How not to run a Health and Social Care Survey, as demonstrated by Cornwall Council and NHS Kernow

This post, which is a revised version of one originally posted on April 17th, 2016, can be downloaded as a pdf file here.

In January 2016 Cornwall Council and NHS Kernow (KCCG), partners in the ‘devolution deal’ for Cornwall, published a ‘Health and Social Care integration questionnaire’ under the headline ‘Have your say on health, care and wellbeing’. Both the design of the questionnaire and the administration of the survey left a great deal to be desired. This report presents a critique of both. It also draws on findings from the public events that were held in conjunction with the survey, and offers some lessons for future exercises of this kind.

The questionnaire
A detailed analysis of the Health and Social Care integration survey can be found below. In a nutshell, the findings include the following:

  • The survey was not based on a systematic sample of any kind. (It was, however, addressed to all age groups, including children under 11.)
  • All the questions were addressed to people receiving care: there were no questions that you could answer as a parent or carer.
  • There were three versions of the questionnaire (on-line, paper and easy-read): they were in material respects different from one another.
  • The questionnaires were not tried out among the general public, and a number of the most important questions were difficult to make sense of.
  • When the questionnaires were published no arrangements had yet been made for a proper analysis of the responses.

And while Council officers will doubtless express their satisfaction with the 2000 or so responses received to the survey, this will represent only 1 in 250 of Cornwall residents.

Who takes responsibility?

This incompetently designed and administered survey appears to have been largely the work of Cornwall Council officers, with NHS Kernow people playing a peripheral role, as witness the answer to a question from the public at the March 2016 meeting of NHS Kernow’s Governing Body:

NHS Kernow colleagues leading on engagement and communications commented on early drafts of the survey. It was then shaped by input from the Single Cornwall Plan steering group, this includes the CCG’s Director of Strategy as the representative for NHS Kernow. The final sign-off came from the Joint Strategic Executive Committee of which the Managing Director and Chair of the CCG are members.

It is not a straightforward matter to discover who among Cornwall Council’s officers was responsible for producing the survey. At the public events (daytime drop-in sessions and evening question-and-answer meetings) members of the Council’s communications team and the Communities and Organisational Development Directorate were seen. It is not apparent from the Council’s website how the latter might have been involved, but the domain of the communications team, according to its web page, includes not only public relations, brand management and leaflet design, but also ‘consultation and engagement’ with local people, to allow them to ‘give their views’ and ‘influence decision making’.

‘Engagement’ is a new name for public participation, which has been around since the 1970s. What seems to have happened here is that the leadership of the communications team successfully staked a claim over ‘engagement territory’, presumably on the basis that they possessed the requisite professional expertise. Evidently this claim went unchallenged: the survey’s many defects did not prevent it from being signed off by senior people in Cornwall Council and NHS Kernow. But practitioners of consultation and engagement need to have some grasp of and training in social research, especially social survey methods, where matters as personal and complex as health and social care are concerned: unfortunately the skills associated with public relations and brand management are very different.

Three different questionnaire formats
The questionnaire was available in three different formats: on-line (with completed questionnaires forwarded to a website in Sweden!), paper (as a pdf to be printed out and filled in by hand if downloaded), and ‘easy-read’. There were significant differences in the questions that they asked, so there were actually three different questionnaires, which will inevitably hinder analysis of the responses.

The survey was manifestly defective in other respects too. It was addressed to people who are receiving services (or who think they might be in future), but not to people looking after those who cannot express their needs for themselves. So the parents and guardians of young children, and carers – looking after people with disabilities, or who have dementia, or who are housebound and lack internet access – were effectively denied the opportunity to ‘have their say’.

And the language of the questionnaires presented problems. Members of a local Patient Participation Group in West Cornwall spent time in the waiting room of their GP practice encouraging patients to complete the questionnaire: they discovered that many patients found the questions difficult to understand and respond to. (See Appendix.) It is apparent that the questionnaire had not been tried out among members of the general public (although we are told that elsewhere in Cornwall members of a PPG, who are of course people with an active interest in health matters, had seen it and commented on it).

For the results of a survey to be of any use, the questionnaire must be designed with an eye to how the responses will be analysed. This one clearly has not been so designed. Several questions (such as ‘What are the three most important things to you when you experience health and social care services and support in Cornwall?’; ‘What would you like to achieve in terms of your own health and wellbeing?’; and the double (or treble) question ‘Do you have any suggestions that would help to improve your overall wellbeing and better meet your health and care needs at less cost?’) are open to being interpreted by different respondents in different ways, so it will be a formidable task to categorize and analyse the responses, especially for someone who was not involved in designing the survey. As of 3 April 2016 (a week after the closing date for responding to the survey) no arrangements had been made for a person with relevant experience to do this.

Comparison of this survey with the Council’s Residents’ Survey carried out in 2014 by the market research company Marketing Means is instructive: it demonstrates conclusively that this one has been formulated and the distribution of questionnaires organized by people with minimal understanding and experience of social research and survey methods. As a consequence there is no way that the findings can be sensibly analysed to guide priorities for the future of health and social care in Cornwall. At best this survey can serve no practical purpose other than as a ‘fishing expedition’ for ideas: a ‘list of mentions’ based on an entirely unsystematic sample is the most we can expect to emerge from it.

The questions that were asked
Q1. Your closest large town
The online and paper versions ask ‘Where is your closest large town?’ We can infer that they are not asking for latitude and longitude, since the paper version adds ‘For example: Truro, St Austell, Camborne, Bude or Penzance’ and the online version offers a drop-down menu with a list of 20 towns on it. Notably, Camborne/Pool/Redruth appears in this list as a single entity, and St Just does not appear at all, although its population is larger than those of Fowey, Lostwithiel and Padstow, which are on the list. So respondents have to scratch their heads and make a judgment as to the largeness of nearby settlements: they can’t simply give the first part of their home address’s postcode, which would of course be a perfectly straightforward thing to do.

