The Consultation Institute Review of PHA proposals to ... - Contact NI

Client Report

Consultation aspect of proposals to change the Lifeline service in Northern Ireland A review by the Consultation Institute

August 2017

Jackie Robinson, tCI Associate

Client reports are confidential and represent the Institute’s considered views on the Assignment Terms of Reference. Clients have a general permission to publish or quote from the Report but subject to specific approval in each case. Client reports are confidential and represent the Institute’s considered views on the Assignment Terms of Reference. 0 | P aClients g e have a general permission to publish or quote from the Report but subject to specific approval in each case.

Contents 1. Introduction …………………………………………………………………….………………….…….…………2 2. Executive Summary……………………………………………………………………………………………….3 3. Aims and Objectives …………………………………………………….……………………….………………4 4. Legal and Statutory Duties …………………………………….………………………………….….………5 4.1 Health and Social Care (Reform) Act (NI) 2009 4.2 The Public Health Agency Consultation Scheme 2012 5. What does Best Practice Look Like ……………………………….……………………………………… 5 5.1 The Gunning Principles 5.2 Northern Ireland Department of Health and Social Care Principles for Involving Stakeholders 6. Equality Screening/Assessment………………………………………………………………………….…6 7. Strategic Outline Business Case 2015 …….……………………………………………………………..6 8. Consultation 2014 Strengths and Weaknesses………..…………………………………………….7 9. Consultation 2015 Strengths and Weaknesses ……....…………………………………………..10 10. Key Issues ……………………………………………………………………………………………………..……15

Appendix 1 Legal and Statutory Duties (p.19) Appendix 2 Background to Lifeline Service (p.22)

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1.

Introduction

Personal and Public Involvement was first introduced as a concept by the Department of Health NI in 2007. It is a central component of the quality agenda, which aims to improve health and social care service provision in Northern Ireland and the individual experiences of those who use the services. Personal and public involvement has been part of health and social care policy in Northern Ireland since 2007 and became law two years later with the introduction of the Health and Social Care Reform Act (2009). Health and Social Care organisations have a statutory duty to involve the public and consult them in relation to their health and social care. Personal and Public Involvement is the term used to describe the concept of involving people and local communities in the planning, commissioning, delivery and evaluation of the health and social care services they receive. The Northern Ireland Lifeline suicide prevention helpline and associated crisis support service was established in 2007 to provide a 24/7, free-to-call, regional, confidential, telephone helpline for people experiencing emotional crisis and at immediate risk of suicide or selfharm, with the provision for relevant follow on support services where appropriate. The service was commissioned as part of the Northern Ireland Suicide Prevention Strategy – Protect Life. Lifeline Crisis Intervention Service is an integral part of Protect Life, the regional strategy established in 2006 and refreshed following interim evaluation in 2012. The Public Health Agency NI is the lead/accountable commissioner for the Lifeline Crisis Intervention Service. This report briefly examines the legal, statutory, and good practice guidance when undertaking public consultation in Northern Ireland. It will highlight where the Public Health Agency, when undertaking public consultation regarding the Lifeline Crisis Intervention Service, met those requirements and where it may not have, by demonstrating the key strengths and weaknesses of its approach, as investigated from available online evidence. Two public consultations in relation to the Lifeline Crisis Intervention Service were held during an 18-month period, both consultations lasting 12 weeks. The first took place 1st April 2014 – 24th June 2014 and the second consultation took place 27th August 2015 until 19th November 2015. Where questions regarding “process” are highlighted in bold, further detailed comments will be made within the strengths and weaknesses sections of this report. This report is written in a plain English format avoiding jargon and acronyms where possible. This is recognised good practice in service user/patient involvement. NOTE: The Institute has no view about the wisdom or otherwise of the proposals in any consultation. It is entirely neutral and is solely focussed on the quality of the consultation exercise, and its ability to provide stakeholders and/or members of the public with a sufficient opportunity to offer informed contributions to influence decisions, policies or programmes of action.


2.

Executive Summary

In order to pass the test of ‘good practice’ any public consultation must conform to the legal minimum standard, well established in public law by the ‘Gunning Principles’. In addition, given their 1985 provenance, and the many complementary legal judgments since then, the Consultation Institute has charted ‘good’ and ‘best’ practice standards in the public consultation arena. This review, based on extensive desk research and interviews with the current provider (but not the Consultor, PHA NI), has found that the two Consultations and Statement of Business Case certainly fall short of ‘best’ practice, have demonstrated some elements of good practice, but demonstrate some areas of remaining concern. Our findings, in summary, are based firstly on the Gunning Principles, and then on established practice within the industry. The four Gunning Principles are: (i)

Consultation must take place when the proposal is still at a formative stage;

(ii)

Sufficient reasons must be put forward for the proposal to allow for intelligent consideration and response;

(iii)

Adequate time must be given for consideration and response;

(iv)

The product of consultation must be conscientiously taken into account.

Formative stage: we find that the two consultations and SOBC show evidence of advance work by the Consultor, mostly with ‘an open mind’ and certainly not ‘an empty mind’; while some matters remain unexplained (the retrospective characterisation of the 2014 Consultation as ‘pre-consultation’, the apparent lack of any comprehensive review of the delivery of the whole service to date, late reintroduction of proposals to ‘split’ the services, and the sudden insertion of NIAS as a possible provider, albeit later withdrawn), it is possible to discern a progression through the stages towards a decision; we have to presume conscientious consideration of the consultee inputs has been accorded, although often without articulated evidence being available to us. Reasons and Intelligent Consideration and Response: any consultee requires adequate ‘level playing field’ access to information, analysis and assessments, so as to be able to apply themselves adequately to the task of offering intelligent input to Consultor options; we identify information complexity, information overload and, as above, an apparent absence of an overall review of the service to date; we discovered that not all contributions at public events were recorded as ‘responses’ and therefore some legitimate data may have been overlooked; we make suggestions as to where improvements could have been made to mitigate these challenges. The equality impact assessment appears exemplary at first stage, but questions remain about the application of its findings, and the proactivity necessary to 3|Page The Consultation Institute (tCI) Registered Office: Lynwood House, Crofton Road, Orpington, Kent, BR6 8QE ● Company Registration: No. 5126414

