Examination of Witnesses (Questions 640
- 659)
THURSDAY 30 APRIL 1998
COUNCILLOR BRIAN
HARRISON AND
CATH CUNNINGHAM
640. Finally, to take another concrete example
with a public health bearing, well women centres, do you think
this is primarily something which should be seen as a local government
responsibility, because well in the community and dealing with
well women, not ill women, or do you see it as a health authority
responsibility to cough in the most, or what; and do you think
there are enough of these centres around the country, and, if
not, why not, and whose fault is it?
(Cllr Harrison) First of all, I think that they should
be local authority led, and they might not be called well women
clinics, they might well have some other name, but there should
indeed be such an organisation and it should be resourced, but
it should be, I think, looking at the people in the round and
not just medicalising every aspect of life, so that it is actually
located within the sort of local authority's responsibilities,
but, nonetheless, with input, when needed, input from the health
services, whatever the health services are, when needed, perhaps
should be available, but only when needed and it should not be
there when it is not needed, interfering. Why there are not so
many I do not know, it might be that the models that are used,
sometimes certain models might go reasonably well in middle-class
areas, in other areas they may not. And I have got a fear about
this, actually, that if you go talking to people about, you raise
issues of health, very quickly, people might think you are into
abstractions and they turn off, and you can have the same impact
without actually mentioning the word health, it could be leisure,
it could be leisure and recreational issues, which impact on their
health, the socialisation of people, which impacts on their health,
but I think if you actually name things, health, then you have
got to be very, very careful that you do not turn some people
off.
Audrey Wise: Actually, well women centres, the
initiative is usually from women's groupings themselves and they
are hugely popular but have to fight for every penny from everybody,
and they are not really accepted as being anybody's responsibility,
but I am interested anyway in your replies on those things. Thank
you.
Mr Gunnell
641. I want to get on to the topic specifically
of local democratic accountability, and I will start it in terms
of a quote from your evidence, because you do state that, in relation
to primary care groups, "the issue of local democratic accountability
remains one of critical importance"; now you would probably
say the same thing about most of the other topics we have talked
about but let us start on primary care groups and see how you
would justify that statement?
(Mrs Cunningham) I think, in my view, local primary
care groups are charged with responsibilities that are more than
simply operational arrangements for delivery of health care services,
that they have some responsibility and contribution to make for
health gain for a local area. Once one accepts that as a principle
for primary care groups one has to accept the need for primary
care groups to have, as an integral part of their structure, whether
that is constant or a dynamic, the full picture of local government
function represented there, so that housing is represented there,
education is represented there, rather than a single social worker
sitting on a primary care group. I also believe that if they are
there to look at health gain for a locality and a local community
there needs to be a mechanism for addressing community representation
within primary care groups, and, for myself and the Association,
the role of elected members in that process is a logical consequence
of that.
642. Would it follow that you think that local
government is more responsive to local voices than health authorities?
(Cllr Harrison) Yes, by far, yes, they have much more
experience; of course, they have got to have the relationship,
they have got to revisit the electorate in metropolitan authorities
every four years, and so there is a very direct relationship that
does not apply with the health authorities.
643. So you would think the mechanism of needing
to maintain the relationship with the electorate for direct electoral
purposes is a factor which is very important in terms of the way
you, perhaps less as an Association but you certainly as a local
authority, that is a vital factor in terms of the maintenance
of accountability?
(Cllr Harrison) Yes. I will be reminded of that tonight
when I am canvassing.
644. I am sure you will. Would you say then
that, in relation to this, there are sufficient opportunities
in the whole area of health and social services for accountability
to be expressed effectively?
(Cllr Harrison) I think that we need better mechanisms
for accountability, especially in the health services. I think
things are beginning to get better in the health services, but
four years ago, when I first went on the authority, we had three
major issues in quick succession, one was a children's hospital,
a tertiary children's hospital, which put me at odds with my colleagues,
decisions were being made which I thought were wrong decisions.
I discovered afterwards, I was informed afterwards, that the chairman
of the regional authority at the time, before regional authorities
were finished, had indicated what he expected and then invited
us to go out and consult on options, but the decision had already
been made about what was going to happen anyway, and, indeed,
in that particular case, that happened, he got the result. Ironically,
because he had to revisit the issue again they came up with the
right result recently and the tertiary hospital is going to be
located where it should be, which is close to a teaching hospital
where they would have the benefit of all the technology and the
various skills that are located there. But that issue of accountability,
and this is one of the problems, as we mentioned before, that
exist between local authorities and the health authorities, they
are getting better but much still needs to be done.
645. You are Chairman of Social Services. In
terms of the area we have talked about, and we have talked about
pooled budgets and various things of that sort, are those areas
and the specific issues that we have discussed, are they issues
which you discuss within your local authority setting, as the
Chair for Social Services?
(Cllr Harrison) Yes. I would say, I am no longer Chair
of Social Services, as it happens, we have a four-year period
in Manchester so we move on, but I still represent the City at
the Local Government Association, on the Social Affairs Committee.
