fulham, NHS Harrow, NHS Lambeth, and NHS Redbridge. The full report covers an analysis of the development of the four polysystems and reports primarily on issues related to project development, commissioning, and organisation, and refers to three of the four evaluation goals – access, clinical quality, and value for money.

This report comprises findings on the fourth evaluation goal - patient and public experience and engagement. The aim of the research is to explore the extent of patient and public involvement in the original and continued development of the four polyclinic case studies. The report is based upon a review of documentation supplied by each of the case studies, and analysis of interviews with key staff from each area.

This summary encapsulates key findings on the extent of patient and public involvement in the development of the polyclinics under evaluation, and highlights important lessons learned.

Variations in patient and public involvement and perception of polyclinicsThe degree of patient and public involvement varied enormously across each of the four case study sites. At Alexandra Avenue polyclinic, where there had initially been a clear lack of engagement in the process of development, public perception of polysystems was in general not positive, especially in the early stages. In contrast, in Redbridge, where the most comprehensive and consistent engagement had taken place throughout the development process, local residents were reported to be significantly more likely to feel that they had a role to play in the planning and decision-making of their PCT. In Lambeth, public engagement was thought to have had a direct impact on how favourably development plans were regarded, and the low number of complaints that were received.

Precursors to polyclinics and local contextFor all of the case study sites, there had been previous developments in local primary health care provision that were effectively ‘precursors’ to the polyclinics – either in the form of a clinic functioning under a different terms (Neighbourhood Resource Centre, Health and Social Care Centre, Primary Care Resource Centre), or, as in the case of Hammersmith and Fulham, as a specific service (the Unscheduled Primary Care service). In all cases, some patient and public engagement had taken place in relation to the precursors to polyclinics. The degree to which this engagement continued during polyclinic development appeared, to some extent at least, to relate to the context in which these previous developments had taken place and how the subsequent polyclinic built on these developments. Where there had been longstanding projects aimed at improving local primary care services, such as in Redbridge and Lambeth, the extent of engagement tended to be greater. In contrast, where the eventual existence of the polyclinic was driven by the need to address an increase in public reliance on A&E services, as in Hammersmith and Fulham where the polyclinics are located in a hospital setting, engagement was much less apparent. Given that polyclinic

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services located at the Hammersmith Centre for Health were put in place over a relatively short time-frame, and are intended to be transferred eventually to White City, it is perhaps unsurprising that little prior patient and public engagement took place. The presence of an existing clinic was suggested by interviewees to be the reason for a lack of significant engagement during the development of Alexandra Avenue polyclinic; it was proposed that little consultation on the development of the polyclinic took place because much of the framework was already in place. However, the notably greater degree of patient and public engagement at the other two sites, where active clinics were also previously in existence, suggests that this not a necessary consequence.

Early engagementA key theme that recurred across the sites regardless of the degree to which consultation had been taking place was the importance of engaging patients and the public early on in the development process. Where consultation had been taking place throughout the polyclinic development, it was recognised that early involvement of patients and local residents had been a vital factor in the success of the engagement process. Where consultation had been lacking, it was also recognised that early engagement would be a crucial element in establishing more effective engagement in the future. Early engagement both allows participants to feel properly included in the process, and provides sufficient time for patients and the public to come to understand fully and support the changes that are being proposed.

CommunicationAlong with early engagement, clarity in all kinds of communication was identified as being crucial for successful engagement. This includes both communication about what is required of participants in engagement activities, and in the information that is provided to patients and the public.

In addition, clear and sufficient communication to patients and local residents about what a polyclinic is and the services that are available is also essential if positive opinions are to be cultivated – preconceptions amongst the public may not always be accurate, and may be inadvertently reinforced by a lack of information.

Early and clear clarification of the objectives of Public Engagement PPI is not an end in itself, it should be focused on an end. Engagement must be seen as an ongoing, iterative process that embraces and build upon policy developments as they emerge, just as much as it revolves around a specific initiative or scheme. Each phase of public engagement should have a clearly defined aim /purpose. Based on the documentary evidence seen in this analysis, one of the issues to emerge was that the objectives of the PPI activities were most often unclear and not generally stated upfront. Improving engagement In Redbridge, a high degree of patient and public engagement has been maintained throughout the process of developing the polyclinic under evaluation. Even for this organisation, valuable lessons have been learned during the

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engagement process and these have fed into the ongoing development of other polyclinics in the area. At sites where engagement was either more limited or focussed on other developments in the region, a culture of good patient and public engagement has begun to spread through the organisations during the process. Where there had not previously been a dedicated engagement plan for polysystem development, a commitment to establishing such a plan in the future has been expressed.

Patient and public engagement has generally been regarded as improving, as evidenced in more effective consultation that has been occurring as part of the development of other polyclinics in these areas. Evaluation of patient and public engagement activities can provide useful information that may inform future planning and strategy.

Effective engagement methodsOne of the most apparently effective engagement methods employed was the creation of the Loxford Polyclinic Community Panel, initiated by NHS Redbridge. This dedicated panel of local residents was involved in the polyclinic’s development from the earliest stages, and continues to be so. It has also become involved in the establishment of additional Community Panels dedicated to the development of other polyclinics in the area.

Since Loxford Polyclinic has been open, ongoing patient surveying has provided feedback that has also had a direct impact on service delivery and the organisation of the clinic.

The impact of patient and public engagementWhilst all four case studies reported, to a greater or lesser extent, a variety of engagement activities, events and initiatives, establishing the impact of these was not always possible. In some instances, substantial evaluation of patient and public engagement had taken place. For others, whilst there was evidence of certain activities having taken place, there was less often evidence of evaluation of these activities, or reporting of their outcomes. It is frequently the case, therefore, that whilst it may be clear how a particular engagement initiative is theoretically relevant to the development of a polyclinic, it is often less clear what, if any, impact it may have had. Improved evaluation of engagement activities in future may increase the likelihood of such initiatives achieving their aims, and of patient and public engagement playing a positive role in polyclinic development.

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Key Lessons Engaging patients and the public early on in any development process is particularly

important Clear communication – both about what is required of participants in engagement

activities, and in the information that is provided to patients and the public – is vital for successful engagement

A clear statement of purpose of the engagement exercise is crucial in order to guide messages and to measure success of the process

Where the most comprehensive and consistent engagement had taken place, local residents were more likely to feel that they had a role to play in the planning and decision-making of their PCT

Evaluation of patient and public engagement activities can provide useful information that may inform future planning and strategy, especially the development of other polyclinics

One of the most effective engagement methods employed was the creation of a dedicated polyclinic Community Panel

Where patient and public engagement was initially lacking, it has generally been regarded as having improved during the polyclinic development process

The prior existence of a clinic at the same site does not preclude further consultation when a new polyclinic is under development

The context in which a polyclinic has come into being may relate to the degree of patient and public engagement that has taken place during its development

Whilst it may be clear how a particular engagement initiative is theoretically relevant to the development of a polyclinic, it is often less clear what impact it may have had

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1 Introduction

The London School of Hygiene and Tropical Medicine together with Imperial College London and the Picker Institute Europe were commissioned by CSL to undertake an evaluation of the development of Polysystems in Lodon. The overall aim of the evaluation is to provide information and support to commissioners (i.e. PCTs) when undertaking the future commissioning of polysystems, polyclinics and support service developments within the London region. Four core goals are covered by the evaluation: access, clinical quality, patient engagement and value for money.The full report (submitted separately) encompasses an analysis of the development of the four polysystems and reports primarily on issues related to project development, commissioning and organisation, and refers to three of the four evaluation goals – access, clinical quality, and value for money.

This report covers findings on patient and public experience and engagement only. The aim of the research is to explore the extent of patient and public involvement in the original and continued development of the four polyclinic case studies.

The four case studies examined in this phase of the research were:1. Hammersmith and Fulham Centres for Health (based at Hammersmith and Charing Cross hospitals; NHS Hammersmith and Fulham)2. Alexandra Avenue Health and Social Care Centre (NHS Harrow)3. Gracefield Gardens Health and Social Care Centre (NHS Lambeth)4. Loxford Polyclinic (NHS Redbridge)

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2 Methodology

The report is based on data collected from reviewing documents supplied by each of the four case study sites, and analysis of interviews with key stakeholders.

In total 115 documents were examined (outlined in Table 1). A full list of documents is included in Appendix 1. In this first phase of the evaluation, key stakeholders from each of the case studies were interviewed between January and July 2010. Table 2 provides a breakdown of the roles of the 19 interviewees who took part. Interviews were conducted either by a researcher, recorded, and then transcribed, or via self-completed questionnaires. The findings in this report provide a summary of the analysis of interview data and documentary evidence. Where the reporting of patient and public engagement activities and events is particularly brief, this is most often due to the limited nature of the information available.