capture equality groups’ inputs; therefore, we cannot be certain about fulfilment of the ‘due regard’ criterion. Adequate Time: we find that the two consultations were both run over 12 weeks, as per the PHA Equality scheme and internal guidelines; although dissemination of the second consultation was more effective than the first, there was an apparent failure to convert the wider pool of interest into actual web-based or hard copy questionnaire responses; and to record fully and effectively, contributions (i.e. ‘responses’) made at public events, as above. Nevertheless, at certain stages in the lengthy process, time lags became an issue that will have militated against consultee (and provider) confidence in the overall process. Conscientious Consideration: we have questions about data gathering, stakeholder identification, profiling and mapping, and demographic capture, (see below); we are concerned about the absence of an overall review or evaluation of the service; and about the lack of a clearly articulated rationale for splitting the services offered. Beyond that, without interviewing internal advisers and decision-makers, we cannot adjudicate on conscientious consideration beyond doubt. Stakeholder Identification, Profiling and Mapping: the missing ‘fifth Gunning Principle’ tCI believes, is the knotty question of who to consult and how to access them; sometimes referred to (patronisingly in our view) as the ‘hard-to-reach’, we prefer the description ‘seldom heard’. In our Consultation Charter and best practice advice, we emphasise the importance of proactive actions through which to assist the goal of giving the greatest number of affected / interested parties, the best opportunity to make their best input to any consultation; we feel that more could have done by the Consultor in this regard. A more proactive programme of stakeholder engagement would have more likely reached the heart of the critical issues in this sensitive topic, and won a stronger commitment for future arrangements.

3.

Aims and Objectives The purpose of this Consultation Institute review is to: • • • •

Examine all relevant available paperwork on the proposed changes to the Lifeline Service and to establish the role played by the public consultation in the process; To consider the extent to which such consultations conform to Best Practice; To assess whether the engagement with stakeholders was sufficient in the development and assessment of options that were consulted upon in 2015; To prepare a concise, comprehensive evaluative report on behalf of the Institute detailing our expert findings and observations.


4.

Legal and Statutory Duties 4.1 Health and Social Care (Reform) Act (NI) 2009 Sections 19 & 20 of The Health and Social Care (Reform) Act (NI) 2009 set out the requirements for the Public Health Agency in respect of personal public involvement, consultation and the development of a consultation scheme. A detailed breakdown is within Appendix 1. 4.2 The Public Health Agency Consultation Scheme 2010 (amended) 2012 As a mandatory requirement, the Public Health Agency produced a Consultation Scheme policy in 2010, subsequently revised in 2012. Salient points from the Scheme have been extracted for relevance to the report and are contained within Appendix 1 – Legal and Statutory Duties

5.

What does best practice look like? 5.1 The Gunning Principles The emphasis of the Gunning Principles is on 'fairness'. The process must be substantively fair and have the appearance of fairness. The Gunning (or Sedley) principles, were advocated by Mr. Stephen Sedley QC and adopted by Mr. Justice Hodgson in R v. Brent London Borough Council, ex parte Gunning (1985) 84 LGR 168 at 169. The four Gunning Principles are that: (i) Consultation must take place when the proposal is still at a formative stage; (ii) Sufficient reasons must be put forward for the proposal to allow for intelligent consideration and response; (iii) Adequate time must be given for consideration and response; (iv) The product of consultation must be conscientiously taken into account. This review will look at the Gunning Principles, plus a fifth one on Stakeholder engagement that we have added, as a Best Practice standard benchmark against the 2014 and 2015 Consultations and will highlight where this requirement has/has not been met. 5.2 Northern Ireland Department of Health and Social Care Principles for Involving Stakeholders Achieving the benefits of stakeholder engagement requires a commitment to the following guiding principles: • • • • • •

Timeliness Transparency, Openness and Clarity Integrity Inclusivity and Accessibility Proportionality Reciprocity 5|Page

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6. Equality Impact Screening/Assessment There is a statutory obligation on public authorities to assess the impact of plans, policies and service changes in relation to equality of opportunity. In response to this requirement an equality screening exercise was undertaken in 2014 which highlighted major implications for people defined by Section 75 and Schedule 9 of the Northern Ireland Act 1998. Equality impacts focus on a number of social categories: People of different religious belief; political opinion; racial group; age; marital status; or sexual orientation; between men and women generally; between people with a disability and people without; between people with dependents and people without. It was acknowledged that the Lifeline service change would affect equality of opportunity for many, and in response, a full Equality Impact Assessment (EQIA) was undertaken in 2015. An Equality Impact Assessment is a thorough and systematic analysis of a policy to determine whether or not it has negative impact on groups or individuals in relation to one or more of the nine equality groups and also aims to promote equality of opportunity. There are several areas of this approach in terms of strengths and weakness that are outlined in the tables below.

7. Strategic Outline Business Case August 2015 The aim of the Strategic Outline Business Case (SOBC) was to identify a Lifeline service model beyond 2015 which best meets the needs of those at immediate risk of suicide or self-harm. In doing this the SOBC must take account of the monitoring and evaluation from the existing service, evidence in relation to service models elsewhere, Departmental policy direction and the public consultation undertaken in April – June 2014. Ultimately, the consultation data and opinions generated should contribute to the option development process. While public consultation is never a ‘vote’, it is legitimate to gauge strength of support from various stakeholders, within the context of a professional assessment of the right course of future actions; many consultations require a balance of trade-offs. The Strategic Outline Business Case reviewed the evidence and refreshed the service options for future Lifeline services. This review included an assessment of monetary and non-monetary costs; the benefits and preferred options were identified. A full Equality Impact Assessment was undertaken to support the second public consultation held from August to November 2015. Following the closure of the second consultation, a final business case will be produced to inform the service specification and tender/procurement process. There are strengths and weaknesses highlighted in this process and a summary is detailed in the table below.