The easy-read version asks ‘Which is your closest large town?’ and again gives the examples of ‘Truro, St Austell, Camborne, Bude or Penzance’. Although there is no ambiguity in the question (asking ‘which?’ instead of ‘where?’), this again calls for a judgment as to what counts as ‘large’.

Q2. Your age
All three versions ask ‘What is your age?’, and offer seven age ranges: Under 11 / 11-18 / 19-35 / 36‑50 / 51-65 / 66-80 / Over 80. Evidently the designers of the questionnaire wanted to cover the entire possible age range, but we may reasonably ask them: ‘What response did you expect to get from children under 11?’ While this is clearly a laughing matter, it raises a serious point which is not a laughing matter at all: Who speaks for the children? The questionnaire is addressed solely to individuals who receive services or might do so in the future: it entirely ignores people who care for them. Parents and other carers are treated as though they don’t exist. They will have experiences in looking after children, people with disabilities, people with chronic illnesses, dementia, etc., but no questions whatever are directed to them.

Q3. Ethnicity and ethnic origin

On this topic we find a great muddle. The paper and easy-read questionnaires ask: ‘What is your ethnicity?’ The paper version offers no alternatives or examples from which to choose. The easy-read version does offer some examples: ‘White British, White Cornish, Black British, White Asians, etc.’ (no ‘mixed’ category is offered as an example). But the very concept of ‘ethnicity’ is a challenging one (the author of the easy-read version seems to have been defeated by it!), and indeed the term is not in use in questions asked by the Office of National Statistics for census purposes. Only the online questionnaire asks the question as it should be asked – ‘How do you describe your ethnic origin?’ – and it offers a range on a drop-down menu: ‘White (for example, British, Scottish); Mixed (for example, White and Asian); Asian or Asian British; Black or Black British; Cornish; Other.’ Even here, however, the category ‘Cornish’ seems to have been added as an afterthought: it is scarcely an alternative to ‘White’.

We may wonder why there is an ethnicity/ethnic origin question at all. What is its relevance? (Did the compilers of the survey feel they were expected to include such a question?)

Q4. Long standing health condition

The online and paper versions of the questionnaire ask: ‘Do you have a long standing health condition? i.e. a physical or mental health condition or illness that is lasting, or expected to last, for 12 months or more.’ Both versions ask for a ‘Yes’, ‘No’ or Don’t know’. The easy-read version uses slightly simpler language – ‘Do you have a long term health condition? … that is lasting, or could last for 12 months or more.’ – and one of the choices is ‘I don’t know’. Again, in all three versions this question is directed only towards people who receive services or, one presumes, who might do so in the future: it is not a question for carers.

Q5. Written care plan

The online and paper versions of the questionnaire both ask: ‘Do you have a written care plan? i.e. an agreement between you and your mental health professional or social services to help you manage your day to day health.’ And both offer three alternative answers: Yes / No / Don’t know. The easy-read version shows that an attempt has been made to use plainer language: ‘Do you have a written care plan? For example: Something between you and your mental health professional or social services to help you cope with your day to day health.’

Q6. Three most important things
Again, the online and paper versions of the questionnaire ask the same question: ‘What are the three most important things to you when you experience health and social care services and support in Cornwall?’ Contrast this with the easy-read version: ‘What are the three most important things that you need when you have health and social care services and support in Cornwall?’ In asking about ‘needs’ the easy-read version is taking a less abstract, more down-to-earth, approach.

Significantly, no suggestions are made for what these ‘important things’ might be. Given the emphasis in the publicity on ‘hear[ing] about your priorities’, one would expect the questionnaire to have been designed to elicit these and place them in order, but this is clearly not the case. Moreover, if respondents had been offered some alternatives, such as suggestions emerging from a trial of the questionnaire, they would have gained some sense of ‘what sort of things’ were wanted. A good survey goes at least some way towards creating a dialogue between surveyors and respondents: questions like these do not.

Q7. Health and wellbeing
Under this heading there are some striking differences in language between the online and paper versions and the easy-read version, as we see in the table below. Contrast ‘What would you like to achieve in terms of your own health and wellbeing?’ with ‘What would you like to do that could make your health and wellbeing better?’ The very language ‘to achieve in terms of’ is abstract, ‘in-group speak’, doubtless commonplace in county halls and commissioning bodies but not out on the street and in people’s homes. And the very term ‘wellbeing’ is used nowadays to describe a wide variety of states: notably economic, social and psychological. How were respondents to know which was meant?

And it is a basic error in questionnaire design to shoehorn two (or more) separate questions together, as in asking for ideas to improve wellbeing but at less cost. By all means ask for ideas about improving wellbeing, and ask for ideas for saving money, but these are separate issues and conflating them will confuse rather than assist respondents.

What was the real purpose of this survey?
Surveys are designed and run for different purposes. It is extraordinarily difficult to pinpoint the purpose of this one.

The publicity coming from Cornwall Council stressed that Cornwall Council and NHS Kernow want to ‘know your health and social care priorities’, but the word ‘priorities’ does not appear anywhere in any of the questionnaires. And as we have seen, no attempt was made to get respondents to place the ‘three most important things’ in order of their importance.

Likewise Cornwall Council’s newsroom news release on February 29th said ‘Public views [are] sought on 5 year health and social care plan for Cornwall …’. but a draft plan had not been published and did not accompany the questionnaires.

Again, although the questionnaire is entitled (on the paper version) ‘Health and Social Care integration questionnaire’, it did not actually contain any question about people’s experiences of health and social care services operating alongside each other, and how well-integrated those services were found to be.

One possible purpose might have been to analyse patterns of need, for example to examine whether there is a correlation between need and particular age/sex groups or geographical location, but the questionnaires included no question about the sex of the respondents, and the question about geographical location (the ‘closest large town’!) was so imprecise as to be useless. Importantly, for such a survey to have value it would have to be comprehensive. If it were felt to be prohibitively expensive to send a paper copy to every Cornwall resident (aged from 0 to 80+), some form of systematic sampling should have been employed, as was done with the Council’s 2014 Residents’ Survey. Or target groups could have been identified, perhaps from the lists of patients held by general practices or lists of clients held by social services. None of these was done.