Table 1: Document types Document type Hammersmith

& FulhamHarrow Lambeth Redbridge

PCT Needs Assessment HFd6; HFd14; HFd30; HFd32; HFd40

Hd1; Hd6; Hd9; Hd13;Hd23; Hd15

Ld15;Ld18;Ld63

Rd8;Rd20;Rd21

PCT Polysystem Strategy HFd10; HFd2; HFd25; HFd27; HFd31; HFd11; HFd14; HFd24; HFd28; HFd30; HFd34

Hd8; Hd1; Hd9; Hd13; Hd23; Hd14

Ld20: Ld1; Ld11; Ld30; Ld34; Ld51; Ld53; Ld20a; Ld31; Ld35; Ld67; Ld68; Ld69; Ld70; Ld71; Ld12

Rd2; Rd3; Rd17

PCT Commissioning Organisational Structure /Charts

HFd10; HFd7; HFd24; HFd40

Ld16 Rd2; Rd7

Polyclinic Scope and Objectives (e.g. Business Case, PID)

HFd2 HFd31; HFd11; HFd24

Hd8; Hd1; Hd13; Hd23

Ld17;Ld6; Ld42; Ld51; Ld13

Rd1;Rd8; Rd16; Rd34

Polyclinic contractual, and financial documents for Services and Building (e.g. tendering process, running costs)

Ld6;

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Polyclinic Service Delivery Progress/ Monitoring

Hd22 Ld14; Ld7; Ld3; Ld5; Ld 9; Ld40; Ld48; Ld52

Rd1; Rd5; Rd6; Rd10; Rd36

Polysystem evaluation/ assessment

Hd21 Ld19; Ld38; Ld44

Liaison with social and community services

HFd10; HFd24; HFd26; HFd29; HFd35; HFd39

Hd12; Hd19 Ld33; Ld52; Ld36; Ld37; Ld56

Rd1; Rd24; Rd25

Leaflets, PR, Communication HFd33; Hd4;Hd16; Hd17; Hd18

Ld49; Ld5 Rd11

Meetings (agendas, minutes) HFd39 Ld4; Ld39; Ld41; Ld54; Ld59; Ld60; Ld61; Ld62

Rd25; Rd26; Rd28; Rd29; Rd30; Rd31

Engagement / consultation HFd26; HFd27; HFd28; HFd29; HFd35; HFd36; HFd37; HFd38

Hd12; Hd19; Hd14; Hd16; Hd17; Hd18

Ld32; Ld44; Ld46; Ld54; Ld43; Ld57; Ld58; Ld65; Ld66; Ld72

Rd22; Rd23; Rd27; Rd33; Rd32

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Table 2: List of conducted interviews

Hammersmith & Fulham

Harrow

Lambeth

Redbridge

Identifier

Interviewee(s)

Identifier Interviewee(s) Identifier

Interviewee(s) Identifier

Interviewee(s)

HFi21 3 PCT Officers Hi21 PCT Staff Li21 Local Authority Officer Ri21 2 PCT OfficersHFi22 Polyclinic Staff Hi22 Local Authority Officer Li22 Polyclinic Staff Ri22 PCT OfficerHFi23 Commissioner Hi23 Local Authority Officer Li23 PCT Staff Ri23 PCT Officer

Hi24 Polyclinic Staff Li24 PCT Staff Hi25 PCT Staff

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3 Case Studies

3.1 NHS Hammersmith and Fulham: Hammersmith Centre for Health (Hammersmith Hospital) and Fulham Centre for Health (Charing Cross Hospital) The development of Hammersmith Centre for Health (HCfH) as a polyclinic took place over an unusually short period of time. Delays in the development of a proposed polyclinic at White City led to a decision by the PCT to proceed with a “rapid introduction of a polyclinic at Hammersmith Hospital”, which was a “departure from earlier plans” (HFd39:41). The long-term plan is for polyclinic services currently located at HCfH to transfer eventually to White City. Perhaps unsurprisingly therefore, patient engagement activities in relation to the development of HCfH were significantly more limited than those that had taken place in White City, the development of which had been underway for some time. White City is not one of the case studies under review here, so information included about engagement activities at White City is brief.

Patient engagement relevant to the development of Fulham Centre for Health (FCfH) and HCfH essentially comprises consultation carried out by the PCT in 2008 that related to the development of an Unscheduled Primary Care service, which had been initiated in late 2007 and was planned to be located at Charing Cross and White City. This service was a “natural precursor for polyclinic delivery” (HFd31: 9).

The PCT also carried out some general consultation activities which may have been relevant to polyclinic development, including a consultation on the 2008 Commissioning Strategy Plan, and a number of general consultation activities that provided feedback on patient experience, both of which informed the PCT’s decision making processes. These consultation activities and events are outlined below.

General patient and public engagement activities by NHS Hammersmith & Fulham Some of the broader engagement activities and events that occurred in 2008 may have been relevant to the later development of polyclinics in the area. The PCT’s Community Engagement Team was expanded in order to carry out effective consultation (HFd10), which included a range of activities during 2008/09: surveys on GP and hospital services, formal consultations, and informal community engagement work (HFd25).

In November 2008, community teams asked local people for their views on the care they received via a survey and face-to-face sessions (HFd25). As a result of these consultations, “the views expressed by local people had a direct impact on the priority projects [the PCT] are investing in during 2009/10” (HFd25: 19). Local residents had in particular expressed a desire to see improvement in location and opening times of primary care services (HFd6).

Consultation on the 2008 Commissioning Strategy Plan (CSP) was carried out over a three month period, and included two CSP consultation events for the general public, voluntary and community organisations and clinicians, targeted local consultations, and

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commissioning voluntary and community organisations to work with excluded groups (HFd10). Approximately 500 members of the public, patients and carers, and members of voluntary and community groups took part in this consultation. The PCT also intended to carry out evaluation of numbers attending these events, together with the collection of qualitative data from evaluation forms (HFd27).

The PCT expressed a commitment to patient and public engagement at this time: “significant consultation has already taken place with regard to [ensuring primary care needs are met] as part of an ongoing dialogue with local residents…This engagement has been particularly strong in the north of the borough and we will work to ensure that residents in the south of the borough are also consulted” (HFd10:68-69).

Patient and public engagement in the development of the Unscheduled Primary Care serviceThe PCT also conducted a range of consultation exercises that related to the development of an Unscheduled Primary Care service. As the development of this service could be considered a precursor to the development of the polyclinics at Hammersmith and Fulham, the feedback from this consultation may have informed the later development of HCfH and FCfH.

Consultation on the Unscheduled Primary Care service included patient and public surveys, a Patient Forum, and a Reference panel. In March 2008, Ipsos Mori carried out interviews and focus groups with patients and members of the public at GP surgeries, WICs, A&E departments across the PCT, and interviews with members of the public in busy public locations. (HFd32). These primarily concerned how patients accessed unscheduled care systems, and their views and preferences about delivery of unscheduled care services, both of which are core elements of a polysystem. In April 2008, the PCT’s PPI project co-ordinator sent out an invitation to join a Reference panel that would inform the development of the Unscheduled Care service (HFd33). The recruitment of the panel was to include networks of patients with long-term conditions, patient forums, and voluntary organisations (HFd36). The Reference panel members would be represented by different patient groups, ethnic minority groups, young people, the elderly, parents, and working people from the community (HFd36), who would be asked for their views about the proposed service. As well as the Reference panel, a local Patient Forum was set up. The Patient Forum was recruited from patient groups and organised by the local LINKs, and took part in the tendering process for Unscheduled Care services in the area. Potential providers gave a day-long presentation, and incorporated patient feedback in their final bids (Hfi21: 27-29).

“[The Patient Forum] were involved in agreeing what the model should be…Then they were involved in the selection of the supplier, so in that the providers were coming up with different models and different treatments and they were commenting back – this

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was part of the competitive dialogue process – what we were commissioning – but they were also giving feedback on how they felt about the providers in i.e. how likely they were to be responsive, how seriously they would take patient/public engagement, how they would be likely to deal with complaints etc. etc” (Hfi23:4)

Patient and public engagement in the development of HCfH and FCfH PolyclinicsThe earlier consultation around the development of the Unscheduled Care service is likely to have been relevant to the development of the polyclinics at both Hammersmith Hospital and Charing Cross Hospital . However, it appears that a communications strategy specific to the development of HCfH and FCfH as polyclinics was not put in place. It is possible that this is because it was not deemed necessary: “We didn’t desperately need a communication strategy to get people to pitch up at our polyclinic because it was front end of A & E and we had a 100,000 and we have now got 114,000 people there every year anyway so it wasn’t something where we were needing to attract people to a different form of care – we were just putting the different form of care there for them….but I suppose our view is that a polysystem from the ‘punters’ perspective doesn’t need to be anything that they need to proactively understand” (Hfi23:2)

One interviewee felt that consultation around the development FCfH may have been particularly difficult due to its location within a large hospital and the nature of the local patient population:“The task of consulting over Charing Cross [FCfH] is enormous…The actual patients coming in to Charing Cross…they’re from everywhere” (Hfi21:11)

Whereas “White City…It’s a real community, not a constructed community and it was able to respond to the invitation to be involved, and the levels of involvement there are quite high” (Hfi21:9)

Patient and public engagement in the development White City polyclinicPublic and patient engagement in the development of the White City polyclinic appears to be the most wide-ranging of all three polyclinics in the area, and is certainly the most well documented. However, as the White City Polyclinic is not one of the sites under evaluation, details included here are brief. Extensive consultation took place regarding the development of a Collaborative Care Centre at White City, a precursor to the planned White City polyclinic, and also on the development of White City polyclinic itself. Activities included: a consultation event (July 2005) by the PCT in conjunction with other partners (HFd31); a consultation with children and young people that targeted primary schools, secondary schools, and community and children’s centres in the area (2004-2006; HFd29, HFd31); a Citizen’s Panel (2005) organised by the Borough (HFd11), projects targeting minority groups and specific service users (HFd31), and the building architects talking to patients (HFi21:6). Feedback received at an open day in July 2005 “directly altered proposals for the Collaborative Care Centre” (HFd38: 10), which subsequently pulled together a range of services under one roof, “in line with the

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vision expressed by local residents, which for the first time may be delivered outside the traditional hospital environment” (HFd38:10). “They were saying what we would like is to have it in one place...we want diagnostics. Now that was something new...” (HFi21:4).