8. The Consultation process 2014 Key Areas

Context Paper Equality Screening Methods Consultation Introduction and Information Consultation Feedback

Strengths Background information gave a good summary of contract information and demonstrated no decisions had been made at this stage; and that the consultation was part of the decision-making process. The equality screening outlined the key groups which would be considered under Section 75 and the circulation list reflected the organisations supporting those groups. The workshops enabled people to engage directly with commissioners and then listen to a presentation. This format explains the context of change prior to attendees having the opportunity to complete a questionnaire. However, the numbers of those in attendance at the workshops was not published and therefore the evidence is not decisive in terms of inclusivity. Pg. 10. States “the report does not draw any conclusions, the primary purpose is commentary and feedback to inform wider decision-making process for contract extension, and/or procurement, business case” There was clarity in responses in the form of bar charts and a summary narrative of qualitative responses (they did not appear on the same page which was onerous to follow). The methodology for coding/analysis/screening responses is unknown and potential bias could be challenged if no independent validation was undertaken. The reviewer cannot confirm whether this is the case.

Aligned to NI Social Care Principles for Involving Stakeholders Timeliness Inclusivity and Accessibility Reciprocity Inclusivity and Accessibility Transparency, openness and clarity

Aligned HSC Reform Act 2009

Aligned to Gunning Principles

1&2

1

Transparency, openness and clarity

For example: 74% of individual respondents (three quarters of whom are service users/carers) and 76% of community and voluntary sector groups and 77% of health and social care, 33% of other statutory bodies and 50% of other respondents all felt the current service was having a positive impact and over 50% of respondents felt the Lifeline Service should be retained in its current form (which included ¾ of the health and social care organisations’ responses). Individuals not wanting change were higher than community and voluntary groups. Of those who felt it should change from directly using the service they preferred to make it more efficient and responsive to clients. Any improvement was ongoing and should focus on priority areas and target those in greatest need. Others suggested extra and longer-term funding should be sought. (Also See SOBC comments in 2015 Consultation). It is apparent from reading a summary of the questionnaire replies that the current provider has responded; however, the volume and quality of their input is not discernible and without external validation of the appropriate balance and weighting of the entire commentary it is almost impossible to validate whether their evidence has been fully assessed and incorporated. From a narrative perspective, a preferred option which respondents valued was having a single contact number; a single point of contact for consistency and accessibility; a single regional service for capacity, quality standards and co-ordination of service; 24/7 service, immediate de-escalation and onward and timely referral. A single access point with holistic service seems to be requested by consultees. However, it states that financial challenges were recognised and the priority was a 24/7 crisis line and assessment service. There was a comment which claimed that onward referral was not happening within statutory Mental Health service provision and service users reported being “passed around” without compassion. Furthermore, from a service user response perspective, it was stated the current provider was less stigmatising, and more accessible compared to statutory services

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On Pg. 25 it confirms the wishes of all respondents in terms of the future service offer of preference to include: Immediate Access: • Immediate de-escalation of caller distress with onward referral • Comprehensive assessment of caller’s risk of self-harm or suicide • Client check-in services • Referral to Trust Mental Health Service Access within 48 Hours • Face to face psychological therapies • Telephone psychological therapies • Outreach Not required for Crisis Service • Complementary therapies • Mentoring • Befriending • Creative Art/therapy • Family therapy • Personal development programmes Key Areas

Context Paper

Equality Screening

Consultation Introduction and Information

Consultation Methods

Weaknesses While the paper outlines that it will take account of the responses to the consultation process, it did not offer any alternative to offer input other than via the PHA website. The 2014 summary report was uploaded on to the PHA website which could not necessarily be viewed by those who responded to the consultation. Consultation managers could have also referred to their own identified Equality requirements in order to make every effort to ensure inclusivity of respondents - especially the ‘seldom heard’. An equality screening exercise was undertaken but no requirement nor suggestion was made to the provider(s) to share the consultation directly with the service users - which is good practice to ensure the target group is reached effectively. Many would not have been able to attend workshops therefore electronic access may have been their only option to respond (see limitations identified above). Within Northern Ireland’s Protect Life “A Shared Vision” it outlines the issues in regard to poor health literacy for men (who are at a higher suicide/harm risk); unfortunately, this was not reflected in how the information was compiled to support their understanding of the current service, the data or how the questions were constructed. Concerns were expressed (Pg. 22) that the information provided as part of the consultation was “over reliant” on activity instead of measures which were outcome and quality focussed; and that clinical outcomes (CORE) were measured but were not included. It also reports that insufficient information and lack of openness and transparency were evident, which was described as a breakdown in partnerships. However, it is not clear whose partnership this refers to. The important factor seems to be that insufficient or not enough meaningful information to inform a decision was highlighted. The questionnaire is long and complex yet the offer of automatic alternative formats was not provided as part of helping service users or others understand the content (e.g. Easy read, audio, and infographics). The offer to request alternative formats came at the end of the questionnaire. The alternative format offer was not on the website where people had been guided to access the information. On reviewing earlier consultations, the PHA undertook in 2013 (e.g. Disability Action Plan) Easy Read and audio was provided in 2012 to support service user involvement. The level of health literacy is low, particularly for men and those with disabilities. This service also supports children and young people but the information would not be considered age appropriate to

Not Aligned to NI Social Care Principles for Involving Stakeholders Reciprocity Inclusivity and Accessibility Inclusivity and Accessibility

Not Aligned HSC Reform Act 2009

Not Aligned to Gunning Principles

20 (4)

2

Inclusivity and Accessibility

2


2


elicit their views. Children and young people using this service may not have been able to understand the format used and digital engagement was not explored as a means of outreaching to those for whom technology is a preferred choice of communication. It would be reasonable to assume that the limitation of the range of formats as core components of communication would have reduced access and respondent rates.

Questionnaire

Complementary Therapies Feedback Comments

The organisation currently providing the service did not share the consultation with their clients and their input would have been extremely helpful in understanding service user experience particularly given the reliance on data feedback from the provider, which from an equalities perspective was not fully informed. The context paper/questionnaire included background information on the current service offer and provided information on helpline and counselling support - and performance against those services. However, the questionnaire then expanded the offer of service to ask if they should be available i.e. complementary therapies, mentoring, befriending, creative/art therapy, family therapy without any background or evidence of what is involved, nor evidence of its impact. Given the literacy barriers, some of the terminology to describe the service will not have been known. In addition, these services had been within the 2008-2012 service offer but then removed (without consultation) due to lack evidence of impact and resulted in an agreement to target resources to maximise impact for those in crisis. It could be questioned why this was then reintroduced? The context paper reported that the PHA evaluation of Complementary Therapies for people in crisis concluded that “talking therapies” are more effective. This resulted in the refocus of resources for those at risk, and the complementary therapies service was removed from the 2012 Lifeline retender specification. However, no service users were asked for their views as recipients of care. Pg. (11) states only 57 were individual responses with the remaining 89 responses from agencies working directly in the area of mental health, wellbeing and suicide prevention. This imbalance could be because many people found the consultation very difficult to access and understand. Some respondents struggled to understand the impact of the service because the evidence base had not been clear, with “ambiguity” about performance in relation to how calls had been recorded as “active”, and level of risk; therefore, it was difficult to determine the appropriateness and benefit. Others said clients should evaluate the impact of their behaviour.