A lack of forethought must also be responsible for the survey’s failure to incorporate questions for parents/carers. This is simply inexcusable. It means that the needs of those who are cared for but cannot express their needs – such as young children, people with certain disabilities, those who are housebound and don’t have access to the internet, those who have dementia – are likely to be overlooked.

Lacking a clear purpose, the only function we can find that this survey performs is that of trawling for ideas: a ‘fishing expedition’. This is perhaps the kindest interpretation that can be put upon this exercise. But fishing expeditions can provide no basis for making policy in the complex fields of health and social care.

A questionnaire incompetently administered

Whatever the purpose of a survey, it needs to be set up and run competently. As the above detailed critique shows, this one has not been.

(1) There should have been no need for a separate ‘easy read’ version of the questionnaire, using plainer language: it was necessitated only by the existence of ‘difficult to read’ versions in the first place. And the person tasked with making it easy to read clearly threw in the towel when he or she came to the question ‘What is your ethnicity?’

(2) A closing date for receipt of responses was published, March 25th. The closing date was then brought forward with no announcement to March 14th, which actually fell before the end of the series of public meetings. At the beginning of March the original closing date was restored, again with no public announcement. But at the Penzance drop-in session on March 8th paper copies of the easy-read version were still showing March 14th as the closing date.

(3) There can be no excuse for not ‘piloting’ a questionnaire among the general public before disseminating it, rather than simply showing it to a small group of health activists.

(4) It is unfortunate that a team from the University of Exeter who have been asked to take part in analysing and interpreting the results were not involved in designing the questionnaire: questionnaires should always be composed with ‘What will the answers tell us?’ in mind.

(5) Finally, it is not clear what advantage has been gained by employing a firm whose headquarters are in Sweden. Who had that idea? It may be that had a firm closer to home been employed some of the errors listed here could have been avoided.

Learning from the public events
Following a series of drop-in displays and question-and-answer sessions around Cornwall, a report presented to Cornwall Council’s Health and Adult Social Care Scrutiny Committee on 5 April 2016 listed a number of ‘topics … building on the emerging themes from the survey’:

  • What’s good about health and care in Cornwall now?
  • What’s not good about health and care in Cornwall now?
  • How can we join up services to better meet your needs?
  • How can we best use the resources and local assets we have got?
  • How can we help you start well, live well and age well – away from hospitalised care?
  • How can we help you access the right care in the right place at the right time? i.e. GPs/doctor’s surgeries, minor injuries and urgent care, operations/surgery, social care, mental health, community hospitals

These questions are manifestly much easier to understand than many of those in the actual questionnaires. Talking to people is often a very good way of clarifying one’s own thoughts and expressing them in plain language.

Conclusions: Lessons for future surveys
(1) It is important to be clear about the purpose of the survey. What do you want from it? As we have seen here, in the present case the aims were variously described as ‘knowing your priorities’, seeking views on a ‘health and social care plan’, and finding out about ‘integration’ of services, but there were no questions about priorities, there was no draft plan to comment on, and there were no questions about people’s experiences of service integration or lack of it.

(2) It is crucial to decide how to sample your population. Do you want a sample covering the whole population that you can generalize from with confidence? Are there distinct groups you want to cover, e.g. carers, parents, women/men, people with experience of hospitalization, people with long-term health conditions, people living in care homes, people who are housebound?

(3) The people who are going to analyse the results should be involved in designing the questionnaire. Among other things, they will always be asking: What will we do with the answers? What will they tell us?

(4) Draft questionnaire(s) should be tried out – piloted – on the general public, not on people who are already well-informed about the subject.

In conclusion, a point needs to be made about the language used by officers and other professionals. Their current preference for ‘engagement’ over ‘public participation’ and ‘public involvement’ not only writes the public out of the term, literally: it places the initiative with the body concerned. The Council and the Clinical Commissioning Group are implicitly seen as active, with officers doing the engaging: the public is passive, on the receiving end, being engaged with. The effect is to reinforce an official mindset that already finds it difficult to cope with initiatives and criticism that come from watchdog groups and others in the public realm. Can we get back to ‘public participation’, please?

I do not doubt the goodwill and sincerity of those who organized the present survey. But the official mindset has not served them well. And they have to realize that undertaking a social survey is not a job for the inexperienced, however well-meaning and enthusiastic they may be.

Peter Levin

© Peter Levin 2016. All rights reserved.

Appendix: Notes from a general practice waiting room in West Cornwall

The following notes have been supplied by members of a Patient Participation Group in West Cornwall, and are reproduced here without any editing or alteration.


Several members of our Patient Participation Group took it in turns to spend time in the waiting room of our practice, encouraging patients to complete the Health and Social Care survey.

Whilst we enjoyed spending the time talking to and listening to what patients had to say to us, we found that the survey was neither clear nor user-friendly in language, and patients found it difficult to answer. In particular, we noted the following:

Q1 Where is your closest large town?
It would have helped to have a list to choose from, rather than just five examples. Were they meant to choose from those?

Q3 What is your ethnicity?

Patients were unsure what to write here – a list of options would have made this easier to answer

Q5 Do you have a written care plan?

Patients felt that the survey was not relevant to them if they did not fit in this category

Q6 What are the three most important things to you when you experience health and social care services and support in Cornwall?

As we were in a GP practice, patients instinctively commented mostly about their experiences of general practice, and couldn’t think much further than that

Q7a What would you like to achieve in terms of your own health and wellbeing?

Patients found that a strange question – they just wanted to be fit and well! They also used these questions to comment on their own experiences, though how that will be used in analyzing the survey remains to be seen

Q7b What are you already doing towards that?

Patients found that difficult to answer, and weren’t clear what they were supposed to say

Q7c What additional help might you need?