A priority of the PCT’s PPI strategy in 2006/2007 was “the development of a proposal to consult and engage with local residents on the design, planning, and delivery of local health services – including the White City Collaborative Care Centre” (HFd38:14). Further details of a number of additional events and activities, including public displays, the PPI Forum, public meetings, residents groups and newsletters, that occurred between 2007 and 2008 are outlined in the White City Polyclinic Proposals (HFd31), and in a report on an engagement event held in October 2008 (HFd35).

Lessons learned from patient and public engagement in the development of HCfH and FCfH The comprehensive patient and public engagement work that has been taking place for some time in relation to the development at White City appears to be having a wider influence on the approach to engagement across the PCT, with particular reference to other polyclinics in the area. The Community Engagement team for the White City project were able to initiate the development of a joint ‘Communication and Engagement’ strategy:

“In the Polysystems Board it was a comms work stream, [but] we managed to say it was a comms and engagement work stream… Which led to the joint strategy, the joint plan…And it has taken the organisation a bit of time to recognise the value of this cross-working, and I think that hopefully, I mean now one can say that they, as an organisation they, a lot more of the organisation are beginning to say look, what about the engagement bit of it?” (Hfi21:49)

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Ongoing patient and public engagement in HCfH and FCfHSince the opening of HCfH, in its Polyclinic Development paper of May 2009, the PCT has expressed a commitment to creating “an ongoing strand of public engagements…that leaves people feeling that they have achieved real change and empowered to continue engaging with the PCT” (HFd2:5). The PCT’s Communications & Engagement Strategy (2009/12) also sets out as one of its key priorities “specific communications work to increase awareness of the quality and availability of local services – showcasing recent and planned improvements linked to polysystem development” (HFd27: 3).

Whilst they are not specific to polyclinic development, the Communications & Engagement strategy outlines a range of currently active general consultation approaches, including patient surveys, patient and public involvement networks, and engagement with hard-to-reach groups in the community (HFd27). Planned activities include patient satisfaction systems in GP surgeries; holding a local health summit; resident satisfaction polls, and website development. Direct ongoing communication with the public is also effectively managed through conducting health ‘MOTs’, “so while they’re giving their opinions they get an appointment with the smoking cessation advisor” (Hfi21:24).

Although no specific consultation activities are detailed that will be particular to the development of polyclinics and polysystems, the Communications & Engagement strategy does affirm that “polysystem related engagement: to ensure appropriate public engagement in service redesign” is a priority for 2010/11 (HFd27:14), and that there will be an “engagement strategy in place with a dedicated plan for polysystems” (HFd27:15). There is also ongoing discussion about the possibility of developing patient participation groups for FCfH and HCfH (Hfi21:34).

Continuing engagement at White City has included consultation with hard-to-reach groups through working with the local community interpreting service (HFi21:20), who have been trained in consultation techniques and have effectively involved people living on local estates and those who speak languages other than English (HFi21:21). They have made use of established networks (set up by the local council) with links into community groups (HFi21:22). These forums were used to discuss NHS services and were believed to have worked especially well (HFi21:23).

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3.2 NHS Harrow: Alexandra Avenue Health and Social Care Centre

In the early stages of the development of the polysytem in Harrow, local perception of polyclinics was not altogether favourable. The limited amount of public and patient engagement that took place during the development of Alexandra Avenue – first as a Health and Social Care Centre, and later as the Centre became a polyclinic – may not have helped to encourage positive opinions. The PCT quickly learned from early engagement experiences, hence subsequent engagement in the development of other polyclinics in the area appears to have been more effective. Ongoing patient and public engagement at Alexandra Avenue has also improved.

Patient and public engagement in the development of Alexandra Avenue Health and Social Care CentreDevelopment of a polyclinic at Alexandra Avenue was preceded by the development of a new Health and Social Care centre on the same site in 2006. As part of this process, services from two other clinics in the area, Cecil Park and Northolt Road clinics, were to be transferred to the new clinic at Alexandra Avenue. The PCT carried out a public consultation on this proposed transferral of services (Hd15; Hi21), and planned to use a number of approaches that included:

meetings with local stakeholder groups including the Patient and Public Involvement Forum;

feedback forms and information leaflets in all clinics and local GPs; information leaflets in libraries;

PALs sessions with each clinic; email and postal contacts for posting comments; bi-weekly newsletter on the PCT website; and comment space on the PCT website (Hd15).

It has not been possible to ascertain the processes of this consultation in detail, although one interviewee did recall engagement activities taking place in the clinics:"I think if I recall for Alexandra Avenue, they had somebody behind a desk at Alexandra Avenue to explain the changes to existing patients, and I think they had likewise in Cecil Park clinic” (Hi22:7)

The consultation was proposed to run for 3 months between April and June 2006, following which there would be “a six month transition period during which services at the two clinics transfer over to Alexandra Avenue with, again, clear information and advice for patients to assist during the transition period.” (Hd15:6)

In July 2006, Harrow Council Scrutiny Committee expressed their concerns about the PCT’s consultation on the closure of the two clinics (Hd12). The Committee: “raises questions about the validity of the consultation processes… The Committee would seek assurances that the PCT has engaged key stakeholders (e.g., users, GPs, partners, the general public, PPIF) in meaningful discussions about these proposals and their effects, and will take into account these views in its final decision”(Hd12:3).

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The Scrutiny Committee raised particular concerns about whether people attending the clinics that were to be closed would be able or prepared to attend the clinic at Alexandra Avenue, especially the elderly and mental health service users. The Committee stated that members of a “Mother and toddlers group currently attending Cecil Park Clinic have clearly expressed that they would not attend any similar provision further away in Alexandra Avenue.”(Hd12:2)

The Committee had also received a formal petition opposing the closure of Cecil Park clinic, with over 300 signatures. “This represents significantly more people than the 150 people the PCT informed us had responded to its consultation within the clinics. Feedback from users of Cecil Park Clinic also suggest how not all people are clear about the proposals meaning both the move to AA Clinic as well as the closure of the existing provision at Cecil Park.”(Hd12:3)

As a result of the Scrutiny committee’s report, the ‘mother and baby’ group was retained in a central location (Pinner Road Clinic) rather than being transferred to Alexandra Ave, (Hi21:11).

Patient and public engagement in the development of Alexandra Avenue polyclinicAlexandra Avenue operated as a Health and Social Care Centre until it became a polyclinic in April 2009. During this time there some limited consultation on its development into a polyclinic took place. As Alexandra Avenue was already functioning as a Health and Social Care Centre, there was some initial consultation with existing partners and stakeholder groups but perhaps less than they would have liked: “The consultation that might be expected on something like this didn’t really take place at the start of the project - as we didn’t really know that it would eventually become a polyclinic. Polyclinic is a word that probably didn’t exist then.” (Hi22:11)

Interviewees felt that this lack of consultation may have been because this was not a completely new project being built from scratch, but rather the development of services that were already in operation at an existing clinic: “It was a straightforward sort of local clinic where people went for things that you do in clinics…they were already starting to develop services perhaps more than they would have from a normal local clinic, a diet clinic and things like that… So in actual fact the consultation around the development of that polyclinic was much smaller than we would have normally done because a lot of the framework was already in there” (Hi21:4)

As a result, patients and the general public may have had limited information about the development of Alexandra Avenue as a polyclinic:“From a public perception, they wouldn't necessarily know that Harrow had a polyclinic until there was already one that was already established.” (Hi22:13)

The PCT did undertake one consultation project specific to the development of Alexandra Avenue as a polyclinic. Direct surveying of patients occurred in February 2009 (Hd22), shortly before the polyclinic was due to open, and was focused upon a transport survey of patients/carers attending the Alexandra Avenue clinic. Although some stakeholders had been negative about the clinic’s location and access, feedback from patients showed that transport to the clinic was not presenting a

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problem for many of them (Hi21:5). However, frequency of bus services was found to be a major problem, and poor public transport links were encouraging service users to travel by car. Existing problems with limited car parking space was thought likely to be exacerbated by the expansion of the clinic into a polyclinic. As a result of the findings of this transport survey, the PCT proposed the development of travel information leaflets and a freephone taxi service. Interviewees felt that the general feedback from the public about the opening of the polyclinic had been positive, as they could see the Alexandra Avenue was now offering much more in terms of extended services (Hi21:11-12). However, despite generally positive patient feedback, interviewees still felt that local residents needed some convincing of the benefits of the polyclinic, along with better information about the services available.