It assumes that a loss of confidential client information by the provider in 2012 “may have damaged trust and confidence in the service”. However, this is not substantiated; as there are no breakdown of ages of respondents it is difficult to qualify this comment, it was not used as question in the consultation regarding how young people using the service feel.

Workshops

Clinical Review Publishing Feedback

The feedback does not include age ranges, gender, ethnicity, or disability, which given the complexity of age range and needs of various service users this would have been invaluable insight to have recorded and could have been achieved anonymously. The consultation report does not describe the format of events; for example: were people invited to raise questions? How were the inputs and responses recorded? Were the questionnaires given out to complete or to take away? Who analysed the findings externally? It is good practice in feedback reports to demonstrate assurance to consultees and those who did not attend how the process was undertaken and recorded. The clinical review was undertaken in 2013 and completed prior to the consultation period, the findings were available and could have been included within the public summary report. However, no details or findings were included and this could have added some value to support non-clinical viewpoints in regard to “outcomes for service users”. This was only available via PHA website, which for many imposes a barrier, hence presumably inclusion of the workshop model. It was unclear if all the organisations originally sent the questionnaire were sent the findings report to disseminate. Overall, the methods deployed limited the promise set out in the PHA Consultation Scheme 2012. “…that all input is formally responded to in terms of advising of the impact of the contribution and subsequent outcomes”.


Reciprocity



9. The Consultation process 2015 Key Areas

Strategic Outline Business Case (SOBC)

Strengths Gave clarity of purpose and asserted that no pre-determination had been made and that the content reflected a range of studies/consultation feedback to support the option development which would then be consulted upon prior to a final plan being agreed. All suggestions for services to be included - and those considered outside of the scope of Lifeline - were cited in the 2014 feedback. However, there are slight changes to the wording. See weakness section regarding membership and decision making of SOBC and comments on separating the services elements.

Aligned to NI Social Care Principles for Involving Stakeholders Transparency, openness and clarity

Aligned HSC Reform Act 2009

Aligned to Gunning Principles

1

Some of the data cited was: 74% of individual respondents (three quarters of whom are service users/carers) and 76% of community and voluntary sector and 77% of health and social care, 33% of other statutory bodies and 50% of other respondents all felt the current service was having a positive impact and over 50% of respondents felt the Lifeline Service should be retained in its current form (which included ¾ of the health and social care organisations’ responses. Individuals not wanting change was higher than community and voluntary groups. Of those who felt it should change from directly using the service it would be to make it more efficient and responsive to clients. Any improvement was ongoing and should focus on priority areas and target those in greatest need. Others suggested extra and longer-term funding should be sought.

Equality Impact Assessment (EQIA)

Consultation Introduction / Information

Consultation Feedback

Of 24 suggested actions in Appendix 2, 21 were within the feedback elements of the 2014 consultation stating, “as required”, supported or suggested for improvement. Please see weakness section for three Actions unsupported. The Public Health Agency has provided a comprehensive analysis to consider the range of people (particularly those under Section 75) which is detailed and fully explained. Staff affected, however, lacked data from the provider – a position that will need to be reconsidered, subject to the outcome of the tendering process. Pg. (58) gives a balanced argument for separation of the service, or remaining with one provider. This would have been more usefully shared earlier in the report to help explain the reasons for potential changes. Appendix 1 was a useful resource to explain the steps to Equality Impact Assessment processes and stages. More vulnerable groups were engaged which reflects the value of the EQIA. There was a significant increase in actions to raise awareness of the consultation via media outlets, with 600 organisations being requested to publicise the consultation. 26 workshops were held, the format being a mix of public meetings and focussed events to target specific communities including Section 75 groups, all of which was broken down helpfully within the public document. This is clearly a positive step forward from the 2014 consultation. This resulted in proactive media attention and social media activity with 506 people posting 3077 tweets, viewed by an estimated 3,278,250 people responding to a “#ProtectLifeline” campaign led by Contact NI. It was estimated that this had an impact on discussions at the workshops and in responses to the proposals. However, the analysis of the feedback must be taken in balance, reflecting views expressed following the presentation by PHA which was to outline the proposals for change. The outcome was 135 questionnaires returned and 24 letters received. There is a section on “Timescales” and how the PHA will publish the findings. However, there are limited options to view this information and the feedback did not occur in the timescale listed in the paperwork. The ambition of the PHA was to publish the findings on 31st December, which given the holiday period, is not the best time to expect consultees to look up information. The findings report is dated January 2016. The long delays in output and outcome reporting are nevertheless regrettable, especially given the urgency and sensitivity of the subject matter.