Patients found that difficult to answer too. They weren’t sure whether they were meant to say “more money”, or “more disability aids”, or something else they didn’t know

Q8 Do you have any suggestions that would help to improve your overall wellbeing and better meet your health and care needs at less cost?
Patients found this a baffling question as it asked three things in one sentence. One lady responded: “What the hell is that supposed to mean?”

Other comments

a) Through whose eyes?
Some people wanted to reflect on health and social care from a carer perspective, and there was little opportunity to do that unless they pretended to be the person they cared for. The same applied to parents of young children.

b) What is ‘well being’?
Generally, the term ‘well being’ is not one used by the average lay person; neither does s/he find it easy to identify their ‘health and care needs’, and certainly not ‘at less cost’, because they don’t know what everything costs anyway

c) A lost opportunity?

I think we as members of the PPG found this an interesting exercise but also perhaps a lost opportunity. A few people managed to express ideas for the way forward whether or not this answered a particular question. How the analysts will use this also remains to be seen. Had the survey been better written and presented, you might have gained really helpful insights into how the community feels about health and social care. As it is, we think you will find it very difficult to use this data effectively or gain meaningful findings from analyzing the data you receive. So it is rather disappointing.

FC, CG and MB 21.03.16


Involving the Public in NHS Commissioning: A Culture Clash in Cornwall

This post can be downloaded as a pdf here. The original KCCG document, which appears to be no longer available on the KCCG website, can be downloaded here

This post takes a close look at how Kernow Clinical Commissioning Group (KCCG) carries out its duty to involve the public in its activities. It focuses on a document entitled Procurement framework for managing Commissioning changes which, although not intended for public consumption, was tabled at a meeting of the Governing Body of KCCG in November 2015. Having been revealed to the public, the document was then announced as being the subject of a ‘piece of engagement’, with comments required within five days, which included a weekend. Following complaints, the deadline was subsequently put back by a month.

West Cornwall HealthWatch (WCHW), an independent voluntary watchdog body, and six other local groups submitted comments on the document. In a detailed and reasoned criticism, WCHW pointed out that it contained no clear statement of the purpose of the document or its intended audience, and that in many places it was difficult to discern what the language used actually meant. Of particular concern was a very confused description of the process of managing changes in commissioning, a description that completely omitted any reference to involving the public in the process, although it is a process that has major implications for patients and potential patients.

Of even greater concern is the reaction of KCCG to the comments submitted and what that reaction reveals about the organization and its culture. The comments were not circulated to all the members of KCCG’s Governing Body, and at a subsequent meeting the document was approved with the wording unchanged. We have learned since that WCHW’s comments were regarded as hostile and aggressive.

KCCG’s reaction is indicative of wide differences between the culture of the organization and that of the public world within which it is situated. Differences in attitudes, expectations and language are so great – and there is so little understanding of them – as to constitute major obstacles to public involvement in KCCG’s commissioning activities. It seems likely that this will be the case in localities across the country, and indeed at national level too.

This paper consists of seven parts:

1. Introduction
2. Detailed comments on the ‘Procurement framework’ document
3. Discussion and conclusions on the ‘Procurement framework’ document (including questions about the way in which KCCG is run)
4. The sequel: how KCCG reacted to criticism
5. KCCG’s constitution and legal duties
6. Is KCCG abiding by its constitution and legal duties?
7. The ‘culture clash’ between KCCG and the public: is there a way forward?

1. Introduction
On November 10th, 2015, a document entitled Procurement framework for managing Commissioning changes [1] was tabled at a meeting of the Governing Body of the Kernow Clinical Commissioning Group (KCCG) [2]. Two weeks later, the co-ordinator of West Cornwall HealthWatch (WCHW) received an email drawing her attention to a ‘piece of engagement … around … a draft procurement framework document’ that had been placed on the KCCG website and informing her that the engagement would close five days later (the five days included a weekend). Following complaints, the deadline was subsequently deferred to December 31st. It is the document on the website, ‘Draft 6’, that is dealt with here. The full version is appended to this paper: there are extracts from it in the text, below, shown in italics.

An earlier version of this paper, under the title ‘The Procurement Framework: a cautionary tale from Cornwall’ was submitted to KCCG on December 29th, 2015 and subsequently published on WCHW’s website. That earlier version comprised an Introduction and two further sections which are reproduced without modification as Parts 2 and 3 of this paper.

2. Detailed comments on the ‘Procurement framework’ document
Section 1, ‘Introduction’
This framework sets out NHS Kernow’s management of major changes to the commissioning of services. Applying a consist (sic) approach for the gathering of evidence, exploration of options and governance, ensuring compliance to all relevant laws and guidance is key to the successful commissioning of services. NHS Kernow is committed to providing high quality clinical services that meet the needs of local communities as set out in its Corporate Objectives and Annual Delivery Plan agreed by the Governing Body. NHS Kernow will look at all options and engage as appropriate to secure the best services for the local population.

What we see here, in the title and the very first sentence of the document, is confusion between structure and process. ‘Frameworks’ are commonly understood to denote structure, something relatively fixed over time, such as an organization or a contractual agreement or – more loosely – a set of arrangements; ‘management’ clearly refers to process, a series of steps, something that proceeds over time. A ‘framework [that] sets out … management’ is a nonsense. The opening words ‘This framework’ suggest that the document itself is a structure, and this is a nonsense too.

Since the term ‘procurement framework’ is clearly a problematic one, capable of being interpreted in more than one way, it would have been helpful to a reader if the document had opened with a definition of it. In mitigation, the treatment of the term and its component parts on various NHS websites is nothing short of chaotic. On one, for example, we find that the answer to a frequently asked question ‘What is a framework?’ begins ‘A framework agreement is …’. [3] On another, belonging to NHS England, we find CCGs advised to ‘establish a procurement framework for “lead providers” …’, although this merely refers the reader to a diagram listing the services that a ‘lead provider’ is required to offer. [4] (The KCCG document makes no reference anywhere to ‘lead providers’.)