“I think there's still an issue about selling the concept to local people, to highlight and communicate to them the actual benefits that a polysystem can give to them...Polyclinic was a bit of a dirty word for a while, so I think a lot of peoples’ mindsets, they've heard what they’ve read in the papers without really realising what they're getting.” (Hi22:13)

General patient and public engagement activities by NHS HarrowIn 2008 and 2009, NHS Harrow expressed a general commitment to patient and public involvement, and carried out a number of engagement activities. Whilst it is not possible to ascertain the extent to which this relates to the development of Alexandra Avenue polyclinic specifically, it may be relevant to the general development of polyclinics in the area.

The Strategic Plan 2008/09 – 12/13 (Hd13) emphasises the importance of consultation and engagement, and refers to a number of consultation activities that the PCT engaged in during 2008/09: “formal consultations, user forums, focus groups, patient surveys and public events both as part of the service redesign process” (Hd13:38). The Strategic Plan presents the case for the development of local polyclinics, a key element of the “service redesign process”, and draws on general patient feedback acquired “through surveys and service reviews” (Hd13:70), “patient groups…and other studies” (Hd13:74), and Healthcare for London findings in support of a case for change in service delivery, in particular the development of the polyclinic model. The Primary and Community Care Strategy (Hd8) also cites a Healthcare Commission survey of local service findings - poor satisfaction with GP services in Harrow – and a “recent primary care survey”, which in which patients reported too long a wait to see a GP, difficulty in contacting their GP, and inconvenient opening times as evidence of local support for the polyclinic .

The PCT itself conducted a public consultation on the ‘Choice and Control’ initiative as part of the development process of the Strategic Plan. This initiative encompasses access to services, which is a significant factor in the development of the polyclinic model. A public meeting was held, attended by members of the public and representatives of charities and voluntary organisations (Hd13).

The PCT declared that there would be additional investment in patient and public involvement, training for staff in engagement, and a review of Partnership Boards (Hd9). However, the PCT also stated that whilst engagement was ongoing, further

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work was needed to develop its engagement strategy and activities, with particular reference to the development of local polyclinics: “The PCT has also commenced user group work to involve patients in PCT Commissioning…further ‘standard’ involvement in the PCT Commissioning pathway could be improved. The PPI Forum continues and is embracing the new role of Local Involvement Networks (LINks), which will connect involvement into the wider public services and provide greater influence within organisations. Internally the PPI function could be better integrated with the PCT’s committee and governance structure. A PPI Strategy has not yet been completed, therefore this should be developed, to include WCC and Healthcare for London (HfL) priority consultations such as those on Polyclinics” (Hd23:8)

Lessons learned from patient and public engagement in the development of Alexandra Avenue Patient and public involvement in polyclinic development appears to have improved since the development of the Alexandra Avenue polyclinic. Lessons learnt from the development of Alexandra Avenue appear to have fed into consultation on the development of other polyclinics: “I think the PCT and the NHS locally progressively got better at engaging the public. So I mean I think that's quite evident in the latest one they did last autumn around the polysystem for East Harrow. They've now built up a database, they know the methods that work, so where it’s a road show, public meetings, you know, leaflets in GP surgeries. I think that was quite slow to get off the ground, so when Alexandra Avenue first started I don't think the response rates were that great.” (Hi22:6)

Before the opening of the polyclinic at Alexandra Avenue, there seems to have been limited information in the public domain about the development and the services that would be available there, although in September 2008, the PCT did issue a press release (Hd4) that provided information on the development of local polyclinics and their potential benefits.

Since then, the PCT has initiated a much wider range of activities and process to publicise the polyclinic and engage patients (see below).

Ongoing patient and public engagement in Alexandra AvenueNHS Harrow has set out extensive detail on its future communication and engagement strategy, including aims, methods, current activities, and proposed actions (Hd20).

The Strategic Plan (Hd13) outlines planned specific engagement strategies around particular services in some detail, and, although not specific to polyclinic development, declares a commitment to a range of consultation activities, including one-off deliberative events, involvement with LINks and PPGs, focus groups, user groups, and engagement with vulnerable and traditionally excluded residents. The PCT also sets out statutory consultation requirements and outlines best practice (Hd20), and a commitment to general ongoing patient and public involvement: “Consultation with the public, service users and where relevant specific patient groups will continue to ensure that services are structured to meet their needs, create simpler pathways and deliver sensible service integration.” (Hd8:14).

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There has been additional investment in the PPI team “to ensure PPI is an integral part of service planning and design” and also plans for the development of skills encompassing patient and public involvement “allowing us to increase patient feedback” (Hd13). With more relevance to polyclinics in particular, “There will be consultation on specific parts of the [Primary and Community Care] strategy e.g. procurement of new polyclinics or GP led health centres, moving services into the community or changing pathways…Consultation will usually be formal. However, when patient/stakeholder involvement is only needed, then relevant community groups and users would be canvassed to help design or tailor services to patient needs.” (Hd8:51)

Recent activities to publicise the polyclinic and engage patients have included the PCT holding their AGM (date unclear) at Alexandra Avenue, with patients talking about their experience (Hd21). Ongoing consultation also takes the form of regular meetings with the patient involvement group within each trust, and the PALs service. During 2010, NHS Harrow has been using ‘Harrow People’, the Council magazine for local residents, to highlight services available at polyclinics, including Alexandra Avenue (Hd19), and the media manager will also continue to issue regular media releases and interviews, and to invite the press to local NHS events (Hi22:20).

Ongoing patient feedback from Alexandra Avenue is also being provided by patient satisfaction surveys (Hd21). Patients are sent a satisfaction questionnaire after their attendance at the clinic. Return rates are unknown, although they are reported to be good. Furthermore, according to feedback from staff, the responses received from the satisfaction surveys show that satisfaction rates have been at approximately 90%. (Note, however, that the primary sources showing the findings from the satisfaction surveys were not provided for this documentary analysis. The result mentioned is based on verbal feedback only.)

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3.3 NHS Lambeth: Gracefield Gardens Health and Social Care Centre

Public and patient engagement relevant to the development of Gracefield Gardens polyclinic occurred in three distinct phases: firstly, as consultation on the development of our strategic services development plan, which identified Gracefield Gardens as a flagship Neighbourhood Resource Centre, which was a precursor of the later polyclinic; secondly, as consultation on the PCT’s Commissioning Strategy Plan of 2007/08; thirdly, as component of the development of the polyclinic itself. It was informed as well by informed by earlier engagement work, both national and local, notably on Your Health, Your Care, Your Say and A Picture of Health in Southeast London.

The PCT has also undertaken evaluation of its engagement activities, which has informed future engagement strategy.

Patient and public engagement in the development of Gracefield Gardens Neighbourhood Resource CentreIn December 2007, Gracefield Gardens Health and Social Care Centre in Streatham opened as a Neighbourhood Resource Centre (NRC). The NRC was part of a ‘hub and spoke’ arrangement of care that was a natural precursor to the development of the polyclinic system. Patient and public involvement in the development of Gracefield Gardens NRC can therefore be seen as directly relevant to its later development into a polyclinic.

Consultation in the early stages of the development of the NRC involved “considerable community engagement during the building process” and included a number of engagement events (Ld7:2; Ld6; Ld14). In 2006, the PCT Estates Department commissioned the Picker Institute to carry out research into patient and staff priorities for new primary healthcare buildings (Ld 38). Patients and staff took part in focus groups, interviews and a questionnaire survey about physical access and the design of internal and external spaces (111 patients and all 11 staff completed the questionnaire). The PCT aimed to use the results to inform detailed design decisions at the new premises at Gracefield Gardens.

As part of its development as an NRC, two GP practices were transferred from old premises to Gracefield Gardens, one of which was the Exchange Surgery. The Exchange Surgery has a Patient Participation Group (PPG), active since 2006 (Ld39). There appears to have been some involvement of patients from the Exchange Surgery in developing responses to issues raised by a GP patient survey, such as extended opening hours and improved access and communication (Ld39). There is also evidence of planned patient engagement around the move to new premises at Gracefield Gardens, which included sending out letters to all patients, information and a newsletter displayed in the practice waiting room, information on the practice website, and flyers through doors and in pharmacies (Ld39). In addition, in March 2007, the PCT held a workshop with Gracefield Gardens staff as part of a mental well being impact assessment of the new NRC. A second workshop with local residents and service users was planned. (Ld19).

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The involvement of local residents, councillors, users and service providers in the development of Gracefield Gardens meant that “people were on board with developments and therefore neither complaints nor opposition were received considering the impact of a major development such as Gracefield Gardens” (Ld44:11) and that due to engagement activity there were “no further petitions and reduced complaints on the development of Gracefield Gardens” (Ld44:16).