Inclusivity and Accessibility Transparency, openness and clarity


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The Summary Response document was broken down into sections to demonstrate the feedback via workshops, questionnaires completed and then split into categories of those in favour of proposals, those against proposals and those with suggestions for service model enhancements. This was helpful and clear. Within the “Public Consultation Report and PHA Recommendations” section, there is a summary of feedback and PHA consideration. Some direct correlation from 2014 survey respondent are: - Respondents questioned the professional qualifications requirement to retain skills and the professional reputation of the helpline staff. This has now been introduced as a specific requirement for staff working on the helpline. Safety check-in following contact with the service (Action 21 in SOBC) was not supported; however, this has now been included in the new service specification. Some areas of mitigation were also introduced; namely it has been added into risk assessment and care pathways for onward support to include a requirement to ensure that callers who needed follow-on counselling would be referred directly to that support rather than being merely “sign-posted”. It will be the responsibility of the helpline provider to ensure the correct service level referral is made and of the specific local provider to support same. This would also respond to the earlier 2014 commentary on an apparent lack of partnership working. Access to psychological therapies received a mixed response with 57% not in agreement, and 27% in support (others not sure/blank). The option does not seem to have changed as a result, other than enhancing carers/family sessions. Remaining issues are handover, and audit, which, from a safety and monitoring perspective, all parties would support. Complementary therapies as part of follow-on support shifted from the 2014 response rates in that more people support inclusion of this as an added service offer. 98 (of 146) respondents in 2014 felt this was not required as a crisis service, however, this was included in the 2015 consultation and received only 42% support. It was challenged in regard to effectiveness; however, respondents also noted the value in empowering individuals as part of self-care. Complementary therapy is now reinstated as a preferred commissioner option to be included within the care pathway, targeted at the most vulnerable and being subject to adherence to PHA standards and evaluation of impact; although it is noted that evaluation had been promised in the previous contract, it was apparently not undertaken. This decision sided with the majority view. Face to Face De-escalation as a walk-in provision was balanced in that 57 people supported this as an added value support mechanism; however, 26 did not and 47 were unsure. Cost, effectiveness, clinical governance and regulation were all highlighted as concerns. The outcome was removed as an option, following responses to the consultation to target funding to the telephone helpline service. This supported the majority view. Commissioning of the telephone crisis helpline was proposed via the Northern Ireland Ambulance Service. This was opposed by 60% of respondents. This option was removed and a public procurement will be undertaken. This supported the majority view. Marketing and communications approach was to retain the brand and apply to all elements of the service. Working with providers to ensure consistency of approach; evaluation of public awareness. This was supported by 52% of respondents. It reports that the inputs to the consultation were clear about the need for robust and regular monitoring and reporting on the Lifeline service. There is also a wish to link this to wider Protect Life strategies (Alcohol and Drugs) which was not highlighted


Summary of Monitoring Returns

Key Areas

Equality Impact Assessment (EQIA)

Strategic Outline Business Case SOBC

specifically as an area of change. It has proposed ‘in-housing’ the communication and marketing to PHA, with a second preference of external provider procurement, and a third option of a split across the provider organisations. Overall, this was supported by the public in principle. This has been clearly reported and is an area of valuable insight and evidence. 67% were female responders, but young people were not highly represented, which is possibly due to the format, the amount and complexity of information and its age appropriateness. Over 66s were also very low responders and, as highlighted in 2014 and this consultation, the over reliance on IT usage would have impacted on response rates for this cohort group. The vast majority are settled, white people with small (proportionately) low numbers of Traveller/ethnic groups. Disability groups have participated and the workshop-that targeted activity would have supported this outcome. LGBT communities responded, again with a targeted workshop also provided. Carers were of children mainly, with smaller numbers supporting older people or those with a disability.

Weaknesses It affirms that provision of the EQIA in accessible formats on request will be considered. However, no Easy Read version was produced and this, along with the questionnaire and SOBC, are complex documents to comprehend. Given the health literacy barriers in Northern Ireland, it would be considered good practice to have produced Easy Read alongside the corporate documentation, or the use of infographics to help navigate people wishing to respond through a simpler process. Pg. (7) states the evidence will inform and assist an empowerment and enablement approach and assumes this will be by supporting options raised by consultees. Pg. 32 states men, older people, and children and young people respond to more targeted communication. However, this was not followed in the approach to this consultation. It is restating good practice, but not completing the action. Pg. (63) is somewhat leading the consultee, as it states that separating the service is the better option; this is before the consultation has begun and could therefore be challenged legally as “pre-determination”. This option had not been widely supported in the 2014 consultation process. The SOBC does not explain who were the decision-makers in the options development process and who was involved in weighting and choosing such options. The options are inevitably contentious and there is a legitimate expectation that this information would be available and in the public documents produced. There was no Easy read version to accompany this document.


Not Aligned to NI Social Care Principles for Involving Stakeholders Inclusivity Accessibility


Not Aligned HSC Reform Act 2009

Not Aligned to Gunning Principles

and

2

The business case omitted some feedback on benefits listed (Pg.39) from (Pg. 14 of consultation) namely; it did not state in benefits in 2014 “de-escalation or empowerment” and these are more likely to be assumptions from later commentary. It does state one respondent said, “talking helps, and talking about suicide helps to prevent people acting out their thoughts on suicide”. Also omitted was an important fact that some respondents stated the lack of data, evidence and independent evaluation made it difficult to measure impact of Lifeline Service. Separating helpline and counselling was not supported by over half of the 2014 respondents highlighted on Pg. 19 and Pg. 20 of the consultation report. However, it has been included in the Business Case. A rationale for each Action for consultation is given. Of the 21 Actions detailed in Appendix 2, three of those which did not win SOBC support have a rationale for this decision explained.


These refer to: Action (8) Referrals into Mental Health Services which was strongly supported by 130 of a possible 146 respondents. Action (15) Helpline staff now being referred to as “Helpline Call Operators” not requiring professional qualifications, which is the Scottish model of call management, not agreed as part of the consultation question.

Consultation Introduction/ Information

Action (21) Provision of Check-in 138 respondents said this was required. Outreach provision 108 also supported this model. Neither intervention offered any evidence cited elsewhere in the SOBC as a ‘duplication of provision’ through the Transforming Your Care policies. The introduction explains the purpose of the consultation “Your View”. However, it does not explain PHA’s commitment to feeding back on the consultation. Respondents are informed on page 32 how the findings will be shared, again via the PHA website (which will have the same issues and barriers detailed within the 2014 section above). Similarly, only on page 33 it offers access to alternative formats, which should really be at the beginning of the information section. No “automatic” alternative formats were provided, which as detailed above, would have been helpful to respondents with health literacy barriers and a young person’s version needed a different approach to allow them to navigate through the options for change more meaningfully.


Appendix 3 “Care Pathway” was not clearly explained; it used boxes with Steps 1-5 but then talked about stages C, D1 and E. There was no Stage A or B? It is unclear how consultees are expected to interpret this. The following Appendix 4 then refers to Stage A and B but it is for Children and Young People. Are consultees to assume A, and B refer to both pathways? This was confusing to follow.