The opening paragraph does not state the purpose of the document, nor does it say for  whom it is intended. If the document is intended to be – or to develop into – a manual or handbook, to guide the process, it should say so. But as it stands this paragraph reads as merely a piece of self-praise.

Section 3, ‘Legislation’
Where NHS Kernow intends to work collaboratively with an existing provider to effect  a major change, it will evidence how due process has been followed to ensure all risks and benefits have been appropriately evaluated adhering to all relevant national and regional guidelines.

When NHS Kernow intends to procure a new contract by testing the market for competition, it will ensure compliance with EU Procurement Directives as implemented by UK Law and national guidance from NHS England, NHS Improvement and Crown Commercial Services …

All this seems to amount to nothing more than saying KCCG will follow the rules and show that it has done so. As for the list of pieces of legislation etc. that follows (see the Appendix), the document fails to conform to the convention that pieces of legislation should be given their correct titles and, in the case of statutory instruments, their S.I. number. Presumably, by ‘2015 Public Procurement Regulations’ the authors mean ‘The Public Contracts Regulations 2015’, SI 2015 No. 102. Accuracy and precision are crucial if a document of this nature to be taken seriously.

Furthermore, it is customary in such documents to distinguish measures according to the amount of discretion – latitude – that they afford to decision takers. Thus Acts of Parliament will typically set out requirements that must be adhered to (although a requirement that an office-holder must be ‘satisfied’ about a proposed course of action does of course allow discretion to that person). Codes of Practice, notes of guidance, briefings, advice, recommendations arising out of research: these allow different amounts of discretion to decision takers. This document fails to note these distinctions or even list the measures in a systematic and recognisable order.

Section 4, ‘Financial controls’
NHS Kernow’s constitution sets out the financial limits for the management best value on any purchases carried out on the CCGs behalf. … NHS Kernow will ensure all commissioned services aim to deliver value for money ensuring best quality and price for the service supplied.

This extremely brief section says nothing whatever about how financial controls are to be exercised. Quoting the ‘motherhood and apple pie’ aspiration of delivering ‘value for money ensuring best quality and price’ is hardly likely to assist someone engaged in the commissioning process.

Section 5, ‘Governance’
We see from the diagram in this section of the document (but not from the text) that the oddly-named Project Steering Group (Task and Finish) – ‘Specific job roles from various departments will be a core group …’ (sic) – will report to the Procurement Committee (and through that Committee to the Governing Body). Three of the boxes in this diagram correspond to ‘chunks’ of organizational structure, and have links that presumably correspond to lines of instruction and reporting, but there is a further box, containing the words ‘Finance, Performance & Quality’, that does not connect to any of the other three. This is more than somewhat unusual for a box diagram that purports to represent the structure of an organization. It suggests that the authors do not have a grasp of the very concept of ‘organizational structure’.

Section 6, ‘Procurement Policy’
Interestingly, there is nothing in this section about the process of forming policy: the section is devoted entirely to the principles – high aspirations: motherhood and apple pie, again – to be followed. There is one oddity, however: this section gratuitously includes the completely irrelevant information that the provisions of the Bribery Act 2010 came into force on July 1, 2011.

Section 7, Major commissioning change process
The process for managing a major commissioning change within NHS Kernow covers 4 key stages:

1. Pre- procurement phase (review and plan for change)
2. Collaboration or Competition
3. Mobilisation of the change
4. Contract and performance management

[In the pre-procurement phase,] each commissioning change will commence with a Project Initiation Document outlining the findings following a review of the current state and where a commissioning view is that change is required. The Procurement Committee will review and endorse further work-up to a full business case for allowing a major commissioning change or advise on what further information is required to re consider the project at a later date. Development of a full business case will utilise a range of skills of individuals within the organisation and the development of a Project Steering Group as a Task and Finish Group will be established to oversee its delivery.

Of these four stages, it is Stage 1 – and only Stage 1 – that actually comprises the decision-making part of the process. Disentangling the wording of this section – necessary because the elements are not presented in chronological order – we see that the decision-making process runs as follows:

(1) ‘a review of the current state’;

(2) the forming of a ‘commissioning view … that change is required’;

(3) the writing of a ‘Project Initiation Document’;

(4) the ‘Procurement Committee will review and endorse further work-up to a full business case’;

(5) a full business case is developed: this includes an outline business case (see the ‘Procurement framework’ document), but we are not told whether or not this precedes the Procurement Committee’s decision to endorse ‘further work-up’.

(6)  At some point during the development of the full business case – we are not told when – ‘the development of a Project Steering Group … will be established (sic) to oversee its delivery’.

Conspicuous in this description of the process is the complete absence of any reference whatever to involvement of patients or the public in this process. KCCG makes great play of its commitment to ‘engagement’, but when we look for some description of how this is to be incorporated in the decision-making process we find nothing at all. Worryingly, what we see here is effectively a prescription for a process of building up such a strong momentum within the KCCG organization that by the point at which the public gain entry to the process it is extremely difficult to change direction: the result, inevitably, will be confrontation and conflict.

If we take KCCG’s protestations of its support for engagement at face value, this document has to be seen as a classic case of what goes wrong when drafting is carried out by people who do not appreciate the wider context within which the organization is situated and who do not fully comprehend the process and how it works. They may be fluent, to some extent, in jargon, but their words require interpreting and disentangling, as the above discussion demonstrates.

‘Collaboration or Competition’ is presented here as a ‘key stage’ in a process, but of course it is an issue, not a stage. As set out in the document, the issue is one for the Procurement Committee to decide, and to decide on the basis of the full business case. This seems bizarre, to put it mildly: collaboration and competition must surely each require their own business case. It is also an issue on which patients, the public and health service staff all have experiences and views that deserve to be taken into account. This is another reason for opening the process up and engaging them at an early stage.

