A pilot project in 10 public library authorities, co-ordinated by health advocacy and library organisations and endorsed by the culture, rural affairs and health ministries, will indicate whether libraries can be effective ‘agents of choice’ in their communities. Elizabeth Manero and Mike Clarke report.
The government is increasingly interested in using choice as a driver for change in public services. ‘The government claims two main benefits for the citizen. First, by allowing users to choose, we can expect greater personalisation; more responsive services that provide a better match of service to user. Second, as dissatisfied users can choose to leave a service provider (and take their funding with them), good performers can be rewarded and poor performers penalised, with the ultimate promise of motivating providers to deliver better services for all - and an escape route for us if they don’t.’1
So stated a report of research into choice in public services, which included interviews conducted by Professor John Clarke of the Open University. It went on to say: ‘To be a success, choice strategies need to address inclusion and equality issues by providing information and financial support. Quite a challenge, but is this what people want?’ Professor Clarke found that only one in five of us supports the idea of citizen as consumer. ‘It’s not like shopping!’ was the resounding message from the interviews.
He points to one critical difference between public services and commercial transactions: people who use public services do not always know what they want. Instead, ‘they hope to meet staff who will respect them and help them make important decisions, sometimes at points of crisis in their lives. Indeed, the key to unlocking public service improvement may lie in a deepening understanding of the relationship between service and user, rather than the blunt instrument of choice.’2
‘The UK government’s current approach to public service reform combines… pressure from citizens (choice and voice)…’3 with a range of other drivers including target setting, performance management and competition, according to the Prime Minister’s Strategy Unit.
Public libraries are affected by this policy of introducing more choice: they need to respond to customer enquiries or requests for help. For example, Hackney is among a number of library services which are responding to the need to support choice-based lettings online, the system for social housing customers seeking accommodation. Library users were asking for help to access the system via the People’s Network (PN), so library staff had to respond. But can libraries be effective ‘agents of choice’ in communities? A project co-ordinated by health advocacy and library organisations, currently being rolled out across 10 public library authorities, may provide some indications.
In 2005, the government announced its intention to extend choice by offering people the opportunity to choose first outpatient appointments from a range of appropriate hospitals. They would be given the chance to compare various factors such as clinical excellence, cleanliness and accessibility for transport. At first this would only involve patients going for elective treatment, but if successful it would be extended to other treatments and NHS services. Patients are offered choice irrespective of the technology in their GP’s surgery, although ultimately the Choose and Book online booking system will spread across all GPs.
Health Link, London Libraries Development Agency (LLDA) and London Health Libraries responded by forming Partnership for Patients (P4P) – a national partnership, reflected by local partnerships, to support people in their choice of hospital by using public librarians as navigators to help people access and understand information.
Health Link is a patient advocacy body, a not-for-profit social enterprise that seeks to enhance the influence of patients on health-care, and improve health and health services. LLDA was set up to develop innovative approaches to expanding the use of libraries and co-operation between the 33 London public library authorities, health and academic libraries. London Health Libraries is a network of libraries serving health-care (and increasingly social-care) staff and students in the capital. There are more than 70 NHS-funded library sites managed either by the NHS or higher education in London, and, in addition, a number of libraries in the independent and voluntary sector actively participate.
A priority for LLDA is combating social exclusion and this meshed with Health Link’s approach of using the patients’ perspective to influence policy and services, particularly those who suffer health inequalities and are socially excluded. This formed the foundation of the partnership. On the basis that there could be a role for public libraries which was being overlooked, we gained funding from the Department of Health (DH) for a feasibility study, which examined existing practice and interviewed public library managers in Barnet, Croydon, Harrow, Lambeth and Lincolnshire.
We found that public libraries are well placed to be health information providers and to contribute to improving public health, and many are involved in initiatives, either self-financed or funded externally. The need for effective information to support health and lifestyle choices is slowly being recognised within the DH and NHS. Policy experts comment that the country will not be able to afford the NHS in the future, with improved treatments, longer lifespans and greater public expectation – unless we all become informed partners in our own health-care, making positive choices about lifestyle and prevention. Derek Wanless, who was commissioned by the government to report on NHS improvement, concluded:
‘People need to be supported more actively to make better decisions about their own health and welfare… [there is] a lack of full information.’4
Navigators for patients
The feasibility study identified that ‘public librarians are information professionals, well placed to act as community navigators for patients, using approaches targeted to local communities. All the evidence indicates that libraries have a crucial part to play in turning the opportunity of choice into the reality of choice for all patients.’5
Given the likely long-term agenda for change in public services, this is an important finding for libraries. Outgoing Health Secretary Patricia Hewitt is clear that informed choice is necessary, and that it could go beyond health service reforms.
