A New Way of NHS Commissioning

On 22nd April I was invited to attend an event in Manchester, jointly organised by NHS North West (the North West region's Strategic Health Authority) and Voluntary Sector North West (VSNW).

The packed audience at one of Manchester City Stadium's conference suites was made up largely of Voluntary (so-called "Third Sector") organisations, who were there to learn about what a change in NHS organisation could mean as an opportunity for them. Over 100 delegates attended.

Transforming Community Services

The Transforming Community Services programme is the latest in a series of fundamental changes to the way that health and social care is conceived, procured and delivered in England.

The process began more than a decade ago, with the devolution of responsibility for health provision to Primary Care Trusts (PCTs), which are responsible for determining how best to serve the needs of their area.

Simply put, PCTs are allocated money from Central Government through their regional Strategic Health Authorities (SHA's) to assure the health and wellbeing of the populations they serve. Crucially, however, nobody from outside tells them how to prioritise what's needed or how to address those needs (other than to meet certain quality standards).

World Class Commissioning

These shifts were also accompanied by a broader understanding of what NHS care is about. The focus has steadily moved from a medically-driven model of curing people who are sick, to a more preventative and socially informed approach, increasingly focussed on developing health and well-being – preventing people from getting ill in the first place.

This kind of change in emphasis was initially slow to take root – mainly because health service professionals who had been brought up on the old way of seeing health provision were slow to break out of the mould of letting service provision be determined by what clinicians thought they should be treating. A new approach was needed – an approach that would encourage thinking about the services that communities actually need, and delivering those services in ways that those members of the public would prefer to see.

Eighteen months ago the Department of Health launched a programme dubbed "World Class Commissioning" (WCC). The aim of WCC is to break that old style model of thinking. It is framed around a whole new set of so-called "competencies" for a new breed of NHS commissioners. Commissioners are the health service managers who are charged with determining service needs, designing how to meet them, looking for suitable providers, legally contracting them and then monitoring to ensure delivery is successful. (In the longer term they also determine whether priorities have changed, or whether different kinds of delivery approach are needed and evolve the services they design and procure to match that.

Involving Communities

A central competency in World Class Commissioning is the ability to engage with service stakeholders in order to really get to the bottom of the evidence for need, an understanding of what people want, and how they want it to be provided.

Good WCC work requires an understanding of local diversity, along with an eye for how to engineer equal outcomes from services, in order to ensure that the NHS meets the needs of everyone, and not just part of the community.

Now, in the latest part of the change process, there is also an emphasis on becoming more innovative regarding service provision.

Resolving a Conflict of Interest

Primary Care Trusts commission services, as described above. Many of those are procured from local Hospitals (Acute Trusts) or specialist services such as Community Mental Health Trusts (CMHTs) or Ambulance Trusts. General Practitioners are also contracted by PCTs.

Yet traditionally PCTs have also been the providers of some of the most important services too, such as local clinics. This then creates potential conflict of interest when it comes to monitoring those services.

Also, PCTs and Local authorities need to be able to work together at local level, especially in services where the division between health and social care is blurred. This becomes more complex when a PCT is both involved in commissioning and delivery.

The aim of TCS

On one level, the Transforming Community Services programme is about removing that conflict of interest and making possible a wider diversity of service provision in areas where PCTs would previously have dominated.

By October 2009, all PCTs are expected to have drawn up plans for how to split the commissioning and provision aspects of what they do. So, in each existing PCT patch there will be an organisation whose sole purpose is to apply the disciplines and competencies of World Class Commissioning to work with communities to design and procure services that are fit for the purposes of their local population. They are expected to develop the means to consult and include real patient stakeholders, and to be prepared to redesign the specifications of services they require on the basis of the feedback they receive.

In some cases very little might change. The kinds of medical services provided by existing local hospitals will still be needed; yet providers might be asked to change finer details of how services look and feel to the public they serve.

In other cases the change process may be far more radical as contracts come up for renewal.

Different approaches are already emerging. Some hospital trusts are already gearing to bid for providing community services to several PCTs at once. In other cases the staff who run existing local clinic services have the opportunity to perform the health service equivalent of a management buyout and bid to become an independent provider. In other areas we are bound to see some services being commissioned out to private sector providers too. Traditional private hospital operators are in a strong position to bid to replace some GP clinics or community hospitals.

Some of these changes are bound to be controversial, and there are still many unknowns. For instance, will staff in provider organisations continue to be employed under NHS terms? (A question with significant implications for pensions, for instance).

However, the aim of this article is to discuss the opportunity opened up to third sector organisations who already provide services which are important at the social care end of the health and wellbeing equation.

What TCS means for charities and social enterprises

The opening up of the market for provision of local services to PCT commissioning arms is new and hugely significant for the future capacity and sustainability of the third sector. In short, it provides the opportunity for those organisations (singly or in consortia) to bid on an equal basis to receive health service funding to provide services to the community on a long term basis.