‘Mobilisation of the change’ and ‘Contract and performance’ are essentially to do with the implementation of decisions, and accordingly fall beyond the crucial steps in the decision-making process. They will need to be thought about in advance, of course, and one might have expected to see the testing of feasibility as a (recurring) stage in the process, but such a stage does not feature in the KCCG document.

3. Discussion and conclusions on the ‘Procurement framework’ document
From its content, it is very hard to discern the purpose and intended audience of the ‘Procurement framework’ document. It may be that these were not actually identified, and that KCCG was simply following an instruction to produce a ‘framework’. Or that the leading lights in KCCG saw an opportunity for self-advertisement. It is certainly strange that the document makes no reference to any of the literature on commissioning already published by NHS bodies, which suggests that the authors have started from scratch and in effect embarked on ‘reinventing the wheel’.

Moreover, the document contains very, very little in the way of practical guidance: instead we find high aspirations, couched in gobbledygook, such as this: ‘NHS Kernow will ensure all commissioned services aim to deliver value for money ensuring best quality and price for the service supplied.’

What is really worrying is the seeming inability of the authors of the document to think in an analytical way. They have not defined the term ‘procurement framework’. They have not grasped the distinction between structure and process, and are demonstrably unable to lay out the elements of the process and see how they fit together. Their jargon-laden writing style too is suggestive of an inability to think clearly. If this is an indication of the calibre of those who oversee and budget for the National Health Service in Cornwall and the Isles of Scilly, then patients, the public and health service staff have every reason to be very concerned indeed.

In appraising the ‘Procurement framework’ document one word comes repeatedly to mind: ‘amateurish’. Judged by both its content and its presentation, it simply does not reach a professional standard. In part this may be attributable to the make-up of the CCG’s Governing Body, the 15 members of which include seven General Practitioners, another Doctor member and a Nurse member. General practices are essentially small businesses, and it is hard to see how running one can be a qualification for  running an organization with an annual budget of more than £700 million. It follows that the Governing Body must be heavily dependent on KCCG’s paid staff for advice and guidance, and accordingly serious questions must be asked about the calibre of those staff. The recent news that, 8½ months into the current financial year, KCCG is heading for a year-end deficit of £14m, having previously forecast a surplus of £500,000, and is to have a so-called ‘turnaround director’ appointed, adds weight to this concern. [5]

What lessons can be learned from the situation in Cornwall? Kernow CCG is just one of 209 clinical commissioning groups in England, and clearly we have no grounds for generalizing from this one CCG to others. But this study does show what can happen when a CCG gets the bit between its teeth. KCCG seems to have gone off on an eccentric foray of its own, and it is only a matter of chance that this latest escapade has come to light. The current financial situation, although it is now receiving attention from NHS England, seems to have been detected very late in the day, and while the diversion of resources into producing a grandstanding but ultimately useless document may not have been massive, it does raise questions about the judgment of those in charge.

So we are left with some questions. Are other CCGs grappling with the problem of having to change contracts that they have commissioned: if so, what guidance have they received from NHS England or other bodies? Is there scope for CCGs to work together on the problems that they face? Are arrangements for overseeing the work of CCGs satisfactory, or is an inspection regime of some kind called for?

And as for Cornwall itself, an improvement to the governance of KCCG is clearly urgently needed. What can be done to provide it?

Part 4. The sequel: how KCCG reacted to criticism
The KCCG Governing Body met in public on Tuesday, January 13th, 2016. The papers for the meeting included a document headed ‘Procurement framework …’: this turned out to be precisely the same document as had been offered for ‘consultation’, apart from the addition to the ‘Governance Structure’ diagram of a line connecting the ‘Finance, Performance and Quality’ Box to the ‘Governing Body’ box. No other changes at all had been made. The Governing Body was asked ‘to approve the final version of the Procurement framework’. [7]

It was reported to the Governing Body that a total of seven organizations had submitted comments, West Cornwall HealthWatch having been one of them. Questions from the public elicited the information that these comments had not been circulated to all members of the Governing Body.

The officers also said that ‘Procurement is not a policy/strategy that CCGs have to consult on’ and that ‘The framework that was discussed in November 2015 is the same one that was previously published on the CCG website, for the period 1st April 2013 to 31st October 2014 and is only updated with changes in the CCG structure and or legislative change’.

The officers reported as follows:

There are two consistent themes in the comments/responses received from the consultation:

1. The documentation is not public facing and therefore contains a number of NHS acronyms and administrative language.

The framework document that went for public consultation was written for an internal NHS audience. It is not necessary for CCGs to consult on frameworks of this nature and initially it had not been NHS Kernow’s intention to hold a public consultation on this updated and amended document from 2013.

To address this issue NHS Kernow is in the process of preparing a subsequent document that will support the framework and addresses the specific procurement regulations and the NHS requirements on competition and choice raised within this consultation. It is anticipated this document will be ready for public consumption in February and the document will be launched at an invitation event from contributors to the consultation held in December.

2. Public and Service User engagement is paramount throughout any service change/procurement.

NHS Kernow has received consistent feedback regarding engagement and as a result are in the process of creating a specific engagement group that deal specifically with service changes and procurement requirements. This group is an addition to the current engagement and service user group already established.

Having been asked ‘to approve the final version of the Procurement framework’, the Governing Body duly did so. [6]

5. KCCG’s constitution and legal duties
Involving the public: what KCCG’s constitution says
Kernow CCG is required to act in accordance with its constitution,7 in which there are numerous sections which refer to involving local people.

  • S. 5.4.1  ‘The governance arrangements … detail the way in which Kernow CCG will demonstrate principles of probity, accountability and transparency to allow the organisation to serve patients and the local population effectively.
  • S. 5.5.1  ‘The Group will demonstrate its accountability to … local people in a number of ways, including by:

 ◊   appointing independent lay members … to its Governing Body;

◊   holding meetings of its Governing Body in public (except where the Group considers that it would not be in the public interest in relation to all or part of a meeting);

◊   meeting annually in public to publish and present its annual report.