‘The political steps are going to be hard. If we can succeed with the NHS, then we can win again to assert the argument over the role of the state.‘6
The Institute for Public Policy Research (IPPR), one of the government’s favourite think-tanks, has no doubt about the significance of the policy:
‘It’s an agenda that has the potential to run across government. According to the rhetoric, users of local public services will soon be faced with new choices at every turn. Ministerial forewords to recent green and white papers for hospitals, primary care, social care and housing argue consistently for user choice and empowerment, with providers motivated to meet users’ needs in a “contestable” market.’7
The IPPR also said: ‘Choice should aim to do more than create a market. The primary goal of choice should be to improve outcomes and reduce inequalities.’
But, building on its joint work with Health Link on the involvement of disadvantaged groups in choice, IPPR raises some potential pitfalls:
‘In the detail, there is a devil of divergence in the policies for “choice”. At their best, progressive policies can provide opportunities for better health and well-being, spread to those most in need. Where empowerment of disadvantaged users is not the priority, however, choice policies can increase inequalities… Disadvantaged groups in particular require support… from a range of sources… that have good relationships with disadvantaged groups.’
‘Choice’ is bound to be controversial – the British Medical Association has accused the DH of suppressing a report that runs contrary to its own policy. ‘The study was commissioned in 2004 by the health department’s research arm, the NHS service delivery and organisation R&D programme. Its summary found that patients wanted better information about treatment options but thought they were given too little information to be able to exercise choice effectively.’8
There is no mention of a library role in IPPR’s comments – it was thinking of voluntary organisations. But DH discovered that the third sector does not always have the resources to provide the kind of support its policies needed, so it had to cast the net wider – which is where public libraries came in.
DH funded P4P’s initial feasibility study to: find out what role public and health libraries might play in supporting patients to access information about their health-care provider; map the decision-making process; assess what funding might be available to exploit that role; and examine the implications of extending the role nationally. Its outcomes included: clearly identifying the role public libraries could play and how health libraries could add value; assessing the support for such a role among health-care and library professionals; and recommending pilot projects in a number of authorities. We identified a need for independent evaluation through a pilot that would assess patient satisfaction and cost and capacity implications for the three sectors. Inclusiveness, in terms of addressing the needs of both Black and minority ethnic communities and those with or without IT skills, should also be analysed.
Following the feasibility study, P4P’s initial objectives were to:
- establish information referral pathways to local libraries from GP practices and agencies offering choice
- pilot, evaluate and finalise materials and training modules for librarians and GP practices
- establish a ‘buddy’ network for librarians in public libraries, with health libraries to support public librarians as needed
- evaluate the model for quality and appropriateness of support service offered, appropriateness for diverse groups of patients, including those with information disadvantage, and sustainability for public libraries, health libraries and GP practices and agencies offering choice (cost and capacity).
We wanted to provide a clear map, supporting materials, networking models and an idea of the resource implications – what impact directing people from GP surgeries and other places to libraries would have on use and on staff. Then, once the pilot is complete we can roll the process out to other authorities as part of their mainstream library offer, in the full knowledge of what it will cost and how it will benefit them.
The Museums, Libraries and Archives Council (MLA) was an early enthusiastic partner, and the Department for the Environment, Food and Rural Affairs (Defra) expressed interest because of its need to ‘rural proof’ new policy areas – examining effects on rural communities and economies. The DH was our most important target for buy-in.
Once the feasibility study was completed, with its clear recommendations for further work, we set about formalising the partnership in autumn 2005. An important part of this was scoping and understanding the strategic aims of the initial, key partners. Later we were joined, first by MLA, then by Defra and DH.
We recruited partner authorities by gauging interest among LLDA’s London borough stakeholders, and, with Defra on board and co-funding the evaluation, we approached those county libraries that met Defra’s requirements for sparse rural population and high levels of deprivation. Our current partners are the London boroughs of Bromley, Greenwich, Hackney, Haringey, Newham, Southwark and Waltham Forest; and the county councils of Derbyshire, Gloucestershire and Suffolk. These provide a good mix of environment, levels of investment in service provision and levels of disadvantage against which to test the implications of the project. For example, Derbyshire has many isolated rural communities, some of which are served by well-equipped and sophisticated mobile libraries.
Each authority will be piloting three sites – involving staff training (provided by DH as part of the partnership), networking events for library and health professionals, and printed and online promotional and support materials for staff and public.
Mapping the process involved in choice is complex, as it involves a range of intellectual and emotional judgments made both by patients themselves and health-care professionals. Yet it was important to understand the decision points – the different points at which patients might want to make their choice and might need support. We have summarised the process as a flowchart (Fig. 1). Although we recognise this is simplifying and reducing the process, it is necessary for health and library staff to understand where they fit in. A patient may make their choice in a surgery or other health-care premises, at home by phone or computer, or in another public environment, and they may need support in any of those locations. The pilot project will assess the extra demand the library element of this choice creates.