The opportunity raises many questions on both sides of the equation. Commissioners have a great deal to learn about how to engage with third sector candidates for service provision. Equally, voluntary and community organisations have much to learn (and some challenges to overcome) in order to be in a position to bid effectively to provide top quality services in a sustainable fashion.

The event in Manchester on 22^nd April was designed to introduce the opportunity and discuss the challenges. Following on from this, a series of roadshow events will be staged around the region to bring commissioners and prospective suppliers together. These will be particularly valuable for specialist services such as Rape and Domestic Violence Centres.

EHRC Responds on the ‘Moving Wallpaper’ Affair

Background

On 20^th March Britain's ITV television channel broadcast an episode of the programme "Moving Wallpaper" which depicted various forms of abuse and harassment of a fictional transsexual character.

A 454 member Facebook protest group explains how the programme was viewed by trans people:

"This programme made gratuitous use of a transsexual character as an object of derision. 'Georgina' joins a team of script-writers and is made to feel unwelcome as the butt of their 'jokes'".

The group lists the catalogue of issues which upset them:

Referring to her as "George" and using male pronouns in reference to her; calling her forthcoming gender reassignment surgery a "knock-through"; threatening to grab her by the Adam's apple, "if she/he still has one"; staff going on strike when Georgina receives a higher rate of pay due to her excellent work; saying she has stubble; calling her "it"; claiming to be scared by her "man hands"; saying she is a man in a frock; writing "vaginoplasty" on her calendar; consistently undermining her right to be part of the writing team and, finally, forcing her to leave by omitting to sign her contract.

According to Pink News [April 1^st], over 50 people made formal complaints to the broadcasting regulator OFCOM. [By the time of writing this is reported to be over 85 people]

The Pink News article quotes Professor Stephen Whittle writing to OFCOM on behalf of Press for Change:

"This programme set out to belittle abuse and insult a transsexual woman, in ways that were completely unacceptable and inciting public derision and hatred of transsexual people."

The same article quotes an ITV spokesperson:

"Moving Wallpaper is a well established satirical comedy now in its second series. All material broadcast was in the context of the nature of the programme and there was absolutely no intention to offend. ITV has a strong record in the positive portrayal of lesbian, gay and transgender characters."

The Press Association reported the star of the show, Ben Miller, offering a defence:

"I find Songs of Praise quite offensive, but I don't want Songs of Praise not to be broadcast on television because I think other people who like Songs of Praise have a right to watch it and simply because I find it incredibly irritating and patronising I think that's my problem. It's not Songs of Praise's problem.

"So I think... the fact that people have been offended, people in the transgender community have been offended, by that episode of Moving Wallpaper I think is a great shame. We want to make people laugh; we don't want to upset people."

Seeking leadership from EHRC

When the events were first drawn to my attention I raised the issue with the local management of the Equality and Human Rights Commission, with whom I work at a regional level. This was within the context of an earlier complaint of mine concerning the commission's lack of visible action on any issue relating to trans people's discrimination and rights – an area which they have a statutory obligation to address.

Since then I have reminded EHRC about the programme on regular occasions, to ensure that the topic did not slip off anyone's desk. Today, being a calendar month since the original broadcast, I reminded them again, via the North West Regional Manager, Catherine May.

This is the full text of Catherine's response:

Dear Christine

Many thanks for raising the issue of the recent broadcast of Moving Wallpaper and the portrayal of the experience of a trans member of staff. As agreed, this was taken up with internal decision-makers at the EHRC who have decided not to follow this up with Ofcom or ITV.

Sadly, the media (both print and broadcast) often produce and say things that individuals find offensive. We frequently get requests both externally and internally asking us to intervene in such matters, often by issuing a statement to the media or by taking some sort of formal action as part of our role as a regulator. However we take the view that standards in broadcasting are not part of our remit (that falls to Ofcom), and if we make exceptions and officially intervene then it's very difficult for us to further manage expectations of other stakeholder groups who have also been negatively affected by offensive or discriminatory programming (which is unfortunately all too common).

I am sure you will understand that these are difficult decisions to make, and we have had similar situations with a few different areas of our work – for example we were criticised for not taking part in the discussions around Carol Thatcher's alleged racist language at the BBC.

We are keen to ensure that we take forward other areas of work that we have discussed that are in the remit of our work, and I will contact you about those separately.

Best wishes

Catherine May
Regional Manager, North West
Equality and Human Rights Commission

What I think

Personally, and in spite of my professional relationship with EHRC, I find this response disappointing.

To defend a decision to step back from intervening in this case with the observation that they don't intervene in others paints a picture of a toothless guardian – a fairweather friend, who can't be relied upon to defend anyone's rights when the chips are down.