Patient and public engagement in the 2007/08 Commissioning Strategy PlanFurther consultation that encompassed the development of NRCs took place during 2007 and 2008. The PCT’s 2007/08 Commissioning Strategy Plan (CSP; Ld34) outlined plans for improved access to services, a wider range of alternatives, shifting hospital-based services to community settings, and the development of some specific community base services, specifically: “a shift in service provision and delivery from acute to community-based settings…with a specific focus on developing collaborative service delivery across a network or consortia of practices/providers, through planned Neighbourhood Resource Centres… (They) will host a number of other locally based teams, including social work and other local authority services and mental health and community teams” (Ld34:43-44).

Extensive consultation on the 07/08 CSP was carried out in two phases. In the pre-consultation phase from July to September 2007, participants were asked to comment on a draft of the CSP. A ‘case for change’ letter was sent to Lambeth Patients’ Forum (November 2006); the Patients’ Forum was given a presentation by the PCT with a question and answer session (February 2007); and an all day public deliberative event was attended by about 70 people (February 2007); (Ld46).

The PCT also commissioned a Citizen’s Forum for Lambeth residents, with over 100 local residents recruited to represent the demographics of the area and various hard-to-reach groups (Ld30). A Steering Group comprising local residents, business representatives, a local Councillor and PCT representatives was also established (Li24).

Between November 2007 and February 2008, the PCT completed a full consultation with local residents and stakeholders on the CSP (Ld30; Ld46). The full consultation was informed by learning from the pre-consultation phase and analysis of PCT stakeholder activities by OPM (Ld 32; Ld33). The consultation included a press release at launch, consultation documents available on PCT websites, and consultation documents and summary leaflets sent to stakeholders, including GPs, Lambeth Council, and the voluntary and community organisations, in particular those representing hard-to-reach groups (Ld 30).

Although there is no specific mention of Gracefield Gardens in the 2007/08 CSP, the feedback that is reported reflects some of the underlying principles that would be realized by the polyclinic system: “The difficulty of accessing both primary and secondary care services (both GP and hospitals) was an issue that recurred in feedback. A desire was expressed to have longer opening hours and better continuity of care in primary care and shorter waiting list times for hospitals. The majority of feedback around access came from the Citizen’s Forum and ‘hard to reach’ groups” (Ld11:33). The PCT reported “a strong and very widespread level

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support for the contents of the CSP. Its strategic goals, themes and the priority areas were backed and welcomed by the vast majority of respondents” (Ld30:12). Whilst there was general support for proposals to develop services in the Streatham area, some residents expressed an anxiety about the relocation of GP services. “There were specific concerns raised regarding Streatham Vale. Local residents and South Streatham ward councillors wanted GP services to continue to be located in the Vale” (Li24:3).

As a result of the 2007/08 CSP consultation the PCT “identified Public and Patient involvement as a key area for development as part of the World Class Commissioning Programme. £300k of non-recurrent funds over two years have been identified to support work to improve this capability within the PCT” (Ld30). The total measurable direct costs of the consultation process around the 2007/08 CSP, including the Citizens Forum, were £57,678 (Ld 30).a

Patient and public engagement in the development of Gracefield Gardens polyclinicBy 2008, many of the required elements of the newly proposed polyclinics were already in place at Gracefield Gardens, and the Centre was put forward as one of the first ‘early implementer’ polyclinics in London. For Gracefield Gardens to function as a polyclinic required GP services to be available 12 hours a day, 7 days a week, 365 days a year. As part of the development of Gracefield Gardens from a NRC into a polyclinic, the PCT set out plans for the procurement of a new bank holiday and weekend primary care service, and the transfer of a range of diagnostic and outpatient based services from Guys and St Thomas’ Hospital (Ld4).

The PCT consulted with stakeholders between November and December 2008 on the draft service specification for the delivery of weekend and bank holiday GP services at Gracefield Gardens. The Director of Primary Care and Community Services wrote to all PCT practices and chairs of practice-based commissioning consortia for their comments (Ld51). In response to the draft service specification, Lambeth Health and Adult Service Scrutiny Committee raised concerns about the possibility of patients passing through 3 different GP services at GG, and its implications for continuity of care – one of the fundamental principles of the polyclinic project (Ld52). The PCT committed to monitoring continuity of care closely and to collect comprehensive feedback.

As well as the extended GP services, the development of Gracefield Gardens as a polyclinic included the introduction of new services that had not previously been provided at the NRC. In Spring 2008, Guys and St Thomas’ NHS Foundation Trust (GSTFT) entered into a partnership with the PCT to provide services usually provided in a hospital setting from a suite in Gracefield Gardens (Streatham Suite), with services operational from October 2008 (Ld4; Ld41). It appears that no engagement activities around this proposed transfer of services took place before the polyclinic opened: “Patients have not to date been involved in developing services at Streatham Suite” (Ld48:16). However, since the transfer of services there has been ongoing patient engagement. Patient satisfaction surveys have been taking place since GSTFT services began operating at the polyclinic (Ld41), with

a This is the only PCT for which any cost information was available. If it’s not been included elsewhere in the report, it’s because the information was not made available for us to analyse.

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positive feedback about staff attitude, comfort and cleanliness of the clinic, and convenience of access to services.Gracefield Gardens polyclinic was also one of two locations proposed for the delivery of a new Community Based Ultrasound Service. Streatham and Clapham Health PBC consortium planned to issue patient questionnaires to gauge patients’ views on the proposed new service in all consortium practices during April 2008 (Ld42).

Additional patient and public engagement activities in the development of the polyclinic included: a press release about Gracefield Gardens and the services available (September 2008), which commended Gracefield Gardens as “one of five healthcare centres across the capital that exemplify the polyclinic service model” (Ld49); two public meetings held with local residents in September and October 2008 (Ld17); and a Patient Forum at Gracefield Gardens that was up and running from September 2008. The PPI lead from PCT was invited to be involved in the Patient Forum(Ld3).

Evaluation of patient and public engagement in the development of Gracefield Gardens polyclinic and lessons learned Feedback on patient and public involvement suggested that there were some areas that could be improved by the PCT: “There is a perception that the PCT could do more to communicate better with both the public and stakeholders on an ongoing basis. There were several comments [in the consultation on the 2007/08 CSP] that the public are not aware of the breadth of services the PCT provides and commissions…It was suggested that the PCT should host more open or community days with the public…Many respondents queried whether patient and public involvement to ensure services are responsive had been given enough emphasis in the document. Though this is mentioned within the strategic goals, there is little detail within the specific commissioning intentions, or elsewhere on how this will be achieved in practice” (Ld34:60)

As a result of the CSP consultation the PCT vowed to “develop a comprehensive communications strategy for involving and engaging Lambeth residents and stakeholders in the ongoing implementation of the Commissioning Strategy Plan and other key strategic initiatives”, and to “ensure that patient and public involvement processes are better integrated into the ongoing development and implementation of commissioning intentions” (Ld34:61). An integrated communications and engagement strategy was adopted by the PCT board in Jan 2010.

A ‘Lessons Learned’ workshop took place to review the development and commissioning of the Gracefield Gardens project, the outcomes of which have informed later developments (Li24). Evaluation of engagement activities has not always been straightforward, and this has influenced how future consultation exercises have been conducted:“Due to loss of corporate memory it has been challenging demonstrating the outcomes from consultation exercises and how these have influenced scheme developments. This has been noted and improved for current/future schemes such as Akerman Road. Local support from the public and councillors for this scheme has been highly commended and played a significant role in obtaining planning permission” (Li24:6)

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Ongoing patient and public engagement in Gracefield GardensThe PCT recognised the importance of ongoing engagement of patients and the public (Ld53; Ld54), and stated that formal consultation on specific commissioning initiatives will take place as required (Ld11). Although not specific to polyclinic development, plans were outlined for engagement events with the local community through the use of public Expos (jointly with LB Lambeth) in September and October 2009, with additional dates planned later in the year and further engagement events with staff, partners, patients and the public in October /November 2009 (Ld1).

Ongoing patient and public engagement at Gracefield Gardens polyclinic has included a Gracefield Gardens summer event, held in August 2009, to raise awareness of services available at the polyclinic (Ld3), in particular the equitable 8am-8pm service (Li24). Leaflets were distributed and comment forms completed by a number of attendees. As of July 2010, Lambeth PCT did not have a communications or patient engagement strategy for the polysystem project (Li24). However, a joint PCT/LINks event on polysystem development took place in July 2010 (Li24), and further consultation on polysystem development has been planned.

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3.4 NHS Redbridge: Loxford Polyclinic

Public and patient engagement by NHS Redbridge has probably been the most comprehensive and focussed of all the case studies. Consultation has been taking place since early on in the development of Loxford clinic, first in its incarnation as Loxford Primary Care Resource Centre, and then later as Loxford Polyclinic. Engagement during the process of developing the Centre as a polyclinic began in the very first stages of planning, and has continued since the polyclinic’s opening.

Patient and public engagement in the development of Loxford Primary Care Resource CentreDuring 2005 and 2006, the PCT undertook extensive public consultation on a proposed development of Primary Care Resource Centres in the area. As with earlier developments at the other case study sites, these Centres are seen as a precursor to the development of polyclinics in the area.