  • S. 6.2.1  ‘[T]he Group will make arrangements to secure public involvement in the planning, development and consideration of proposals for changes and decisions affecting the operation of commissioning arrangements by …

◊   working in partnership with patients and the local community to secure the best care for them;

◊   involving patients and the public, encouraging and taking account of feedback in the planning of commissioning services and in developing, considering and making decisions on any proposals for changes in commissioning arrangements that would have an impact on service delivery or the range of services available to demonstrate transparency, inclusiveness, fairness and accountability in decision making;

◊   making decisions in an open and transparent way so that people can understand how services are planned and delivered;

◊   making it possible for patients, the public and other stakeholders to be involved in decisions about services for the local population;

◊   consulting with people who are affected by service change …’

  • S. 7.5.4  The Governing Body may delegate authority to the People’s Commissioning Board and make decisions on any aspect of its work deemed appropriate by the Governing Body. The Lay Member for patient and public involvement is the Chair of the People’s Commissioning Board and will bring reports, recommendations and requests from it to the Governing Body. The Governing Body is required to ratify any recommendations or decisions made by the People’s Commissioning Board.
  • S. 8.7.1  The Chair of the Governing Body is responsible for …

◊   overseeing governance and particularly ensuring that the Governing Body and the wider Group behave with the utmost transparency and responsiveness at all times;

◊   ensuring that public and patients’ views are heard and their expectations understood and, as far as possible, met;

◊   ensuring that the organisation is able to account to its local patients, stakeholders and the NHS Commissioning Board …

  • S. 8.11.1&2  There are two lay members appointed to the Governing Body, one to lead on audit, remuneration and conflicts matters, and one to lead on patient and public participation matters. The lay members have a non-executive role within NHS Kernow CCG.

Involving the public: the law
Under Section 14Z2 of the Health and Social Care Act 2012 (Public involvement and consultation by clinical commissioning groups), KCCG ‘must make arrangements to secure that individuals to whom the services are being or may be provided are involved … in the planning of the commissioning arrangements by the group, [and] in the development and consideration of proposals by the group for changes in the commissioning arrangements where the implementation of the proposals would have an impact on the manner in which the services are delivered to the individuals or the range of health services available to them’. [8] In other words, KCCG has a legal duty to involve the public in planning its ‘procurement framework’ and in the actual process of developing and considering changes in commissioning.

The law has also something to say about the role of the Lay Member on the Governing Body. There are statutory Regulations, published by the NHS Commissioning Board, which cover this. [9] The Lay Member has ‘a lead role in championing patient involvement’. ‘Their focus will be strategic and impartial, providing an independent view of the work of the CCG that is external to the day-to-day running of the organisation. … This person will help to ensure that, in all aspects of the CCG’s business, the public voice of the local population is heard … In particular, they will ensure that the CCG … responds in an effective and timely way to feedback and recommendations from patients, carers and the public.’

6. Is KCCG abiding by its constitution and legal duties?
‘Accountability’, ‘transparency’ and ‘involvement’ are fine words but how can they be translated into practice? All of them imply a relationship with the public, so to put them into practice necessitates asking ‘Accountable to whom?’, ‘Transparent to whom?’, ‘Involving whom?’

To answer these questions, within an organization that deals with the public, there have to be some people on the staff and Governing Body who are able to imagine how that organization and its behaviour look to people outside. They have to be able to put themselves in the shoes of members of the public. Sadly, despite KCCG’s constitution committing it to transparency, it evidently did not occur to anyone that choosing the Isles of Scilly as the venue for its 2015 annual meeting, to publish and present its annual report, as its constitution requires, was guaranteed to prevent the attendance of any member of the public from mainland Cornwall, a plane ride away.

Likewise, it seems not to have occurred to the authors of the ‘Procurement framework’ document that it should as a matter of course be made public, even though the Health and Social Care Act 2012 requires CCGs to involve the public in the planning of its commissioning arrangements and in the development and consideration of proposals for changes in commissioning arrangements (see above). This rather contradicts the view expressed in the report to the Governing Body at its January 2016 meeting in the case of the ‘Procurement frameworks’ document that ‘[it] is not necessary for CCGs to consult on frameworks of this nature’. And clearly, to make no provision for involving the public in the ‘Major commissioning change process’ is also cocking a snook at the law.

In this context, the position of the Lay Member for patient and public involvement is of particular interest. The person appointed worked for 31 years in the NHS. At the point when he retired he was Chief Executive of two primary care trusts. His long experience and seniority will have given him considerable insight into the complexities of managing health services and a sympathetic understanding of the viewpoints of NHS staff. Within KCCG he has been appointed Chair of the Procurement Committee, although under KCCG’s constitution the lay members have a non-executive role within NHS Kernow CCG (S. 8.11.1&2) and the statutory Regulations explicitly say (see above) that he must provide ‘an independent view of the work of the CCG that is external to the day-to-day running of the organisation’. Perhaps it was his managerial experience rather than a grassroots affinity with patients and public that secured his appointment to the KCCG Governing Body. (Interestingly, although the KCCG constitution specifies that ‘The Lay Member for patient and public involvement is the Chair of the People’s Commissioning Board’, there is no indication on the KCCG website that such a body actually exists.)

7. The ‘culture clash’ between KCCG and the public: is there a way forward?
From the point of view of an organization such as West Cornwall HealthWatch, a voluntary, independent health watchdog that monitors developments and campaign to safeguard and improve existing services provided in West Cornwall by the National Health Service, KCCG’s constitution says many of the right things, with its references to public involvement, partnership and so on, and especially transparency and accountability. But the experience with the ‘Procurement framework’ document is a case-study of the gulf between a statutory body and a local watchdog group. It is a gulf that arises from a clash between two very different cultures.

