Examination of witnesses (Questions 380
- 399)
TUESDAY 15 FEBRUARY 2000
DR MARIAN
BARNES, MS
SOPHIA CHRISTIE,
DR SUE
BROWNILL, MR
NEIL MCINROY
and MR DANIEL
DOBSON-MOUAWAD
380. All you people cost a lot of money and
you said in your own presentations, "We need investment and
resources are short." When they were going to try and close
my hospital we did not need consultation committees. The councillors
and Members of Parliament called a public meeting and circularised
everyone and that is what representative democracy is about, not
an unelected committee having focus groups.
(Ms Christie) If I were Devil's advocate I would say,
`And had those councillors been provided with the information
and the knowledge base that allowed them to think that retaining
that hospital in that place with that level of investment was
the best way of spending NHS money?' Sometimes it is important
to take the difficult decision and to say, "Actually no,
it is more medically effective, it is going to provide better
access, in the long run it is going to be a better way of providing
services, to congregate services on a different site." That
would be a deeply unpopular public decision and it would be very
difficult for local councillors who are dependent on the public
voting for them, but unless they have also been engaged in the
process and the public has been engaged in the process and given
the information that allows them to understand what those decisions
might be about, then having a knee-jerk, "This is an easy
public campaign and it is a good vote-winner" approach is
not necessarily going to be in the best interests of that public.
381. You do not need to have professionals with
a lot of investment. In our area we have got a hospital defence
league. There is a very good exchange of information between the
hospital management, the GPs and the public. This is all part
of the democratic system. It seems to me that people like you
are trying to set up another level which is removed from councillors,
removed from Members of Parliament and costs a lot of money. My
question to you is: if you asked people—I do not know how
many millions you are talking about—"Would you like
£50 million spent on having better consultation or would
you like £50 million put into health care?", I know
the answer you would get.
(Ms Christie) It is not an either/or question really.
Chairman
382. The essence of the question is: is there
not a participation industry that is under way and is there not
a trade-off between that and the hard delivery of services?
(Dr Brownill) I think this is where we go back to
the distinction between structures and processes, and participation
is a process, and we can get too hung up on whether or not this
is an elected body or a non-elected body. It is actually about
having clear processes, about having the idea of building a social
and political capital and infrastructure in areas that can then
increase people's awareness and involvement both in the democratic
structures of the more traditional local government and other
issues, as well as leading into these newer types of agencies
of governance.
(Mr Dobson-Mouawad) There is another dimension which
is very critical here and which you have highlighted yourself
about the level of complaints about services. When people complain
it is because they are not getting the service that they want,
and so therefore the system is failing them. Tackling that level
of service and targeting it to where it ought to be applied in
the first instance will prevent wastage of money being targeted
on services to people that do not require the services or where
the service is failing them. You actually nip the problem in the
bud before it arises and before anybody has to complain.
Mr Townend
383. Are you saying that health services are
provided to people who do not really need them? I do not understand
you.
(Mr Dobson-Mouawad) Let me remind you of a report
which I read last week about the amount of prescriptions wasted
on people who did not actually need them or did not follow their
treatment or did not take the medication that they were prescribed.
The amount of wastage there was actually in terms not of millions
but billions. That is a waste. Clearly, if you engage the community
in identifying how best the service that they receive ought to
be targeted to meet their requirements then you will have less
wastage and less wastage equates with less public money being
essentially—
384. We are all in favour of doing away with
wastage, but you are not suggesting, are you, that somebody who
only takes half the prescription should then be banned from having
the prescription? You cannot sit in people's bathrooms and say,
"Do not forget to take your pills this morning." It
is fatuous.
(Dr Barnes) Can I widen this out? The whole issue
about complaints is that a complaints system is focused on specific
services. One of the things that we were doing in our introductions
was identifying the way in which the development of more effective
working across the boundaries of different public agencies means
that it is important to think about policies as well as services
and the way in which both policies and services can effectively
be brought together so that they can deliver the outcomes that
are sought. In that situation it is hard to see how an after-the-event
complaints system could do what a before-the-event system could,
by involving people who can identify where the problems are in
terms of services and policies not being consistent and co-ordinated
and actually create a more effective way of dealing with problems
that do not relate to one particular service.