But, yes, we do, indeed, talk of pooled budgets. And just one
thing which might interest you, perhaps; taking the lead in health
issues in Manchester is an officer who is located in the Chief
Executive's department and not in social services, the lead member
is in the Chief Executive's department, and that is how it should
be.
646. Yes; does that make it a little more remote
from locally elected people?
(Cllr Harrison) No; no.
647. So, in terms of specific areas, for instance,
you have talked about how social services and health have combined
to use the winter monies, but those specific plans did not have
to be endorsed by a specific group of local authority members?
(Cllr Harrison) They would have been, because that
would have been reported to social services committee and then
it would have gone through the council cycle, so those arrangements
were, indeed, we had a health sub-committee, which would have
dealt with that, would have gone to social services committee
and then would have been presented at the full council.
648. What I am trying to say is, where we think
there is effective local accountability, in terms, for instance,
of budgeting arrangements, would local authority members not be
somewhat concerned, if they thought that the social services committee
was picking up charges which they really felt ought to belong
to the health authority?
(Cllr Harrison) They would be concerned, yes, and
would state so, indeed. Over the past few years, we have had a
bumpy relationship, the local authority and the health authority;
now it has sort of settled down, after a number of years, and
part of the issue which was indeed coming from the officers working
down the line was this issue of the shunting of responsibilities.
And the arguments again how you compute the bed-blocking, the
arguments about the real cause of bed-blocking, at times it might
be that the consultant only comes round every ten days, or seven
days, or whatever, people might be ready to leave or might have
been ready to leave hospital on a Friday but they are not going
to be able to because they cannot go until the consultant says
so. Now I think they are developing other arrangements where nurses
will have the power to make these decisions. But there has been
all those problems, and they are not all clear but I think that
we are getting a better grip of the issues and we are working
much better.
649. So in relation to primary care groups,
specifically, are there any additional safeguards for local democratic
accountability which you would wish to suggest to us, as a Health
Select Committee, in terms of what we are looking at as recommendations
for the future?
(Cllr Harrison) Yes. I think there should be local
representation, local councillors should be represented on those
primary care groups.
650. And they should be represented as members
of the local authority?
(Cllr Harrison) Yes; I believe so, yes.
Mr Austin
651. My nods of agreement with you when you
responded to John Gunnell as to whether social services were more
responsive to local voices than health services was out of my
own personal experience, having been a former chair of social
services, elected several years in succession, but also having
been on a health authority, appointed to represent local interests
and having been removed by the Secretary of State for doing that
very thing. But can I come on to another issue, because there
are other mechanisms for the user's voice and accountability,
one of which was the community health councils, which are not
directly elected but are set up in a way as to represent the local
community, and the Association of Directors of Social Services
certainly recommended that the community health councils' remit
should be widened and extended to take in, in relation to primary
care and primary care groups. I am wondering if you support that
view, that is taken by your directors, and, if you do support
that, how that then fits in with the answer you have just given
to John Gunnell about the direct role for councillors?
(Cllr Harrison) Yes, the community health councils.
I think one thing is certain, that we need to review their role
in cities such as Manchester, where, historically, they had three
health authorities plus the family health services. Whilst they
merged, and that helped tremendously, once they were in relationships
with the local authority, nonetheless, just merging does not erase
years of cultural viewing. We have found that the health authority
themselves were so constrained by the boundaries, the traditional
boundaries, of the three previous health authorities, they think
in those terms, the hospital trusts in Manchester, there are three
major ones plus (Christy's ?), they actually consider their catchment
area to be the historic boundaries of the old health authority
areas. Now coming to the community health councils, there was
one for each health authority; there are still, in Manchester,
even though there is only one health authority, three community
health councils, and what they have tended to do is track the
providers, the hospital trusts, rather than what, in my view,
strategically, at the authority, mapping and training, the authority,
and I think that the community health councils themselves need
to think about what their role is, whether it is monitoring the
providers, I think that is part of their role, but whether it
is also more than that, looking at the strategic decision-makers,
and also inputting into the strategic plans. So I think that it
needs reviewing. In relation to the primary care groups, well,
I do not know their structure, I just have not thought that out.
652. One of the functions which a community
health council has, though, apart from having some input into
the strategic planning, through its mechanisms of meetings and
consultation, it also has a very clear monitoring function and
seeing how effective the services are. Would you not see that
as a major possibility for the CHC at primary care; of course,
at the moment, the CHCs are restricted, even now, in terms of
their access to GPs' premises, for example?
(Cllr Harrison) Yes, precisely, but it just might
be, structure-wise, that rather than have separate CHCs, we have
got separate CHCs now, in relation to the trust, it might be that
there could be a sort of strategic body and that they could have
working groups, or whatever, monitoring primary care groups and
the hospital trusts.
653. And, as an elected councillor, how would
you react to the suggestion that the CHC's role might be widened
to have some overview of social service provision as well?
(Cllr Harrison) That would be interesting. I would
say, I am always in favour of being, I think we should be monitored,
scrutinised, our experience is, over the past decade and more,
so that it does nobody any harm.