Questionnaire

Pg. (4) states that over 200 people attended the 2014 workshops, however no breakdown of those figures was published in the feedback report and of the 154 questionnaire responses, 146 were quantified (eight were expert commentators from outside Northern Ireland) and only 57 of those were from individuals, the remainder being from “agencies/organisations”. This was not fully explained and should have been to demonstrate greater clarity of all the figures stated.


This was a very long and complex questionnaire which again, given the number of respondents (159), and over 300 people attending workshops, as well as information in the public domain, perhaps did not effectively engage people to respond; or neglected to record the views and opinions expressed at those deliberative events. The anticipated benefits whilst clear, did not address the negative impacts in balance.

4

The reader would have to review the SOBC to understand this and the SOBC is a very complex document. The Equality Impact Assessment questions are not easy to reply to; this is a complicated legal issue and while the EQIA was complete, the reader would need to refer to this to understand the context of the questions. Overall this was not an easy questionnaire to answer and whilst workshops helped to generate a greater understanding by a verbal exchange, the key information disseminated widely was the SOBC, the Equality Assessment, followed in the hierarchy by the questionnaire for completion. The survey (unlike the 2014 iteration, that asked on p.4: Do you have experience of using the Lifeline service on behalf of another person or yourself?) did not differentiate whether respondents were individual users of the service or organisational representatives; this would have been helpful in understanding reach. Despite that, we are therefore uncertain as to how attribution is made to service user input, when that designation had not been identified, nor requested. In the report, at p.15, it


states: “Whilst some respondents highlighted the lack of robust evidence for complementary therapies, the feedback from service users, in particular, noted the value of complementary therapies in helping them deal with crisis”.

Complementary Therapies Input comments

Contradicts findings in the 2014 consultation as the resource and the client group has remained unchanged, but the service has been proposed for resumption in the new specification without any evidence-base on effectiveness which is also aligned to the Royal College of Psychiatrist view and stated within the SOBC (Pg. 51) The analysis following the workshops (Pg. 6) states that it was not “pure “science. The responses were manually read and themed accordingly by PHA staff. Given the unavoidably emotive nature of suicide prevention and impact across Social Media from the Protect Lifeline Campaign, it would have been good practice to have this work externally undertaken – or at least validated - to reduce any challenge of subjective commissioner bias under pressure as the “Summary of Responses” 2016 report states on Pg. 2 (reporting on feedback at workshops of a “fait accompli”).

Inclusivity and Accessibility Transparency, openness and clarity

Pg. 21 in regard to Options for Delivery to separate the helpline from the follow-on support, omits the response rate. This was strongly not supported by 86 of 146 responders in the 2014 consultation. Within the 2015 consultation, this is the only question where clear data (i.e. pie chart representation) was not used to report respondent preferences and concerns. It is a significant area of consultation concern which respondents would wish to know how the underpinning rationale was influenced. The summary was reported in narrative only. It uses terms like “many respondents” and “varied responses”; it is vague and not satisfactory at this stage of a report. One would question the reason for this important omission and given the weight of negative feedback this option received the commissioner decision to continue with the proposed SOBC separation of crisis counselling provision across smaller locality lots, when the similarly contentious SOBC proposal to commission the helpline from statutory services was reversed in the final proposal, after PHA Board discussion. A challenging statement in regard to the costs of the existing provision states “there was no challenge to the idea the PHA must ensure that delivery of the service is within arrangements that are free from potential of the provider to refer callers to other often costly follow-on support service to increase income rather than meeting defined service user need”. The evidence for this should have been made available.

Workshops Publishing Feedback

Delivery of follow-on support services provided by non-statutory providers at a locality basis and procured via public tender was mixed in support, with 31% in support, with 49% not supporting this option and 15% unsure. Locality knowledge was seen as positive; however, lack of consistency across five geographic areas was seen as a weakness and could cause fragmentation of provision. A common specification for all providers was suggested by PHA to mitigate those views and enhance a local integrated service model, standards etc. Evaluation would also form part of the service contracts. Overall, the decision was to procure separate contracts. This is not aligned to the expressed public view; however, it did retain a preferred option as having one single provider - until the specification is known the final decision is not clear. It is difficult to determine where carer involvement was within the consultation process. No specific group appears on the workshop list, however, that does not mean that carers did not attend events. This was only available via PHA website, which for many, presents a barrier, hence the choice of the more oral workshop model. It remains unclear if all the organisations originally sent the questionnaire were sent the findings report to disseminate. Overall, the methods limited the promise set out in the PHA Consultation Scheme 2012 that “…that all input is formally responded to in terms of advising of the impact of the contribution and subsequent outcomes”.

Transparency, openness and clarity Transparency, openness and clarity


10. Key Issues 2014 Consultation Contact as the commissioner of this review, shared a copy of their input responses to the consultations in 2014 and 2015, through their completed questionnaires elucidating their proposals for improvement and enhancement of the existing model of care. It is not possible to determine how this was assessed and weighted within the overall PHA Lifeline consultation summary document, as the commentary from all other parties are not known, nor was it within our remit to recode and reassess the raw data; therefore, it is unclear how this particular submission was weighted and valued within the overall summary. The summary report does reflect some aspects of the Contact NI proposals but does not provide sufficient detail on the range of options suggested. The findings within the PHA summary report were not externally validated, nor can the balance of different views be confirmed. It would be a recommendation that future consultations on such sensitive services which may draw contested stakeholder responses, are externally validated to avoid the challenge of perceived bias or self-interest by the commissioner or provider. On balance, it is considered that the consultation reach (i.e. clarity of the narrative, stakeholder identification and choice of appropriate dialogue channels) was not inclusive of the depth and range of respondents required. Regarding the format of the information supplied: there was no Easy Read, nor infographics. However, the context paper did outline the service and the performance of the current provider. The option to request alternative formats was not on the website - which should have been a primary issue to ensure the principles and commitment of the PHA Stakeholder Scheme had been fully met. There was no option to view the output feedback (i.e. what consultees said) from the consultation, other than via the PHA website, which for some digitally disadvantaged respondents would not be a suitable vehicle through which to consider the consultation outputs and possible future outcomes.