Chairman
385. Does a complaints system count as participation
and does a good complaints system count as innovative participation?
(Dr Barnes) I act as an independent chair of a social
services complaints review panel so I have some experience of
social services complaints system. I would say that however well
you operate that this is not a system of participation. There
are very few people who complain in the first instance. There
are far fewer who get to the point where that complaint is investigated
on an independent basis. The whole process of dealing with it
is such that almost by definition nobody finds that it produces
a satisfactory outcome. I think this is a very different situation.
386. In terms of people's ability to convey
their feelings about services, surely complaints systems are a
rather robust way of doing that? Some might say it is more robust
than ticking boxes on questionnaires.
(Dr Barnes) I do not think any of us here are talking
about ticking boxes on questionnaires. We are talking about a
process of dialogue whereby learning can take place, that the
service providers, the policy makers, can learn from the people
on the receiving end what it feels like to use the service, what
it feels like to live in a particular area, what it feels like
to live with a particular health problem, in order to inform the
development of more appropriate services, more appropriate policies.
It is not about feedback on something that has already been provided.
(Ms Christie) Can I come back to the issue of investment?
Although you were there playing a Devil's advocate role, there
is a very—
387. Oh no. This is the Devil.
(Ms Christie) There is an important issue about value
for money. In a situation of limited resources and is this the
best way of spending the money, from my experience the worst way
you can spend the money is to think that just spending money on
health services will be a good thing. It is very easy to spend
the money on services that are not the most relevant for the local
population, are delivered in ways that are not particularly acceptable
to that population or ways that are not going to be effective
in terms of the way in which that population uses them. Some early
investment in building a consensus and understanding around what
service is required and how should it be delivered, what is the
style of the service, would be much more effective. A lot of the
issues that come out of complaints are not about how much money
has been spent. They are to do with personal interactions and
lack of communication, the feeling a person gets that they are
not being valued, they are not being respected. That is not a
money issue. That is a style issue.
Mr Townend
388. It is still a complaint.
(Ms Christie) We can waste a lot of public money delivering
the wrong types of services to the wrong population in the wrong
place whereas if we did some of the participation work a bit earlier
down the line we could deliver something much more appropriate
that would be effective in reaching the right people.
389. So this is market research that you want?
(Ms Christie) No. Market research is a slightly pejorative
term that implies that kind of one-off consultation. You cannot
get information out of the one-off. It can give you some directions
about what to explore in more detail, but you need to do some
longer term work with people. This is perhaps where some of the
issues about the different publics come in. A lot of my experience
in working with established groups has been working with people
with mental health problems. Doing the one-off meeting with a
group of people with mental health problems you do not get information
because (a) they do not trust me because I am a manager in a suit,
(b) they do not know me from Adam so they are going to be fairly
wary about what they are saying to me, (c) I can be quite intimidating.
What am I going to do with the information that they tell me about?
It actually takes a bit of time. Over a period of time you build
up some trust, you begin to get into more of a shared understanding
of what the issues are that then allows decisions to be made about
how we need to re-jig services, sometimes very simple things to
do with things such as the timing of outpatient clinics so that
it is after the bus pass comes into line which instantly reduces
your "do not attend" rate, really basic issues that
allow the service to be delivered more effectively so that people
feel as if they have had some value in participating in it which
makes it a good use of money.
(Mr Dobson-Mouawad) I would suggest that participation
is at the heart of democracy. People ought to have the opportunity,
the choice and the support to be involved if they wish to be involved.
Clearly that is what happens at elections. What we ought to be
ensuring is that anybody who wants to be involved in helping guide
the investment, whatever the investment might be, from health
authorities, from local government, from central government and
so forth, ought to have a channel to help that process and to
be engaged.
Mr Lepper
390. I was not going to begin my remarks by
giving my own CV but since John Townend has I think I ought to.
Before being in this place I spent 17 years as a local councillor
and was a former council leader. The general election came along
just at the point where, as chair of an embryonic regeneration
partnership locally in my own constituency, we were beginning
to battle with the sorts of issues that we have been discussing
this morning. The point that Mr Dobson-Mouawad just made about
democracy and participation is a vital one. However, I think John
Townend has touched on what seems to me to be a very important
point and that is, what is the role at the local level of the
locally elected borough or unitary authority or county council
in a situation where, quite rightly, it would seem to me, and
I suspect we come from a different standpoint here, he and I,
both the previous government and this government, are saying to
us in terms of regeneration schemes, it is the participation of
the local community in shaping the way those schemes are delivered
locally that is vital. Indeed, it is the quality of the community
involvement that might determine whether or not your community
becomes part of one of those schemes in the first place. I wonder
if we could explore a little bit that interface between that sense
of participation and the role of the locally elected council?