It also sends a signal to broadcasters and journalists that it's still open season on Britain's tiniest, most vulnerable and most wickedly caricatured and maligned minority. "Go ahead. EHRC aren't vexed".

That makes me, as a transsexual woman working very much in the public eye, an easy target.

I had made the point to EHRC that this was such a straightforward open and shut case. The discriminatory content was evident to all – except perhaps Ben Miller and ITV's official spokespeople.

It was an opportunity for the Commission, which has so often sent mixed messages about its' support for the rights of trans people, to draw a very clear line in the sand and state clearly that out and out bullying (which often takes place in the pursuit of laughs) is not acceptable. And this, no mistake, was an act of bullying by TV – exploiting its' position of power to lampoon – and clearly liable to incite copycat behaviour in viewers.

The excuse that EHRC should not intervene on OFCOM's territory is not convincing to me. There is absolutely no reason why two regulators cannot work together on a case like this – the one commenting on the illegality of the scene portrayed, the other on the conduct of programme makers. In fact EHRC has, by inaction, robbed OFCOM of a point of reference when they adjudicate the complaint.

And the future?

I'm promised that EHRC are still diligently working on the broader issues that I raised three months ago in January. Having hung up my campaigner hat to be more "corporate" (as they call it) I'm in the difficult position that I have to award the professional benefit of the doubt to the commission and hope that, at some point in time, they will speak up publicly on behalf of trans people and manage to acquit themselves.

And I do repeatedly stress to the commission that they really need to achieve something concrete to acquire any vestige of credibility in the eyes of a community of people who have so far seen no positive outcomes on which to judge them.

In the meantime, I can only hope that EHRC seriously don't expect me to go out on a limb and try to convince any more vulnerable, frightened, angry people that they should put their trust in them sorting anything out for trans people in distress. At the moment I would find that unconscionable.

I'm your critical friend guys, but you surely don't expect me to offer your excuses as well?

The Lovelace Colloquium Videos

The second annual BCS Lovelace Colloquium took place at the Electrical Engineering Department in Leeds University on 16^th April 2009.

The aim of what is now an annual national event is to reach out to young women undergraduates and inspire them about the opportunities for them to pursue both academic and business careers in technology areas such as Information Technology.

A "Just Plain Sense" Podcast about the event contains interviews with the organisers, some of the speakers and the delegates too. Below you can also see a selection of videos showing parts of some of the actual presentations.

Introduction by Alan Pollard FBCS CITP – President of the British Computer Society Alan Pollard explains why he thinks that women have special qualities to bring to IT
Keynote speech by Gillian Arnold of IBM Gillian talks about the fun beginnings of her career and then points to the research that underpins why many companies are now seriously keen to employ more women in technology management and leadership roles
"Are we having fun yet?" - Dr Julie Greensmith Julie Greensmith bubbles over with infectious enthusiasm for her work within the "Thrill Laboratory" at Nottingham University, where she and colleagues do serious research about measuring human reactions, and use rollercoasters as their laboratory tools.
"Unify your communications" by Eileen Brown - Microsoft Eileen is a technology evangelist at Microsoft. She is one of the few women among 300 or so similar evangelists and her particular speciality involves developments which bring together different communication technologies in one joined-up whole: Email, Phones, Voicemail, Video, Text, and Instant Messaging all working as one
"Software Engineering Meets Social Networking" by Professor Cornelia Bolyreff - University of Lincoln Professor Cornelia Boldyreff shows off a "One Laptop Per Child" (OLPC) XO device and talks about the collaborative approach used by developers building software tools and applications for the device.

Updated position on Equality Bill provisions for discrimination based on “Perception”

The Leader of the House of Commons, Ms Harriet Harman, yesterday made an important announcement in Parliament concerning the Government's planned approach towards protections relating to discrimination that is related to either perception or association. That is, it deals with cases where people are motivated to discriminate against someone either because they associate with a member of a particular equality target group, or because they perceive someone (rightly or wrongly) to belong to that group.

Her statement is reproduced in full from Hansard below.

Cabinet Office

Equality Bill

The Leader of the House of Commons (Ms Harriet Harman): In Great Britain, we already provide protection against direct discrimination and harassment that arises because the victim is wrongly perceived to belong or subscribe to a particular race, religion or belief, or to have a particular sexual orientation. Direct discrimination and harassment arising from association with a person of a particular race, religion or belief or with a particular sexuality are also prohibited.

The Government's response to the consultation on reform of discrimination law(1), published on 21 July 2008, set out how we proposed to deal with direct discrimination and harassment based on perception and association in the Equality Bill. But we also made it clear that we would need to consider carefully the terms of the judgment of the European Court of Justice in the Coleman case(2), published on 17 July 2008, before determining the final approach for the Equality Bill.