A consultation paper (Rd23) outlined the PCT’s strategy for providing primary care services in three or four purpose-built Primary Care Resource Centres. The first part of the consultation, which took place over 14 weeks from November 2005-February 2006, asked for opinions on the proposed new structure of services and the proposed locations of the Centres, one of which was Loxford (Rd23). Consultation methods that were employed included three public meetings, presentations to community groups, a questionnaire at the end of the consultation paper (Ld5) that could be returned by freepost, and email, postal, and telephone contact details for the submission of comments.

The second part of the consultation, taking place over 12 weeks between November 2006 and February 2007, asked for further responses to the proposed development of a Primary Care Resource Centre at Loxford. A consultation paper was produced that outlined the proposed developments (Rd23), which would entail the closure of two existing clinics. Consultation methods that were used included four public meetings, provision of post and email address in the consultation paper for sending comments, and space at the end of the consultation paper to include comments (Rd23).

Questionnaires were available in multiple languages and formats, and drop-in information sessions were held in both practices that were to be closed, covering daytime and evenings. The drop-in sessions utilised the services of an interpreter and a signer (Ri21:3).

Proposals for the Primary Care Resource Centre at Loxford received “strong local community support” (Rd8), and the public appeared to be generally in favour of the plans.

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Patient and public engagement in the development of Loxford polyclinicThe PCT identified that informing patients and stakeholders of development plans and service changes, encouraging feedback from patients/carers and providing opportunities for patients/carers to be involved in service development should be key objectives of its Communications Strategy (Rd22). More specifically, consultation activities in the polysystem development initiative were identified as a priority, in particular involving statutory, voluntary, private organisations and local communities, and more community engagement with diverse and hard to reach groups (Rd3).“Communications, engagement, and patient experience” was an element of the vision and objectives of the Loxford Polyclinic (Rd1). One of the most successful elements of the engagement process in the development of Loxford Polyclinic has been the creation of the Loxford Polyclinic Community Panel. The PCT’s Community Engagement and Communications team, along with the PCT Patient Experience team, led the development of the Community Panel (Rd24). Responsible officers were the Community Engagement and Equalities assistant, the Loxford Polyclinic manager, and the Assistant Director of Community Engagement and Communications (Rd35).

In conjunction with the local umbrella Voluntary and Community Services (VCS) organisation, the PCT appealed for local residents to join the Community Panel, whose involvement would be dedicated to the development of the Loxford Polyclinic. Over 30 residents joined the Panel (Rd24), which was active from early on in the polyclinic’s development (exact date of inception is unclear). Funding of the Panel was factored into the overall Loxford Polyclinic development cost, and was “integral from the outset” (Rd24:1).

“[The Community Panel] got involved very early on in the process, it was just literally the site had been chosen and they just, and the foundations going in” (Ri21:7) “I’d say that one of the best things about the panel is they've had influence from the very beginning and I think they would say that as well” (Ri21:20)

Panel members were recruited to be as representative of the community as possible, although additional effort was made to try to include younger participants:“Age is always an issue with these kind of panels, you don't often get very young people on panels, and so we had to do wider engagement work to include young people… we did some presentations to a lot of schools and also we did some work with the local community and voluntary sector youth panel and asked them for their views” (Ri21:19)

The objective of the panel was “to provide high level feedback and engagement on Loxford Polyclinic services” (Rd35:1). The Community Panel included a Board non-executive director as a member, to ensure that “the polysystem community voice has real impact” at the highest level (Rd21: 20).

Panel members sat on the tender panels that deliberated over who should run services, in particular for the café, pharmacy, reception and administration at the polyclinic (Ri21:8-9). The Panel was involved in the design of publicity materials, provided feedback on the Strategic Plan, and assisted at outreach events (Rd24). Feedback from Panel members also influenced “practical issues around how the

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centre looks, the way-finding and signage” (Rd24:1), and helped to ensure that the building was user-friendly. Through local contacts and membership of local groups, the panel was able to feed information directly back to, and from, the community in a way that would have been difficult for the PCT to achieve.

“I do think that there's been a case of feeding things back to the local community and just in chatting to people in shops… They'd come to panels and say to us I was chatting to so and so in the local supermarket and they think this, and so that was really useful for us.” (Ri21:10)

“I think that a lot of people are aware of the community panel and I think they've been really, really useful in educating local people.” (Ri21:25)

The panel was also used in the resolution of concerns about transport, “probably the most contentious part of the project really” (Ri22:22).

“What's been really nice is that as the process has gone on [the Panel have] been really positive, very critical at times but generally very positive because we've never held information back from them. It’s, you know, it’s a matter of trust, I mean we've taken information that's quite kind of difficult and kind of confidential and they’ve given us feedback, and there's that nice relationship. And so they’ve actually become really positive vocally in the community in answering questions and talking to local people” (Ri21:9)

The Community Panel was a new initiative for the PCT, and required some dedicated work to cultivate trust and good communication.

“The café tendering process…[the Panel] were told they'd be invited back by the café tendering process team, but they never found out the outcome… at the point when this was being done we’d never had a community panel in the Trust before, not really, we’d had a patient experience panel but it was slightly different… as an organisation it was quite difficult, because obviously I was onboard with this but getting other teams to understand the importance of community engagement and the panel took quite a while, if I'm honest, a lot of people just thought it was a bit of kind of well, you know, it was just something, it was a pain…. And that comes across to people…I arranged for them to join this team to do the café tendering and they weren't fed back to, and so we had to kind of work on those relationships.” (Ri21:13-14)

Feedback from the Community Panel has had a direct influence on the services provided at Loxford Polyclinic:“We got feedback that in the original spec we weren't going to have our blood testing services available at the polyclinic but feedback from the local community was no, we want that, we want that locally. So it’s there now, it took a while to get it up and running but it’s there now” (Ri22:20)

Other sources of local feedback influenced the choice of services that were to be provided at Loxford Polyclinic. The local Health Scrutiny Committee expressed concern that initial plans for services to be provided at LP did not included radiology. The Committee advised “in the strongest terms” that they expected X-ray services to

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be provided (Rd25: 8). As a result of this feedback, an X-ray service was included in the development of the Polyclinic (Rd24).As well as the Community Panel, the PCT initiated a number of other engagement activities during the development of Loxford Polyclinic. Plans included a polyclinic page on the NHS Redbridge website, leaflets on services and transport options, floorplans, patient packs and other promotional items (Pd1).

Between February and April 2008, the PCT carried out an 8-week consultation on a proposed relocation of two GP practices to the new polyclinic. Patient letters outlining the proposals were sent to all patients at both practices (Rd25). The PCT produced a consultation paper that was made available at the surgeries or via email/telephone (Rd25), and a form at the end of the letter and consultation paper was provided for comment, along with an email and freepost address. Community based drop-in sessions were also held at the surgeries.

The PCT also organised workshops with young people, faith events, council tenant fun days, and road shows as alternative ways to encourage people to become involved in the development of Loxford Polyclinic (Rd24). Roadshows held in local shopping centres, assisted by LINks, attracted over 500 attendees (Rd21). Presentations were also conducted in local schools and with staff and members of local community centres and voluntary organisations (Ri21:19). The PCT Community Engagement team arranged sessions and presentations to the wider VCS network, the Borough’s LGBT forum, and a local youth panel (Rd24). Local VCS were offered the chance to run sessions and services in the polyclinic (Rd24).

During the construction of the new building, hoardings surrounding the site displayed key messages about the services that were to be provided within the clinic; which were “well received by the local community and the press” (Rd6: 29), and local press releases were prepared, including articles for the local Asian press, and interviews were conducted with local radio and media (Ri22:8).

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Evaluation of patient and public engagement in the development of Loxford polyclinic and lessons learned The PCT Community Engagement team held an evaluation session with the Community Panel to discuss any improvements that could be made (Rd24).“After seven months we did make sure that we had a kind of, what we called a health check with them and we asked them what their issues were with panel, what they'd enjoyed or they hadn't enjoyed… it was things like…they wanted to chair the panel themselves, which was fine, and we then organised that” (Ri21:12)

Once Loxford Polyclinic was about to open, the PCT Community Engagement team held another evaluation session with the Community Panel to discuss how to take the group forward, given that the panel’s function would inevitably develop from its initial remit (Rd24).

Interviewees who had been involved with the Community Panel reported that they had learnt a number of valuable lessons through their work. These included the importance of involving the public early (Ri21:35), and ensuring consistency in the staff working with the panel (Ri21:18). Clarity in communication also proved vital – avoiding the use of jargon, avoiding PowerPoint presentations, and being clear about what was required of Panel members and in the information that was provided for them (Ri21:17-18).

The success of the involvement of the Community Panel in the polyclinic at Loxford has had an impact on other developments in the area. The PCT Community Engagement team have shared the community panel approach through Healthcare for London forums, at pilot meetings for other polyclinics in the area, and highlighted the role of the panel wherever possible (Rd24). The terms of reference of the Community Panel have been changed since its initial inception. The Panel has assisted in the development of similar panels for four other polyclinics in the area (Rd21) and provided peer support and advice to prospective panel members both locally and for panels being established elsewhere (Rd35). Experiences drawn from working with the Loxford Community Panel have fed into the strategy development for new panels that have been set up.

