Select Committee on Public Administration Minutes of Evidence

Examination of witnesses (Questions 380 - 399)



  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.


  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.


  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.


  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.


  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.


  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—


  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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