(Mrs Cunningham) May I make a brief response to something
that you said earlier. I think community health councils have
been traditionally viewed as the patient's advocate, in the context
of health care services, and there is an issue there about representation
of whole population on primary care groups. I certainly would
support the review of CHCs, advocated by the ADSS, but I do not
think that that would necessarily replace the role of somebody
with a mandate of a local electorate with a broader perspective
against a broader view of local government services within that
context of health gain. I think the two actually could be very
complementary, but, clearly, CHCs need to be developed and empowered
in their role as monitoring.
654. That leads me on to my next question, because
local government is not static either. I know the hunt Bill is
currently stalled in Parliament but the Government has issued
its consultation paper about different methods of working in local
government, and one of the possibilities is, particularly if local
government moves towards a more cabinet style of a core group
of councillors, who are the policy-makers and cabinet, that the
rank and file, or back-bench members, may have a much different
scrutiny role and even an advocacy role in terms of issues outside
of the authority, and I wonder if you warm to that kind of mechanism?
(Cllr Harrison) Yes, I do.
Mr Gunnell
655. Could I just ask you if there is any recommendation
you would welcome seeing from the Select Committee in the whole
role of the relationship between health and social services, as
you have experienced it? I ask you that because I think one of
the groups that we met on our visit were probably anxious that
we did not make any recommendations at all, because they felt
that if we made any recommendations their own present structures
might be a bit threatened by it, and I just wondered if you had
got any specific hope, in terms of the fact that it is our job
to report on the relationship between health and social services,
is there any specific thing, conclusion, you hope we will come
to?
(Mrs Cunningham) For me, one of the things that I
would hope the Committee would look at, apart from making obvious
links with things like the Royal Commission on Long-Term Care
and the recommendations that they will be making, would be about
the process of monitoring evaluation, monitoring effectiveness
of evaluation, that hopefully the new duty of partnership will
have a significant impact on improving collaboration between the
Health Service and local government as a whole, not just for social
services. The one thing that I would wish to see is the process
of collaboration being examined, rather than the product, the
product often being a piece of paper signed by two senior officers.
So I would like to see the Committee looking at the process of
collaboration as well as product.
Chairman: On the first point, just for your
information, we are actually meeting Sir Stewart Sutherland this
afternoon.
Audrey Wise
656. We have not asked any questions touching
on quite a lot of the sections of your evidence, but it will clearly
be still taken into account, but there was a substantial segment
on training and professional boundaries, and in that you said:
"Much of the newly created NHS Education and Training Consortia
business will have social services implications, however social
services interests are often at the margin of the deliberations
of the consortia", and you want more inclusion of social
care education training needs. And then you go on to say that
early comments from participants suggest that, one of your bullet
points there is: "there is some evidence to suggest that
support from the Regional Office of the NHS Executive may be overly
directive, or may focus primarily on number crunching." I
was not clear, when I read that, exactly what you mean by overly
directive or what kind of number crunching?
(Mrs Cunningham) This is an anecdotal response from
some social services departments, so if it could be received by
the Committee in that context. The involvement of social services
officers on NHS consortia varies substantially, both in terms
of the level of officers involved and the grade or status of officers
involved. There are examples of good working but there are examples
of less than good working and limited understanding of the impact
that the NHS professional training agenda can have on social care
in local government in its broadest contexts. Given that, the
training consortia's agendas are sometimes dominated by traditional
financial, Health Service financial planning issues, which do
not encourage inclusion of officers from local government in the
debate, or of contribution to the agenda, necessarily. I think
what we were trying to say, from that evidence, is there is a
need to look at perhaps the agendas of consortia so that opportunities
are given to working more closely with local government colleagues,
maybe on a split agenda basis, maybe on an alternate meeting basis,
to explore those issues for the social care agenda more fully,
rather than have them swamped by the examination of financial
profiles.
657. And whose responsibility would it be to
get these changes that you want going?
(Mrs Cunningham) The NHS Executive.
Chairman
658. If there are no more comments from my colleagues
or questions, do you have anything to add, in terms of areas that
you feel we ought to be aware of or have not covered?
(Cllr Harrison) Just one, because it has just been
mentioned, the issue of regional organisation. If we have a look
at the Government's plans in relation to the regional structures,
it strikes me that there is a big gap there in the health services.
We have the local health authorities, but then all of a sudden
you talk about region, and, region, we do not know who is at region,
there is no structure there now. And I really do believe that
we should consider that regional level of organisation, there
is a regional level but that is an executive level, there is a
regional, accountable level, because it is at that level, of course,
where many strategic decisions are made, or should be made, in
relation to especially the high specialisms, and I think that
that should be looked at very, very carefully.
659. Can I thank you both again for your written
submission, which was most helpful, and for being willing to come
along here to be questioned by the Committee. We are most grateful
to you. Thank you very much.
(Cllr Harrison) I would like to thank you, Chairman,
for inviting us.
Chairman: Thank you very much.
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