“One of the issues that we had with the panel from the beginning is that they said they should have been involved before the site was even chosen, which obviously is a lesson learned and for the rest of the panels we've taken that into account” (Ri21:7)As for future patient and public engagement activities, the PCT Communications and Engagement strategy 2010-2015 (Rd32) has declared that each engagement initiative will have a detailed evaluation plan, and have outlined a range of methods that may be used, including online feedback forms, stakeholder surveys, public polls, patient surveys, and feedback from LINks.

Ongoing patient and public engagement in Loxford polyclinicSince the opening of Loxford Polyclinic, the PCT has emphasised the importance of “strong community/patient engagement” in the commissioning of services as part of local polysystem development (Rd2: 11).

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The Panel has also been given responsibility for acting as community spokepersons for Loxford Polyclinic, and taking part in strategic activity. The Community Panel continues to be engaged in monitoring services and contributing to projects “e.g., care pathway work, procurement and monitoring of services” (Rd21:8). The Panel has a dedicated media manager (Ri21:15).

Alongside the continuing work of the Community Panel, many other ongoing public and patient engagement activities have been taking place since the Loxford Polyclinic opened.

Loxford Benefits patient survey (developed with the involvement of the Community Panel) was carried out for three weeks between November and December 2009, with the aim of measuring patient satisfaction and ultimately establishing the benefits of Loxford Polyclinic (Rd36). The survey asked patients about satisfaction with services, opening hours, location, transport, access, facilities, and what other services they would like to see available at the polyclinic (Rd36).

Staff and patient volunteers distributed the patient survey in the reception areas of the clinic. Meetings with staff and the Community Panel were planned to feedback results, as well as a range of information sources to be set up in the polyclinic, including a notice board, posters, intranet, a ‘we did, you said’ table of improvements, leaflets, and booklets (Rd36). There were also plans to install touch screens the polyclinic to collect patient feedback –questions that patients could respond to would be presented on the touch screens. Issues that were raised by the survey included car parking, the phlebotomy service, waiting times, the emergency triage service, and access to GP appointments. As a result, 18 additional hours of GP time have been made available, the triage system is being improved, and an audit of waiting times is taking place (Ri21:21).

In addition, ongoing measurement of patient experience will be gathered on-site using hand-held devices, and feedback will be gathered each month in an ‘exit poll’ survey (Ri21:23). On-going public engagement also occurs regularly with LINks and 15 community and voluntary groups running more than twenty engagement or feedback sessions per week at the polyclinic (Rd21).

The PCT also has monthly dedicated health pages in a local free newspaper, Redbridge Life, which goes out to all the houses in Redbridge. Much of this has been used to publicise developments at Loxford Polyclinic (Ri21), and has also been used to launch the PCT’s five year plan (Ri22).

The wide-ranging patient and public engagement activities that have occurred before, during, and since the development of Loxford Polyclinic may have had a positive impact on public perception of their role in local health care provision. The PCT Strategic Plan 2010 reports a recent IPSOS Mori report showing that residents in Redbridge are more likely to feel that they can influence what their local PCT does than residents in other PCT areas (Rd17)

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4 Key Lessons

Engaging patients and the public early on in any development process is particularly important

Clear communication – both about what is required of participants in engagement activities, and in the information that is provided to patients and the public – is vital for successful engagement

A clear statement of purpose of the engagement exercise is crucial in order to guide messages and to measure success of the process

Where the most comprehensive and consistent engagement had taken place, local residents were more likely to feel that they had a role to play in the planning and decision-making of their PCT

Evaluation of patient and public engagement activities can provide useful information that may inform future planning and strategy, especially the development of other polyclinics

One of the most effective engagement methods employed was the creation of a dedicated polyclinic Community Panel

Where patient and public engagement was initially lacking, it has generally been regarded as having improved during the polyclinic development process

The prior existence of a clinic at the same site does not preclude further consultation when a new polyclinic is under development

The context in which a polyclinic has come into being may relate to the degree of patient and public engagement that has taken place during its development

Whilst it may be clear how a particular engagement initiative is theoretically relevant to the development of a polyclinic, it is often less clear what impact it may have had

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Appendix 1: Documents reviewed: ID Title Date File

typeNo. of pages/ sheets/ slides

Hammersmith and Fulham

HFd2 Polyclinic Development. Briefing Paper for the NHS Hammersmith and Fulham Board Meeting - May 2009

01/05/2009 PDF 8

HFd6 Improving health and healthcare in Hammersmith and Fulham. The case for change

c. 10/2009 Word 8

HFd7 Finalised Structure Chart (PCT organisational chart?)

not dated PowerPoint 15

HFd10

NHS Hammersmith & Fulham Commissioning Strategy Plan

01/11/2008 PDF 378

HFd11

Hammersmith and Fulham Polyclinic Project Initiation Document. Draft

14/01/2009 Word 11

HFd14

Implementing 'Healthcare for London' Commissioning Strategy Plan NHS Hammersmith and Fulham. Sarah Whiting's presentation

30/09/2009 PowerPoint 54

HFd24

NHS Hammersmith & Fulham Strategic Plan 2009 - 2014

01/11/2009 PDF 83

HFd25

NHS Hammersmith & Fulham Strategic Plan Annual Report 2008/09

Not dated Word 43

HFd26

Well London Appreciative Enquiry Workshop and Cafe notes

Not dated Word 52

HFd27

NHS Hammersmith & Fulham Communications Strategy 2009-2012

19/02/2010 PDF 40

HFd28

NHS Hammersmith & Fulham Communications Strategy 2007-2010

06/2010 PDF 19

HFd29

Consultation on Collaborative Care Centre White City Feedback event 2005

02/11/2005 Word 16

33


HFd30

Estates Strategy briefing paper for NHS Hammersmith & Fulham Board Meeting

09/2007 PDF 34

HFd31

Polyclinic proposals briefing paper for NHS Hammersmith and Fulham Board meeting

09/2008 PDF 24

HFd32

Health for London Study of Unscheduled Care in 6 Primary Care Trusts

04/2008 PDF 177

HFd33

NHS Hammersmith and Fulham invitation to join Reference focus group for Unscheduled Care

09/04/2008 Word 1

HFd34

North West London Healthcare Strategic Framework Governance Arrangements

10/2007 Word 10

HFd35

Report on consultation and engagement on NHS Hammersmith and Fulham LIFT projects

12/2008 Word 11

HFd36

Outline of PPI in Unscheduled Care Commissioning

Not dated Word 3

HFd37

Hammersmith and Fulham PCT protocol for patient and public consultation – briefing paper for NHS Hammersmith and Fulham Board meeting

09/2004 Word 9

HFd38

NHS Hammersmith and Fulham Patient and Public Involvement Strategy

Not dated PDF 22

HFd39

London Borough of Hammersmith and Fulham Health and Adult Social Care Scrutiny Committee meeting July 2009 minutes

July 2009 PDF 120

HFd40

NHS Hammersmith and Fulham Organisational Development Plan – briefing paper for NHS Hammersmith and Fulham Board meeting

21/01/2009 PDF 843

Harrow

Hd1 NHS Harrow Commissioning Strategic Plan 2009/10 to 2013/14 version 15

26/02/2010 PDF 67

Hd4 Harrow Primary Care Trust Polyclinic Press Release

10/09/2008 PDF 2

Hd6 Harrow's Joint Strategic Needs Assessment Source Document for 2009/10

01/10/2009 PDF 51

Hd8 Harrow Primary Care Trust Primary and Community Care Strategy 2008/9 - 2012/13

18/11/2008 Word 52

Hd9 Implementing 'Healthcare for London' Developing a Commissioning Strategy Plan ( CSP) for Harrow Dr Sarah Crowther Chief Executive

not dated PowerPoint 38

Hd12

Harrow Council Adult Health and Social Care Scrutiny Committee response to Harrow PCT consultation on Cecil Park and Northolt Road clinics

05/06/2006 PDF 4

Hd13

NHS Harrow Commissioning Strategic Plan 2008/09-2012/13

21/11/2008 PDF 192

Hd14

NHS Harrow Consultation on Enhanced Primary and Community Care Services in East Harrow: Stakeholder Communications and Engagements – Framework and Action Plan

Not dated Word 16

Hd15

Harrow PCT Community Facilities Review Not dated PDF 6

Hd16

NHS Harrow Better Care, Closer to Home consultation document

Not dated PDF 24

Hd1 NHS Harrow Better Care, Closer to Home 25/01/2010 Word 1

34


7 consultation letterHd18

NHS Harrow Better Care, Closer to Home poster

Not dated Publisher 1

Hd19

Harrow Council Adult Health and Social Care Scrutiny Committee response to NHS Harrow’s Better Care, Closer to Home consultation

02/2010 Word 6

Hd20

Harrow PCT Communications Strategy 2008-10

Not dated PDF 76

Hd21

‘Harrow Polyclinic: initial visit 30th November’ notes

30/11/2009 Word 3

Hd22

Harrow PCT transport survey of patients/carers attending the Alexandra Avenue clinic

03/2009 Word 6

Hd23

Harrow PCT Organisational Development Plan 2008-2010

Not dated PDF 57

LambethLd1 NHS Lambeth’s 2009/10 Commissioning

Strategy Plan Refresh30/09/2009 PowerPoint 20

Ld3 Gracefield Gardens Building Board Minutes 09/04/2008 - 30/09/2009

PDF 23

Ld4 Board Minutes. Developing the Neighbourhood Resource Centre Hub and Spoke Model at Gracefield Gardens: Improving Access and Relocation of Services from Guy's and st Thomas' Foundation Trust (GSTT)

01/09/2008 PDF 6

Ld6 Lambeth, Southwark & Lewisham NHS LIFT. Business Case for Approval to Proceed to Financial Close

05/05/2004 Word 63

Ld7 Early Implementer Template Lambeth [GG assessment by HfL]

not dated Excel 1

Ld11 NHS Lambeth 5 Year Commissioning Strategy Plan

2008/09 Refresh PDF 240

Ld14 Lambeth - Gracefield Gardens Services Verification

not dated (08/2009?)