(Mr Dobson-Mouawad) I will kick off as I have already
been quite forward in making some views known. The mandate that
local councillors get at any one moment in time ought really to
be topped up over time by keeping in touch with their communities.
Any councillor who would suggest that they can deliver their remit
without being in touch with their communities should be challenged
on that point. The critical aspect here is that government, in
promoting regeneration programmes, have stated that they are trying
to shift the power from Whitehall to local communities and make
government more responsive to the needs of priorities set at the
local level. Clearly that is the principle of subsidiarity. Agencies
such as ourselves ought not to be viewed as negative organisations
just trying to create some work for themselves and perhaps a penny
or two because what you have to understand is that my organisation
in particular is a non-profit making organisation, it secures
its money and it works partly on blood and sweat and all my officers
are engaged on a vocational basis and they could easily gain much
greater financial remuneration working in the commercial sector,
but that is not where their heart lies. Clearly we are providing
a valuable service and it is one that I believe complements the
local democracy and also the role of local councils. This is precisely
why the government is now pushing the local government to change
in order to make it more accountable to local people and to engage
local people in the decision-making process. This is where I would
suggest that democracy, participation and decision-making all
ought to be linked up. It is about getting people involved through
a democratic process in the decision-making process that will
inevitably channel investment and the right level of service to
their local community.
(Dr Brownill) I think it is wrong to see regeneration
partnerships as a threat or a competition to local authorities
because they usually have a lead partner and that usually is the
local authority, so the local authority has a key role in these
partnerships. One aspect of that role is to identify what is the
appropriate level of participation and involvement in particular
areas. We have heard a lot from the panel about how it is very
difficult to have a blanket, either a top-down strategy about
participation or even views because it is very different in different
areas. There are different communities in each area, there are
different strengths, there are different levels of organisation
involved, and so it is one of the key roles of councils to know
their area, to have a profile of their area, so that when something
like a regeneration scheme comes along where there may be the
need for some development work to get people involved as well
and so to build that social/political capital in areas is going
to have spin-offs for other areas, not just for regeneration partnerships
as well. That might mean having an idea of a longer term strategy
about where participation fits in to the whole of that regeneration
project or process over time, about what happens when that initiative
finishes because we are also very much into short life initiatives.
You can have something that is ongoing for five years. What happens
then to those networks that you have built in? It is the role
of the council to forward think how they can support those and
how they can draw on those networks and the confidence that may
have been established in an area into other initiatives and into
other services delivery and policy planning.
(Ms Christie) There is an issue here about the diversity
of the local electorate and we know that not all parts of the
population vote in the same proportions. I would guess that as
a local councillor there are times when you are accountable to
an electorate, but there is the point which Daniel made earlier,
that the ward for which you are responsible, only a small proportion
of the people in that ward might have voted. There are issues
about what are the other support mechanisms that might be put
in place that can help you feel comfortable about the kind of
information that you are getting. There are people who will come
to surgeries and talk to you as ward councillors about what is
going on. They are a fairly small proportion of any population.
We know that young people do not tend to do that much as older
people do. We know that people in jobs might have less time to
be available to do it than people who are retired, that there
are barriers of language, class and culture that mean that some
people are more likely to come forward than others. To me there
is a symbiotic relationship between representative democracy and
participative democracy. Representative democracy is almost one
end of an extreme, there is a voting, an involvement mechanism
that is a one-off thing that you do on a day in May every so often,
and for most people that is their contact with it. Then there
is, what are the other processes that can help support that and
make that a living and real process that gives councillors a real
sense of what it is that is going on out there, and recognising
that the people you have the face to face contact with will be
very important sources of information but they are probably part
of a particular part of your local community and there will be
other sections of that community who are very unlikely to make
that face to face contact. Having some investment in other ways
of engaging their understanding and their opinion will give you
a much broader sense of what the issues are for those different
communities.