I am today announcing that we have decided to extend the prohibition against associative and perceptive direct discrimination and harassment to other strands and areas where this does not currently apply. The Equality Bill will therefore prohibit direct discrimination and harassment based on association and perception in respect of race, sex, gender reassignment, disability, sexual orientation, religion or belief and age and in relation to both employment and areas beyond this, such as goods, facilities and services.

This extension will implement the Coleman judgment in Great Britain and the extension to other protected characteristics is in keeping with the aims of the Equality Bill to simplify and strengthen the law.

(1)Cm 7454

(2)Coleman v Attridge Law and another (Case C-303/06).

European Parliament approves new anti-discrimination legislation

The following press release has been issued today by Emine Bozkurt MEP concerning the vote to approve new EU non discrimination legislation

Press release:

European Parliament approves new anti-discrimination legislation

European Christian-Democrats vote against

"A wonderful victory for equal rights in Europe", says Dutch Member of European Parliament Emine Bozkurt who led the negotiations on the issue for the European Social-Democrats. She feels however very disappointed by the no-vote of the European Christian-Democrats. During the votes it became clear the overall majority of them voted against the new directive. The proposal for legislation banning discrimination based on sexual orientation, religion, age and disability throughout the European Union was approved despite this opposition by the largest political group in the EU Parliament.

The European Parliament proved to be extremely divided about the new legislation. The European Social-Democrats stressed from the start the need for the new directive which eliminates the hierarchy between different grounds of discrimination. Bozkurt: "It is so important that all people in Europe are protected against discrimination. It is absolutely unbelievable that so many MEPs still voted against. It is just impossible to explain why still not everybody is protected against unequal treatment. Discrimination harms our entire society and we need to tackle this in all possible ways."

The newly proposed rules will ban discrimination on the basis of age, handicap, sexual orientation, belief and religion. They are meant as an addition to existing rules which currently only protects certain groups from discrimination or only in certain situations. The new anti-discrimination directive should guarantee that European citizens can move freely in each EU Member State without facing discrimination. Bozkurt: "Throughout the EU people are still discriminated, they are denied insurance, education or a home just because of their age, religion or sexual orientation. Furthermore, at the moment only three countries in Europe have legislation against multiple-discrimination. This means for example that a gay woman in a wheelchair who is discriminated will usually be forced to choose on what ground she suspects the discrimination took place when she files a formal complaint. Thanks to Social-Democrat proposals people will no longer be forced to make such an absurd choice."

The impact of the new rules will be different in each EU country. Bozkurt: "In some East European countries the LGBT-community now hardly has any legal protection but it is wrong to generalise and there is no real East-West divide. Also, legislation to enable handicapped people to fully participate in society is far behind in many European countries, including my own. This directive is ambitious to change this but also reasonable and realistic. It gives countries and businesses plenty of time to make the necessarily adjustments."

ENDS

GEO assurances on Equality Bill provisions for trans people

During the recent reception at 10 Downing Street in celebration of LGBT History Month I fell into conversation with a senior official from the Government Equalities Office (GEO) and used the opportunity to relay the concerns being expressed by some transsexual people about the Bill's expected provisions. I followed this up by email as well.

Recently the senior civil servant responsible for this aspect of the Bill wrote to me with some specific assurances and, with permission, I've placed his comments below.

The Equality Bill is expected to be tabled in Parliament very soon now so everyone will then be able to see exactly what it does and doesn't say.

Extract from GEO official's letter:-

Last year we published a comprehensive document on the content of the Equality Bill which also summarises the responses we received to the Discrimination Law Review consultation held in 2007. A copy of the response can be found at http://www.equalities.gov.uk/pdf/EqBillGovResponse.pdf

In summary the main proposals which relate to gender reassignment are that we will in the Bill:

• provide protection against direct discrimination for people who associate with others who are planning to undergo, are undergoing or have undergone gender reassignment;
  
• provide protection against indirect discrimination for people who are planning to undergo, are undergoing or have undergone gender reassignment;
  
• provide protection against discrimination because of gender reassignment in the exercise of public functions; and
  
• change the definition of gender reassignment to make it clear that protection against discrimination on this ground is not dependant upon a person being under medical supervision.
  

Since the consultation response was launched, DCSF have subsequently announced they propose to use the Bill to extend gender reassignment protection to schools.

With regards to the use of perception we are aware of the difficulties of the practical application of the law with regard to discrimination on the ground of gender reassignment outside the workplace, which is not just for the Equality Bill but became an issue as soon as we introduced the Regulations that amended the Sex Discrimination Act 1975 (SDA) in April 2008. We believe that education and practical guidance will have an important role to pay in this. Nevertheless, in drafting the Bill, we will be exploring to see if there is any way of increasing the clarity on the face of the legislation.