Friday, 1 September 2017

Wise to start 'Choosing Wisely' prescribing policy engagement again North West London CCGs told

Brent Patient Voice has written to Clare Parker, Chief Officer of the Collaboration of North West London Clinical Commissioning Groups, raising vital issues about the 'Choosing Wisely' engagement on prescribing policies in the eight North West London CCGs.

Here is the letter:

The Steering Group of Brent Patient Voice (BPV) has asked me to write to you urgently about the confusion surrounding the current phase of the “Choosing Wisely” engagement process relating to prescribing policies with the 8 NW London CCGs. The Collaboration of NWL CCGs which you head appears to be leading this process.

The history of this exercise seems to be as follows:

On 19 June Christian Cubbitt for the Collaboration informed BPV that there was an engagement exercise ending 30 June about achieving savings via proposed changes to prescribing arrangements in NW London. We learned that the exercise was deemed to have begun on 12 June, though we have seen no evidence that emails or letters were sent to anyone in the week beginning 12 June, either by the Collaboration or Brent CCG. When we asked Brent CCG in the pre-Governing Body questions from the public session on 2 August why BPV as a body and various individual members who are on the CCG engagement lists had not received notification of the exercise before Christian’s message of 19 June they could not provide an answer. It is not credible to suggest that both BPV and individual members had dropped off the CCG list accidentally. Therefore in our view the effective time allowed for the engagement was 2 working weeks. This was totally inadequate on any conceivable scenario.

However the scenario itself was also deeply flawed for two main reasons.

The first was the absence of information about the existing situation needed as context for a rational judgment about changes which were claimed to be capable of saving over £10 million. We pointed out - and others have done so - that the public would need to know the annual prescribing expenditure on each of the medications listed as not to be prescribed or as suitable for private purchase instead of NHS prescription, accompanied by a clinical assessment of short term and long term medical conditions where savings could be made without risk to patient safety. Manifestly no individual patient reading the questionnaire was likely to have personal experience of more than a small percentage of the medications and would therefore need to know the wider potential impacts before answering the questions.

Secondly the theme suggesting that GPs could ask patients if they minded paying for all or any of these medications out of their own pockets raised obvious issues about ability to pay which were directly affected by a person’s economic situation. There was no indication of any attempt to ensure that the questionnaire would reach a representative selection of individuals in recognised socio-economic groupings or requirement that respondents should indicate what their income bracket or situation in respect of benefits might be. 

In addition it is our view that an Equalities Assessment should have been carried out before the engagement was launched to ensure that it was organised in such a way as to secure that groups with protected characteristics would be reached.

As things stand we have no idea as to the geographical location (even by borough), socio-economic class or long-term medical situation of those who responded to the first online and hard copy exercise. While much material in response to the online survey was available to read (some 300 plus responses), the same does not apply to the 800-900 written replies. We question whether some of the key objections given in the online response were adequately summarised in the papers submitted to Brent CCG GB on 2 August. For the written responses from individuals we have no idea whether these were tick box responses and where they came from.  

Following this deeply flawed sequence of events Brent CCG considered proposals on Choosing Wisely at the Governing Body meeting on 2 August. Among the papers before them was an EQIA from PHAST which contained a series of negative findings about the impact of the proposals on protected groups. No reference was made in the discussion of the item to the nature of these findings but only to the arrangements for the public EQIA Validation event in Harrow on 8 August. The decision was to go ahead with the proposals subject to the outcome of the 8 August meeting. In BPV’s view the decision was defective because no reason was given for ignoring the negative findings of the EQIA. There was also no reference to the National Health Act which determines who should be exempted from prescription charges.

At the EQIA event there was no attempt to “validate” (i.e. check against reality) the EQIA document as laid before the Brent CCG GB. Instead participants were grouped by tables and invited to consider issues under the Equalities Act. Despite this unsatisfactory procedure participants (including several from BPV and pharmacist representatives) contributed what they considered to be relevant concerns about the proposals which they insisted on having recorded. I am to ask for a record of the meeting and in particular the contributions made by participants. Can you please specify a deadline as to when this will be available and on the Collaboration website?

Now to the crux of the matter as far as this letter is concerned.

During the course of the “validation” meeting and apparently on the basis of decisions taken before it began, the Chair, lay member Angeleca Silversides, announced that there would be a further engagement exercise based on modified proposals and “Easy to Read” questionnaires, some copies of which were handed out. A new deadline of 15 September was mentioned. We have learned that Ealing CCG has written to its stakeholders about this exercise with a copy of the new leaflet. In Brent we have heard nothing.

BPV are taking the view that this new or extended engagement has not been communicated by the Collaboration or Brent CCG to those who received the earlier notifications or to those who responded to them, in so far as different. An announcement at a meeting attended by a small fraction of the 2,000,000 people affected cannot be regarded as a satisfactory communication for the purpose. Nor is it clear if this is a revised proposal on which all are invited to comment irrespective of any previous input.

Can you please say urgently therefore:

1. What is the status of this further exercise?
2. Does it replace the first round of engagement and responses to it?
3. If not are people who responded to the first round to respond to this one?
4. If the proposals have been modified how can the two sets of results be amalgamated?
5. Why has the new questionnaire and an explanation not been sent to all stakeholders in NW London and all who responded to round one?
6. What is the status of GB decisions which in the case of Brent envisaged an August start to the new arrangements? (Presumably Ms Silversides has no power to set them aside.)

In view of all these uncertainties would it not be preferable to draw a line under what has happened so far and start afresh with a planning group involving pharmacists, GPs and patients to produce a properly explained and representative survey of prescribing arrangements and possible improvements to them? 

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