2015 Consultation The Equality Impact Assessment undertaken to support the consultation is a highly comprehensive and reflective document detailing those potentially affected by service changes which has demonstrably looked at the needs of respondents to the 2014 public consultation. Interestingly, and without explanation it characterised it as a “pre-consultation”, PLEASE NOTE: this term was never used in the 2014 Context Paper, Questionnaire, or Summary 15 | P a g e

Findings Report but was subsequently introduced within the Strategic Outline Business Case). The Consultation Institute confers particular characteristics on, and standards to ‘preconsultation’, as a means of helping scope out a formal consultation, identify stakeholders and begin to select appropriate dialogue methods for stakeholders thus identified; but without commencing the dialogue itself. This designation cannot therefore be retrospectively applied. We find this redesignation to fall below the best practice threshold. There has been a greater effort to engage more widely on this consultation and indeed the level of media interest, in particular through social media, has brought this consultation to the attention of significantly greater numbers than those previously. However, the level of formal responses – through the online or hard copy questionnaire route - remained relatively similar to that held in 2014. This was an extremely voluminous consultation with a substantial amount of information within the Strategic Outline Business Case and Equality Impact Assessment for people to review, and then make comment via a lengthy questionnaire. The failure to deploy the intelligence gathered from within the Equality Impact Assessment in regard to targeting communications appropriately, age appropriately, etc., e.g. the absence of Easy Read, infographics etc. to help people navigate this important information is disappointing; this would probably have been a positive step in attracting more respondents. The feedback mechanisms were also poor in comparison to the effort made to share the consultation (600 organisations) to seek responses. Online is not an acceptably accessible means of communication for many, and the timing of this being released over a holiday period may not have been wise; nevertheless, it is recognised that the timing was tight to enable a procurement process to be undertaken. Yet despite this rationale, publication was delayed without explanation for a further eighteen months. Information Within the 2015 public information, the 2014 “consultation” began to be termed as a “pre-consultation” which was not so described within any of the 2014 literature or summary report documents. This anomaly is nowhere explained; it therefore remains unclear why a second consultation was required (if it was indeed, as promulgated, a full consultation) or why the normal linear progression from pre-consultation to actual consultation has been lost. It is this reviewer’s understanding that there has not been a full evaluation of the entire Lifeline Service or the commissioning governance arrangements since it was initially commissioned. This would have given a greater insight into the strengths and gaps in provision and comparisons to “best practice” which unfortunately has resulted in a fragmented review process. A more systematic, and independent, evaluation of Lifeline service provision and the apparently contested governance arrangements would have


provided a more rounded information source to consultees, through which to consider the future planning requirements of Lifeline. Several comments were made regarding the reliance on data information and how calls are termed, e.g. “active” or “missed calls”, “answered calls”, or “calls answered by counsellors”. The range does risk misunderstanding or differentiated interpretation. One universal term would have allowed ease of analysis for consultees to consider the overall volume of activity. The data boxes and subsequent narrative was split across pages so did not allow ease of reference for consultees to view; one needed to keep going back to pages to correlate information. A clearer layout would have been easier to follow. Socially disadvantaged groups are known to be disproportionately impacted by suicide, by a multiple of four. Working aged males are three times higher the risk of females. Similarly, minority groups are identified as high risk and the public documents did not tend to support these groups in terms of health literacy levels. Consultees were expected to comprehend complex and very detailed reports, as 2015 respondents were advised to read the SOBC recommendations prior to completing the 2015 consultation questionnaire. Young people’s engagement requires an age appropriate method and this was not supported in any way in the publicity materials produced. Older people’s access to IT is limited in terms of access, and although large print was offered, it was only at the end of the document, as were all alternative format requests. Therefore, there are grounds to argue the consultation process may have been constrained by the absence of effective measures to promote full accessibility and visibility. The PHA-supported Service User Advocacy (SUA) group had no apparent remit to disseminate information/feedback from service users broadly. Therefore, an alternative method of monitoring user views to support representatives could be developed which would enable a longer-term evaluation of impact from “experts by experience”. Such a service user consultation and evaluation process is more likely to succeed when arranged independently of the Lifeline commissioner and the provider. Overall, while the 2015 consultation engaged more people, in regard to Options for Delivery to separate the helpline from the follow-on support, the report omits the response rate. This was not supported by 86 of 146 responders in the 2014 consultation. No data was reported from the 2015 exercise - which omission stands out, as all other areas give facts and figures; it may therefore not have been sufficient to determine support for change. The increase in promoting and sharing the consultation significantly improved in 2015 and raised awareness. However, the format and content was complex and difficult to follow in 2015 (due to the volume of information). The survey respondents in 2014 were asked to identify if they were service users, however this was not repeated in 2015 and


therefore is not broken down specifically by service user comment. It is therefore difficult to confirm how the 2015 consultation attracted their demonstrable input. The consultation in 2015 did inform the decision-making process and options in the SOBC, which then informed views about the likely effectiveness of the new arrangements; it clearly outlined where this was accepted and where the initial proposals in the SOBC were changed as a result. However, the evidence base in support of the SOBC’s strongest contention - the separation of the regional crisis counselling service from the helpline – appears to have been omitted from the final report. The Consultation Institute © August 2017


Appendix 1 Legal and Statutory Duties Health and Social Care (Reform) Act (NI) 2009 Sections 19 & 20 of The Health and Social Care (Reform) Act (NI) 2009 sets out the requirements for the Public Health Agency in respect of personal public involvement, consultation and the development of a consultation scheme. A detailed breakdown is within Appendix 1. Section 19. - Each body to which this section applies must take such steps as it considers appropriate⎯ a. To promulgate information about the health and social care for which it is responsible; b. To obtain information about⎯ (i) the needs of persons to whom that care is being or may be provided; and (ii) the efficacy of that care; c. To encourage and assist persons to whom that care is being or may be provided⎯ (i) to avail of that care in an appropriate manner, having regard to the need to use resources in the most economic, efficient and effective way; and (ii) to maintain and improve their own health and social well-being. 2. Health and Social Care (Reform) Act (Northern-Ireland) 2009 c. 1 13 In particular, each body to which this section applies must, before the end of the period of 9 months beginning with the day appointed for the coming into operation of this section, or, if later, the establishment of the body concerned⎯ a. prepare a consultation scheme in accordance with section 20; and b. in the case of a health and social care body, submit the scheme to the Department. 3. The Department may direct any health and social care body to which this section applies to submit a revised scheme to it. 4. The Department may, after consulting the Patient and Client Council, approve a consultation scheme submitted to it under this section with or without amendments.