Chairman
391. Can I put it this way: do we need more
participation, say, in the Health Service because it is a non-elected
service, or does it not matter? Should the same requirements,
the same techniques, be equally applicable across the elected
and non-elected sectors?
(Dr Barnes) I would say yes.
392. Yes to what?
(Dr Barnes) To the second part, that you need the
same sort of processes. One of the issues for me is the distinction
between decision-making and decision-taking, and I think it is
important that the process of decision-taking does require a clear
structure of legitimacy so that the people who take the decisions
are taking them because they have a legitimate position which
allows them to take them. That could be either because they have
been elected in order to take decisions or because they have been
appointed to a particular management role which carries those
sets of responsibilities with them. What we are talking about
in terms of enhancing the level of participation is to inform
the decision-taking process. Maybe this relates back to the question
I asked before about do people want to be involved. One of the
things which people are actually quite reluctant to be involved
in is decisions which seem to involve them in taking decisions
about rationing or some other decision about the allocation or
otherwise of particular resources. One of the things they say
is, "We have no locus which enables us to take this
decision. We are ourselves not accountable, we cannot be challenged,
we have not been elected into a position to take this decision,
we are not being paid to take this decision." That is where
the difference comes, there needs to be some sort of clarity about
who it is has the role of taking decisions. At the moment that
is different in the context of the NHS and local government services
at a local level, which I suspect, as partnerships develop and
new forms of governance are emerging, in itself might be questioned,
whether that sort of difference is sustainable. I would wonder
whether it is sustainable.
Chairman: Thank you for that.
Mr Trend
393. I am not persuaded about the distinction
you see in different ways between a representative democracy and
a participative democracy. It seems to me that in the end the
people who can pull the levers and push the buttons and spend
the money must be accountable to the people who have given the
money, paid the money in the first place. With something like
rationing that would in the end become a national debate, it could
not be held at local level, and a new consensus might be reached
or it could be taken forward to a general election because it
is such an important issue it could only be tested in such a way.
I am sure a lot of local authorities are very good and I would
be intrigued to press your view on CHCs and see how effective
you think they are, although I understand they are different in
different parts of the country. There is an argument for bolstering
up the services we have, for trying to get local authorities to
do a lot of the things which people do themselves, to get CHCs
to become not just a reactive but a proactive body in terms of
the Health Service. I am slightly tempted just to leave that aside
because that is just my view on what has gone on. In another way
you represent collectively a new group of bodies which in a sense
are trying to ask the same question which other bodies have done
in the past but you are doing it in a slightly different way.
I do not know about Thames Gateway but I dare say everybody else,
as indeed we are, is in receipt of public funds to do this. You
are too. Then we all work for the taxpayer. How does the taxpayer
know they are getting value for money, efficient services, effective
services, from you, if I may lump you together, as a group of
professionals? What are the measurements in this? How do you measure
whether there is demand for something? You may feel very strongly
that people ought to do this but how do you measure if there is
a demand? How do you measure the outcome of this? How do you know
you have been successful? You talk about social capital. What
does that mean and how do you measure social capital? Is there
a social capitalometer to do this? You want these clearing houses
and these one-stop-shops and I dare say you would like to run
them. How are people going to check the effectiveness of your
work?
(Dr Brownill) That is a very interesting question
actually and certainly in the regeneration area there has been
a lot of debate about this. At present the system is very much
about outputs—how many jobs are created, how many meetings
are held—rather than the issues we have been talking about
which, as you say, are very hard. You can be creative about some
of these indicators and measures and one of the important things
is about having a good idea about where you are starting from
and where you want to go to and the measures you need to achieve
where you are going. It is possible to have that as a kind of
process indicator certainly for something like participation where
you might start off with your regeneration scheme—how are
the communities working together, where are the gaps, where do
you want to put in money to create those, what are the decision-making
structures we want on our partnership board, how are we going
to measure how that is effective. I am not saying they are the
definite blue-prints there but they are beginning to evolve and
Daniel might have some experience of this in the Thames Gateway
area.