As part of the pilot we are also mapping the catchment areas of GPs and other health-care providers; these overlap with public library provision, and we want to ensure that people are working together efficiently. In the pilot, this will be a supported process for each library and primary care trust; longer term, we want to see what links can be forged and how this process could happen without a friendly project team urging both groups of professionals on!
DH involvement is critical to the project’s success. Patient choice is one of many strands of its policy of extending choice,9 and while initially there was some interest expressed in the idea, DH concentrated on GPs and the voluntary sector to support the extension of choice. When considering inequalities it became clear that there was a risk that choice would exacerbate inequalities because disadvantaged groups might have difficulty accessing the information and the support needed to make choices. This was where libraries came in.
In discussions with civil servants at DH, P4P emphasised a number of benefits that libraries would bring to the project. These included:
- a wide, accessible network (many were surprised to learn, for instance, that London has more than 350 public libraries)
- high level of customer use and trust
- optimising usage of the People’s Network in which another arm of government had invested.
Another point which we emphasised, which they found particularly convincing, was the growing evidence of the positive impact public libraries can have on health outcomes, if used appropriately and supported. In PricewaterhouseCoopers study of public library impacts for the Laser Foundation, for example, it was shown that almost half of Gateshead Libraries’ users had accessed health or lifestyle information in the preceding 12 months.10
Getting ministerial sign-up was an important milestone. All three of the then ministers endorsed the project – David Lammy for Culture, Barry Gardiner for Rural Affairs, and Lord Warner at Health – and there is interest in the outcomes at other levels in government. Positive results in the evaluation will undoubtedly boost the profile of both public and health libraries.
The project was publicly launched in November 2006. A joint letter to all English chief librarians and PCT chief executives, signed by John Dolan, Head of Library Policy at MLA, and Bob Ricketts, Head of Access Policy Development & Capacity Planning at DH, which underlines the unprecedented nature of this joint working, has already raised awareness and interest at senior level in both sectors, among those not participating in the pilot phase. Perhaps the most important benefit for public libraries to date is that DH has offered to provide point-of-use support materials, a range of leaflets, posters and banners, including a locally-specific Choosing Your Hospital booklet (Fig. 2) in every English public library – not only the pilot sites.
Over six months, we will monitor usage and evaluate outcomes in the pilot sites. Statistics unit Lisu at Loughborough University will be evaluating the project against our criteria, with a particular focus on hard-to-reach and diverse users. We hope its evaluation will be able to provide some hard evidence of the added value public libraries bring to patient choice, and the effectiveness of cross-sectoral co-operation. As many observers, including those outside the library sector, have noted, there could be wide-ranging implications.
References
1 Helen Coleman. Choice in Public Services: not like shopping. (www.esrcsocietytoday.ac.uk)
2 ibid
3 Prime Minister’s Strategy Unit. UK Government’s Approach to Public Service Reform: a discussion paper. Cabinet Office, 2006 (www.cabinetoffice.gov.uk).
4 Derek Wanless. Securing Good Health for the Whole Population. Dept of Health, 2004.
5 Health Link. Information and Support for Patient Choice and the Public Library Service. Partnership for Patients, 2005.
6 John Kampfner. ‘Patricia Hewitt: The New Statesman interview.’ New Statesman, 25 July 2005 (www.jkampfner.net).
7 Joe Farrington-Douglas: ‘This time it’s personal.’ Society Guardian, 1 March 2006. (www.ippr.org.uk/articles) and Joe Farrington-Douglas and Jessica Allen. Equitable Choices for Health. IPPR, 2005.
8 John Carvel. ‘Doctors claim study on patient choice repressed.’ Guardian, 1 January 2007 (http://politics.guardian.co.uk/publicservices/
story/0,,1980852,00.html ).
9 Department of Health. Our Health, Our Care, Our Say. TSO, 2006 (www.dh.gov.uk/PublicationsAndStatistics/
Publications/PublicationsPolicyAndGuidance/
PublicationsPolicyAndGuidanceArticle/fs/en?CONTENT_ID=4127453&chk=NXIecj ).
10 Laser Foundation libraries impact project. PricewaterhouseCoopers, 2005.
Elizabeth Manero is Executive Director, Health Link (www.health-link.org.uk). Mike Clarke is Director, London Libraries Development Agency (michael.clarke@llda.org.uk). The authors would like to acknowledge the contributions of Jenny Sharp (Health Link) and Lynn Plant (Department of Health).
This article was written before the recent government reshuffle.
Updated: 12 July 2007