Excel 1

Ld17 Project Execution Plan for Gracefield Gardens Early Implementer Polyclinic

c. End 2008/2009

PDF 11

Ld19 Mental Well-being Impact Assessment on Gracefield Gardens. A report of two workshops - 15th and 29th March 2007; and Equality Impact Assessment for the (local council) Joint Service Centre at the GG - 28 Feb 2008

2007/2008 PDF 36

Ld20 NHS Lambeth Strategic Plan 2010/11 to 2014/15

25/01/2010 PDF 322

Ld30 NHS Lambeth PCT Commissioning Strategy Plan Report on Full Public Consultation (19th Nov 2007 – 11th Feb 2008).

13/02/2008 PDF 19

Ld32 OPM (2009) Review of Communications and Stakeholder Engagement. Report for Lambeth PCT.

07/2009 PDF 40

Ld33 Lambeth LINk Steering Committee. Minutes of meeting on Wednesday 17th June 2009

17/06/2009 Word 5

Ld34 Lambeth PCT 5 year Commissioning Strategy Plan 2007/08 – 2011/12

18/09/2008 PDF 65

Ld38 Designing GP buildings: staff and patient 10/2007 PDF 105

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priorities for the design of community healthcare facilities in Lambeth, Picker Institute Europe, October 2007

Ld39 The Exchange Surgery Patient Participation minutes

06/2006 – 10/2009

8 xPDF 19

Ld40 Local Government Delivery Council (2009) Lambeth Gracefield Gardens Customer Centre. IDeA, February 2009

02/2009 PDF 9

Ld41 GSST NHS FT Board of Directors Meeting 22/07/2009 PDF 10Ld42 Business case for Commissioning a

Community Based Ultrasound Service03/2008 Word 25

Ld44 Evaluation of patient and public involvement at Lambeth PCT March- June 2007

27/06/2007 Word 24

Ld46 Lambeth PCT Communication and Engagement Plan 2007

Not dated Word 7

Ld48 GSST Gracefield Gardens progress report January 2009

01/2009 PDF 25

Ld49 Lambeth PCT press release ‘gracefield gardens helps set the capital trend’ September

10/09/???? Word 2

Ld51 Gracefield Gardens Neighbourhood Resource Centre - GP Services Provision: paper for consideration by Lambeth Health & Adult Services Scrutiny Sub-Committee

16/11/2008 PDF 8

Ld52 Lambeth Health And Adults Service Scrutiny Sub Committee response to Gracefield Gardens Neighbourhood Resource Centre: draft service specification consultation December 2008

03/12/2008 Word 2

Ld53 NHS Lambeth 2009/10 Commissioning Strategy Plan Refresh

30/09/2009 PowerPoint 20

Ld54 NHS Lambeth Communications and Stakeholder Engagement Strategy 2009/10-2011/12

Not dated Word 28

Ld55 SEL Masterclass_Lambeth comments document

09/09/2003 Word 1

Ld56 Lambeth Council response to Lambeth PCT’s Fit for Purpose

20/06/2008 PDF 2

Ld57 FutureStreatham Consultation Questionnaire 04/2008 PDF 8Ld58 FutureStreatham Workshop Slides 15/08/2008 PDF 15Ld59 Lambeth Health And Adult Services Scrutiny

Sub Committee meeting12/2006 PDF 36

Ld60 Lambeth Health And Adult Services Scrutiny Sub Committee meeting

12/2007 PDF 6


03/2007 PDF 10


11/2008 PDF 8

Ld63 NHS Lambeth Joint Strategic Needs Assessment Process Evaluation Report

12/2008 PDF 18

Ld64 Lambeth PCT Annual Report 2007-2008 2008 PDF 58Ld65 Lambeth PCT report to PPI Steering Group: A

Picture of Health08/03/2006 Word 8

Ld66 Lambeth PCT Toolkit for Involving Patients and the Public in Lambeth PCT

Not dated PDF 74

Ld67 Lambeth PCT Report to the Board: Strategic Planning : Healthcare For London, A Picture Of Health And Commissioning Strategy Plans

19/09/2007 Word 12

36


Ld68 Lambeth PCT Report to the Board: Service Redesign and Sustainability Project

22/01/2007 PDF 20

Ld69 Lambeth, Southwark and Lewisham NHS LIFT Strategic Service Development Plan

03/2008 PDF 75

Ld70 Lambeth, Southwark and Lewisham NHS Strategic Service Development Plan

01/2006 PDF 60

Ld71 Lambeth PCT Report to the Board: Update on Lambeth PCT Strategic Capital Development Programme, including LSL LIFT

19/11/2007 PDF 19

Ld72 West Norwood Town Centre Masterplan Stage 3 consultation report

03/2009 PDF 18

RedbridgeRd1 NHS Redbridge Loxford Polyclinic. Polyclinic

Objectives and Scope19/12/2008 Word 15

Rd2 Developing Borough Commissioning 01/08/2009 PDF 17Rd3 NHS Redbridge Draft Strategic Plan 2008/09 –

2012/1327/02/2009 Word 233

Rd5 Redbridge Loxford Services Verification c. Aug-09 Excel 1Rd6 Loxford Services progress c. Dec-08 Excel 1Rd7 Clinical Commissioning governance c. Aug-09 PowerPoint 2Rd8 Full Business Case for South Ilford Primary

Care Resource Centre (later Loxford Polyclinic)

Not dated c. 2006/7 (pre-Darzi)

Word 29

Rd9 NHSR Organisational Chart Not dated c. Feb-10

PDF 7

Rd10

Loxford Operational Management and Governance Structure

Not dated c. Feb-10

Word 2

Rd11

Interview with Redbridge CEO on the polysystem strategy. Bringing services closer to home

16/09/2009 PDF 3

Rd16

Loxford Benefits c. June-09 Excel 2

Rd17

NHS Redbridge Commissioning Strategic Plan 2010-2015

01/01/2010 PDF 108

Rd20

2009-2010 Public Health Report NHS Redbridge

c. 2009 PDF 116

Rd21

NHS Redbridge The Case for Change 30/09/2009 PowerPoint 20

Rd22

NHS Redbridge Information Governance Communications Strategy

15/06/08 PDF 11

Rd23

Redbridge PCT Consultation on the Implementation of the Estates Strategy – paper for the London Borough of Redbridge Health Scrutiny Committee meeting

08/02/2007 PDF 25

Rd24

NHS Redbridge Polyclinic Community Panel project summary

Not dated Word 6

Rd25

London Borough of Redbridge Health Scrutiny Committee meeting November 2007 minutes

12/02/2008 PDF 111

Rd26

London Borough of Redbridge Health Scrutiny Committee meeting October 2008 minutes

11/2008 PDF 51

Rd27

Health for North East London consultation document November 2009 – March 2010

11/2009 PDF 56

Rd28

Rd28 London Borough of Redbridge Health Scrutiny Committee meeting September 2009 minutes

09/2009 PDF 153

Rd2 London Borough of Redbridge Health Scrutiny 08/04/2008 PDF 126

37


9 Committee meeting February 2008 minutesRd30

NHS Redbridge Strategic Plan 2008/09 summary – paper for London Borough of Redbridge Health Scrutiny Committee meeting February 2009

25/02/2009 PDF 32

Rd31

Health for North East London consultation report – paper for London Borough of Redbridge Health Scrutiny Committee meeting January 2010

13/01/2010 PDF 86

Rd32

NHS Redbridge Communications and Engagement Strategy 2010-2015

2010 PDF 54

Rd33

Health for North East London Consultation and Communication Plan

17/11/2009 PDF 31

Rd34

Health for North East London Pre-consultation Business Case

11/2009 PDF 192

Rd35

Loxford Community Panel terms of reference 06/2009 Word 3

Rd36

Loxford Polyclinic Benefits Patient Survey analysis

Not dated Word 17

D16 Healthcare for London ‘Consulting the Capital’ 01/07/2008 PDF 128

38