(Mr Dobson-Mouawad) My view comes from several points,
including some evidence you have already received from the Audit
Commission. Organisations such as ourselves are audited at some
stage and the critical aspect is whether that audit procedure
can acknowledge what participation process has actually been engaged
and what are the outputs from that. Challenging the aspect of
how you define outputs, a lot of regeneration programmes want
to quantify outputs into little boxes and tick little boxes. We
have a major problem with that purely because we are about quality
as opposed to quantity. I could easily invite the community to
come and see a film in a local cinema and give them free tickets
and get everybody to come out and I could easily put down that
I have secured 300 people participating in some sort of event.
I am not interested in that, I am interested in people coming
out and participating in the system on a qualitative basis as
opposed to a quantitative basis. So there is this bit of chasing
the tail game which happens in the regeneration process where
people are just trying to clock up outputs to make their regeneration
initiative look good as opposed to looking at the qualitative
aspect. I concur with the Audit Commission that there is a mechanism
to be developed, which can be developed, which can assess the
level of quality in the participation process; if you like the
best value process. The critical aspect here is that these are
some of the systems which we have been playing a part in developing
on a European basis within the Recite Lotus 2000 Project, where
we can actually create sustainable indicators and weight them
to create indices to identify what are essential aspects of a
process, what are desirable, and certainly you can quantify and
specifically identify those which are most definitely not worthy
of support or investment and certainly ought to be left on one
side. There is a mechanism to assess that but until we actually
develop that mechanism we are failing the system, because quite
clearly we will not know between one agency and another which
is actually progressing good practice and providing a good service
for the money they receive.
Chairman
394. Does Michael Trend not have a point though
in saying that—and many of you have said this in your submissions—somehow
process is more important than product? In saying that and emphasising
social capital, is that not a kind of way of saying, "You
cannot point to defined outcomes"?
(Dr Barnes) The outcome one is very, very difficult,
is it not, because at what point do you measure? I was talking
earlier about a process of learning and part of what we are talking
about in terms of referring to process is the way in which the
understanding of people working in public agencies is in large
increased demand through the process of engaging in dialogue with
community groups, with user groups, with citizens, which leads
to outcomes which are very diffuse and operating at very different
levels. They could be outcomes in terms of the way in which a
GP interacts with his or her patients on a daily basis; they could
be outcomes in terms of the training which is provided to Health
Service professionals based on what we have learnt about what
feels effective in terms of interpersonal relationships, as well
as some of the more, if you like, obvious outcomes about shifts
in policy, shifts in the way services are designed. So the whole
issue about outcomes is that it is very diffuse and it is perhaps
more effective to talk about the way in which both sides can actually
learn and develop, rather than to say, "What we want to do
is measure whether a particular outcome has been achieved at a
particular point in time."
(Ms Christie) At the risk of being simplistic, there
are two questions which are always important to me in working
with the public—is it going to make a difference and can
we actually monitor that process. I think there is a legitimate
question to be answered around the investment in the process,
and if the decision is effectively made or is non-negotiable then
there is no point putting a public participation process around
it. If you go for a very elaborate process which is not affecting
the quality of the decisions and the nature of the debate, then
it is probably not a very effective process. So looking at and
learning from previous experiences locally, and looking at how
we can develop that system as we go on, allows us to have a better
sense of when it is important to put what kind of investment in
and what sort of things do we go for a big public participation
around and what do you just do. There is a second issue which
is around at a very early stage getting a sense from local people
about what their expectations are and letting those expectations
help define the outcomes we are looking at. An example of that
would be in the Health Action Zone in Sandwell. At the moment
we are just in the middle of a process which is about getting
local people to identify the ten key things which would say to
them that the HAZ had made a difference. So there is a whole structure
outside which is about the national evaluation and efficiency
reviews and all that kind of stuff, but for me one of the key
issues is, are there local people saying this has made any difference
whatsoever to the way in which they perceive processes? I cannot
define what those things are. I do not know what those things
are going to be but we are looking for a limited list of measurable
indicators which actually are meaningful at local level. That
would be a real test for me about whether we have achieved anything.