Public involvement: consultation schemes 20.1. A consultation scheme must make it clear how the body to which the scheme is to apply will make arrangements with a view to securing, as respects health and social care for which it is responsible, that the following are (directly or through representatives) involved in and consulted on the matters mentioned in subsection 2. Namely⎯ (a) the Patient and Client Council; (b) persons to whom that care is being or may be provided; and (c) the carers of such persons (that is to say the individuals who provide a substantial amount of care on a regular basis for such persons but who are not employed to do so by a health and social care body). 19 | P a g e The Consultation Institute (tCI) Registered Office: Lynwood House, Crofton Road, Orpington, Kent, BR6 8QE ● Company Registration: No. 5126414

3. Those matters are⎯ (a) the planning of the provision of that care; (b) the development and consideration of proposals for changes in the way that care is provided; and (c) decisions to be made by that body affecting the provision of that care. 4. The consultation scheme must provide for the body to which it is to apply⎯ (a) to have due regard to any comments submitted to it in response to the consultation; and (b) to prepare a written statement which⎯ (i) summarises the comments received; and (ii) sets out the body’s response to those comments. (4) The consultation scheme must provide that the body to which it is to apply shall take such steps as in its opinion will give adequate publicity to the statement. The Public Health Agency Consultation Scheme 2010 (amended) 2012 As a mandatory requirement, the Public Health Agency produced a Consultation Scheme policy in 2010, subsequently revised in 2012. Salient points from the Scheme have been extracted for relevance to the report. Bolded areas specifically will be addressed in regard to compliance with and how the consultation processes for both 2014 and 2015 public consultations were undertaken. The Public Health Agency Consultation Scheme states the following (Pg. 6) “The Public Health Agency supports the following core values of Personal Public Involvement: • Dignity and Respect • Inclusivity, Equity and Diversity • Collaboration and Partnership • Transparency and Openness It also recognises that Personal Public Involvement must promote equality of opportunity between all groups below: • Persons of different religious belief, political opinion, racial group, age, marital status or sexual orientation; • Men and women generally; • Persons with a disability and persons without; and • Persons with dependants and persons without. The Public Health Agency and Health and Social Care Board will engage on three broad levels i.e. • Patient and Client Council • Service users and • Carers of service users On Page 8 of the Consultation Scheme it is stated: “In relation to those persons for whom care is being or may be provided the Public Health Agency will also work with a range of organisations, groups and individuals that represent the views, experience and aspirations of those for whom care is being or may be provided and for those who care for service users.


Stakeholders have highlighted the fact that input from an individual’s perspective must be considered in the process. Stakeholders give a very clear message that Personal Public Involvement must make a difference and that organisations are held to account. Stakeholders wish that the Health and Social Care Organisations work with them to ensure that the input to the process of engagement is recorded and acted upon. This will include how the Public Health Agency will ensure that all input is formally responded to in terms of advising of the impact of the contribution and subsequent outcomes”.


Appendix 2 Background The helpline was originally commissioned via the Southern Health and Social Care Trust in 2006 and was initially piloted in one area of Belfast which targeted the under 25’s. The 2008 this service expanded and was subsequently mainstreamed for access across all Northern Ireland for all age groups (Adults and Children and Young People). This was further enhanced to include a follow on short term (circa 6) counselling face to face sessions for those who required this further support. The overall aim of the service is to provide additional support to people at immediate risk of suicide or self-harm across Northern Ireland, thereby helping to reduce the levels of suicide and self-harm incidents, as part of a range of measures to tackle suicide under the suicide prevention strategy ‘Protect Life’. In 2008-2012 contract period, the service increased its offer to include complimentary therapies, befriending, mentoring referred to as wraparound services. This was not an evidence based commissioned provision and no formal consultation on enhancing the service was undertaken. Contact NI sub-contracted this provision to external community/ voluntary service providers. In 2010 the contract management responsibilities transferred to the Public Health Agency. As part of this new responsibility to manage the Lifeline Service 2010 it is stated in the 2014 consultation report that “one of the first priorities in respect to the contract was an assessment of the effectiveness of the service in order project performance management as well as future commissioning. The PHA undertook a pilot of the project of the process to evaluate outcome for Lifeline clients and found that when comparing talking therapies which complimentary therapies, talking therapy proved more effective”. However, no service users were involved in this evaluation process. The report further states “as a result, in order to focus the resources on those at greatest risk, the service specification was changed to telephone helpline and referral into talking therapies. The contract was retendered in 2011/12 via public procurement and Contact NI was successful in securing the contract. There is no evidence of service user involvement in evaluating the wraparound service and no consultation was undertaken prior to removing this service from the new specification in 2011/12 which is contrary to the requirement of Health and Social Care(Reform) Act 2009, Section (20) (b), and (c). The Lifeline service was retendered in 2011 excluding the wraparound service. The current contract awarded to Contact NI was initially for a three-year period, April 2012 to March 2015, with the potential for a further 18 months extension, to September 2016. This contract has continued and is provided by Contact NI until March 2018. A new procurement is due to be undertaken in October 2017. In 2013 the Public Health Agency commissioned a clinical review of the Lifeline service which was concluded in April 2014 (at the same time the first consultation was underway). The findings were not published or used in the content of the Consultation document which was 22 | P a g e The Consultation Institute (tCI) Registered Office: Lynwood House, Crofton Road, Orpington, Kent, BR6 8QE ● Company Registration: No. 5126414

repeated in 2015. Detailed within the Context Paper supporting the 2014 consultation it stated (Page 9, 6.5) “The review sought to identify best practice in the delivery of Lifeline and highlight any areas for development or further review. As well as informing the management of existing service, the findings of the audit will inform the development of future services” The final summation of this was not made public which could be considered a key requirement of Health and Social Care (Reform) Act 2009, Section (20) (b). This may also be considered contrary to Gunning Principle 2. “Sufficient reasons must be put forward for the proposal to allow for intelligent consideration and response”. The Key Performance Indicators 2012 – 2014 have remained unchanged during contract award extension periods. All Key Performance Indicators (KPIs) has a target of 100% success