Aspects of KCCG’s culture are readily apparent from the saga of the ‘Procurement framework’ document. Those within the organization are evidently very conscious of the boundary between the organization and those outside it. They have their own  specialized language – ‘administrative language’ – which members of the public do not comprehend. They work in a disciplined hierarchical world, where it is very clear who is above you and who is below, and in which the higher you are the more deference you expect and are accorded. Decisions are taken in committees, where there is pressure – which may be overt or subtle – to come to agreement, to a consensus: the phenomenon of ‘groupthink’. Disagreement is embarrassing, especially if it becomes public, and is consequently to be avoided if at all possible. As we have seen, the Governing Body approved the ‘Procurement framework’ document despite members not having read the critical comments from the public, a step that is hard to explain in terms of rational and independent consideration.

The links that KCCG people have beyond the immediate organization are with health service  ‘professionals’, who are accustomed to possessing a domain in which they have a good deal of autonomy, scope for exercising their ‘professional judgment’. (And in the healthcare world there is a pecking order of professions, to which everyone is very sensitive.) Asserting professional judgment amounts, of course, to claiming that members of the public have little or no right or competence to contest the decisions arrived at.

The culture of a watchdog group such as West Cornwall HealthWatch is very, very different from that of KCCG. There is no ingrained deference towards those high up in the hierarchy: indeed, there is hardly any hierarchy. There is a genuine desire to know what is being planned, and a desire to have matters explained, but the face that KCCG presents is seen as a smooth, hard, expressionless one, with no cracks that would allow outsiders to gain some purchase on what is going on inside. At times there will – understandably – be frustration when it appears that answers to questions are designed to fob off the questioner, and suspicion when it appears that full and accurate information and clear and convincing explanation are not being freely given. At such times some sensitivity to being treated with condescension may be evinced. Some members of the WCHW committee have worked within the NHS, so may be particularly aware of ‘staff side’ views. Some members are opposed on principle to policies such as ‘contracting out’ and other forms of privatization. (WCHW is strictly a non-political party organization, however.) But all are members of the public.

So what happens when a clinical commissioning group meets a watchdog group? One piece of evidence is KCCG’s treatment of the views on the ‘Procurement framework’ document submitted by the seven responding groups. These views were not circulated to members of the Governing Body, and that body approved the document rather than asking for more information or referring it back for further work. We have also learned that the Lay Member for patient and public involvement (who also chairs the Procurement Committee) found WCHW’s paper aggressive and hostile, and he has queried whether WCHW thinks it would be effective in changing people’s minds.

What we see here is a classic case of non-meeting of mindsets. Generalizing for a moment, we have the KCCG mindset, which frames WCHW’s critique as aggressive and hostile: but we can envisage the possibility of a very different mindset, which would see the WCHW critique as forthright and challenging. In the first mindset the critique is an attack, and accordingly to be repelled; the second admits of the possibility that the challenge can be constructively engaged with. One wonders, however, whether people within KCCG are actually aware of having a mindset. Organizational cultures are liable to be so dominant and all-pervading that there is no awareness of mindsets other than the one that is prevailing, no capacity to imagine that there are other ways of looking at the world.

To WCHW committee members, the point at issue over the ‘Procurement framework’ document is different: less subtle, more straightforward. ‘You asked us what we think. This is what we think. These are the questions that we have. Oh, you don’t like them! Are we meant to apologize?’ Arguably, shorn though it may be of tact and diplomacy, theirs is a more honest and direct mode of discourse.

When it comes to resolving issues, there will be a similar divergence of expectations and approaches. In the present case, we wait to see what will happen next. KCCG is in the process of preparing a new document ‘that will support the framework and addresses the specific procurement regulations and the NHS requirements on competition and choice raised within this consultation’. This document is due to be published in February and ‘launched at an invitation event from contributors to the consultation held in December’ (sic). So we wait to see what is in this document, whether there will be an opportunity to read it before the ‘event’ and ask questions at the event itself, whether the ‘Procurement framework’ itself is modified, whether there is any limit on the number of people from the contributing organizations attending – and indeed whether the event is held in mainland Cornwall or on the Isles of Scilly!

The forum of public involvement is an unruly one. Away from statutory bodies and big corporations, it is not hierarchical. Issues are not resolved by top-level negotiations between a select few senior people, to whom others defer, in private round a board-room table. Anyone can ask a question, in public, and all questions come with an entitlement to be given an answer, also in public.

For a constructive debate to take place, certainly the members of watchdog groups need to appreciate the difficulties that managers and professionals face in allocating resources and in planning and developing services.

For their part, the managers and professionals need to understand that transparency and accountability require them to be open, speak in a language that ordinary people can understand, forswear the habit of expecting deference, accept that there are valid mindsets besides their own, allow for and answer honestly questions that they might find uncomfortable, be prepared to learn from outsiders, and indeed take with a good grace some occasional mockery at times when the gulf between the cultures opens up. We trust that this is not too much to hope for.

© Peter Levin 2016

29 December 2015 & 25 January 2016


1. The document is attached to the pdf version of this post as an Appendix. It can be downloaded here. It was formerly to be found on the web at:  (Accessed 27/12/2015)

2. Kernow Clinical Commissioning Group, KCCG, which is the CCG for Cornwall and the Isles of Scilly, also styles itself NHS Kernow. (Kernow is the Cornish language name for Cornwall.)

3. NHS London Procurement Partnership (Accessed 27/12/2015)

4. NHS England, Questionnaire on supporting clinical commissioning groups to buy commissioning support (Accessed 27/12/2015)

5. BBC News, ‘NHS Kernow ordered to deal with financial problems’   (Accessed 16/12/2015)

6. (Accessed 16/01/2016)

7. There appears to be no link to KCCG’s constitution on its own website, but that document can be found here: (Accessed 16/01/2016)

8. Health and Social Care Act 2012, S.14Z2 Public involvement and consultation by clinical commissioning groups (Accessed 21/01/2016)

9. Clinical commissioning group governing body members: Roles outlines, attributes and skills, published by the NHS Commissioning Board, October 2012, pp17-18. This version incorporates The National Health Service (Clinical Commissioning Groups) Regulations 2012S.I. 2012/1631.  (Accessed 21/01/2016)