Mr Trend
395. I very much liked Daniel's example of giving
people a camera and asking them to take photographs, but in a
sense the local authority can organise that as well as anybody
else could. Somebody referred to it as being a matter of style
and maybe we have the wrong style of local government. Can I ask
a different question? I wonder how far this is fair because we
know, particularly from the Health Service and primary care, the
differences around the country which can be measured which reveal
certain important facts. Engagements such as these which take
place mainly at a local level will surely result in some parts
of the country having a splendid consultative system in health
care or in new business ventures or whatever it is, and other
parts of the country not being up to that standard. This will
become a problem for the national government at some stage and
far from making it more diverse they will wish to nationalise
it. What do you feel about that? Is it fair, that is the main
question?
(Dr Barnes) Is it fair now? I am in the middle of
looking at some of the developments which are going on within
primary care resulting from the Primary Care Act and the diversity
is there and it is inevitable, it seems to me. The question is,
is there a national expectation that everybody should be doing
this, not is there a national prescription about how everybody
should be doing it. I think there does have to be a clearly defined
expectation that, if you like, participation is not an option,
this is part of the way in which decisions are going to be made.
How that actually is implemented will be very dependent on the
nature of the particular local communities and the sort of mechanisms
which are appropriate. Just thinking about some of the pilot sites
we are looking at in the context of the Primary Care Act initiative,
we are looking at sites in commuter belt Surrey and we are looking
at sites on Streatham Hill; entirely different communities, entirely
different populations of primary care service users. The mechanisms
you need to engage people have to be different, you cannot be
prescriptive about mechanisms.
(Dr Brownill) The example of regeneration shows how
funding is quite key. The regeneration partnerships have to consult
to get the money and that has certainly focused a lot of agencies
and authorities who may not have entered into that same level
of participation had that carrot not been there. That is not to
say that you cannot have a national top-down blue print but I
very much agree with what Marion said about how local areas will
differ and will be on different timescales. There is a role for
local government and even for regional government because the
Government Offices for the Regions have been very key in monitoring
regeneration activities and actually pushing a lot of partnerships
along the way to more meaningful participation.
Chairman
396. Is that example not precisely what gives
consultation a bad name, the fact that people have to consult
in order to get the money? They have to be able to tick the box
which says, "Did you consult and then we will give you the
money?" That is exactly the kind of instrumental attitude
towards it which breeds this cynicism towards the whole exercise.
(Dr Brownill) I agree with you in one sense but there
are ups and downs to that. It does focus people's minds. It has
to be properly monitored. Over the seven years of the Single Regeneration
Budget it is interesting the way that the Government Offices for
the Regions have changed their way of monitoring precisely to
counter some of your points. That is why we have been talking
about quality and the qualitative things, and participation as
a process is actually very important. That is the danger again
of having top-down requirements from Government because some agencies
and authorities are quite cynical and do the absolute minimum
they have to.
Mr Townend
397. Do you believe in using local referendums
to find out what people think? With participation it always seems
to me that so many people are excluded, are you really getting
the views of lots of people?
(Ms Christie) Referendums are a knee-jerk reaction,
it is very difficult to frame a set of complex issues into a single
question and get any kind of reasonable—
Chairman
398. Would you like to join the euro? Something
like that?
(Ms Christie) Exactly! We are doing a piece of work
at the moment—
Mr Townend
399. You really do not like democracy, do you!
You like participation that you can control.
(Ms Christie) I like democracy that is a thought-through
democracy which gives people a number of opportunities to participate,
not asking someone a one-off question, "How do you think
the NHS could be improved?" We have just been doing some
vox-pop work in Sandwell and the kind of responses people gave
to the one-off question versus the sort of responses they gave
when they were talking in groups or where they were given a longer
time to respond was really interesting. The knee-jerk reaction
you could take from that morning's papers' headlines and the thought-through
responses and negotiations were very different. Unless you have
a very simple question in a referendum, and there are few of those
around in the context of health regeneration, it is difficult
to get something which is worth the investment. If we are talking
about value for money, you do not get good quality information.
(Mr Dobson-Mouawad) I agree, it depends on what the
question is, but once you do have a referendum the thrust of it
ought to be that the process of participating in the referendum
ought to be as simple as possible. Particularly in light of the
fact you are giving some attention to the development of IT, one
could suggest that perhaps using Lottery terminals is one way
whereby people can participate in the referendum because quite
clearly a great number of people already participate and know
how to participate in such a simple process. If you can tick that
you want to go to the millennium dome on a certain date at a certain
time, why can you not tick that you want yes or no to a simple
question.
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