Examination of Witnesses (Questions 40-59)
MR TOMMY MORGAN, MS PAT CADWALLADER, MR ROBERT HALL, MS JANE JEFFS, MS CAROLYN THEOBALD AND MR CLIVE BARNBY
MONDAY 17 JUNE 2002
40. It is certainly not in the Bill.
(Mr Morgan) May I add one more thing. Talking about the Regulations, we expect to be consulted in detail about the Regulations relating to the Act. The provisons in the Act are so broad that we are unlikely to disagree with them, but most of the issues that we have concerns about will be addressed in the Regulations. As an Association we feel we ought to be involved in the discussions when the Regulations are being set up.
41. So essentially what you are asking for then is the right to consult with the Assembly when they are drawing them up?
(Mr Morgan) Yes please.
42. Good afternoon. Perhaps we could turn to the membership of community health councils. They have been loosened up somewhat. Would you like to see the Act make any stipulations as to who should be in the CHC membership?
(Mr Hall) What we were in favour of is the opportunity to change the existing legislation because we were not particularly happy with the 50 per cent membership by local authority representatives. We all accept that throughout Wales conditions vary and local authorities vary and the members that come on to CHCs will also vary. Our biggest problem has been the fact that local authorities nominate their members but it does not always mean that they have the commitment or the time to fulfil their obligations to the community health councils. The figures that have been put forward by the Minister for Health and Social Services, Jane Hutt, have been generally accepted by the CHCs in Wales as the way we would like to move forward, which is one quarter local authority representation, one quarter voluntary sector and the rest through open advertisement. We also would like the facility provided where we can interview the nominated or selected persons for the post who wish to become members of community health councils. Unfortunately, they really do not understand the commitment involved in becoming a health councillor especially the time. You all work in politics and I have worked in local authorities and I have been a local authority councillor so I know it does require a great deal of time. If you are going to be an effective CHC member you have to understand exactly what is going to be involved should you become a member of a community health council.
43. When you say "we", is it as Chairman of a community health council?
(Mr Hall) As Chairman of a community health council I interviewed the voluntary representatives, as it was being piloted throughout Wales as an initial scheme, but we would like to do it for every possible member of the community health council. That is the only way for it to be totally fair, to be honest with you, and then they would really understand what is involved in becoming a community health councillor. It can become a large commitment. Local authority representatives are sometimes so busy that it should apply across the board. Any selected representative for a community health council must understand what is involved because it is a very, very long, hard commitment.
44. Local authority members will also be members of the local health boards in future and CHCs. Is there any conflict of interest there or is it a good thing?
(Mr Hall) I think it is a good thing. We also should have under the legislation for legal health boards put forward by the Assembly the right to be there and speak and observe in some capacity at any rate. In some respects they could wear two hats. The nominated members of the local health boards would not be the nominated members for the CHC. The biggest problem is the nomination because they always nominate people through that process that are already involved in their own local authorities. They have the opportunity to put forward people from community town council or even members of their own groups, but they sometimes tend to bring forward council members and they are not always the best persons to be there, unfortunately. I think really it is simply a matter of how busy they are and they do not realise the time involved in becoming community health councillors.
45. You have already indicated that you feel it would be appropriate either in the Act or the Regulations that there should be the power to make employers give employees time off. Is that because you have already got experience that employers do not give employees time off?
(Ms Cadwallader) The point about that one is that we are cutting a lot of people out who could be very valuable members of CHCs because they cannot get time off from work. We are also tending to get older people in the CHCs and we need some younger blood in. Even though we will pay their expenses and reimburse them for their time it is still down to whether the employers will give them time off from work, and a lot of employers will not.
46. So you are not asking for employers to give paid time off, or are you?
(Ms Cadwallader) Not necessarily.
47. Or are you suggesting that CHCs should be able to have the power to pay people to attend their meetings.
(Ms Jeffs) We do at the moment.
(Ms Cadwallader) We will reimburse people for lost earnings. In an ideal world, yes. If you go to various other things, then the employer is legally obliged to pay you, but if you go on jury service the employer is not obliged to pay you. Whichever way it went, the person would not suffer financially but also there could be a big gain to the CHCs a) as an aid to recruitment and b) to get some younger blood instead of all the time people who are retired and
(Mr Hall) Did you say tired?
(Ms Cadwallader)and the do-gooders, and you would get people who are genuinely interested.
48. Moving on now to co-terminosity and the shape of the future community health councils, do you think that there could be a sufficient reason for a local health board and community health council not to be co-terminous or should this be left to the Assembly's discretion?
(Mr Barnby) I think this is one we have given a lot of thought to particularly in my own area because the truth is that these are not co-terminous with the local health board. The main reason for that in a sense is because the two trusts there are not co-terminous with the local health boards either. I think from our own point of view what we are more concerned about is that whilst in many ways it would be convenient if we were co-terminous, we felt that the first priority is probably towards patients and patient flows and where patients go to. I think we have felt locally that as most of the patients from my council, Pontypridd and Rhondda, are seen in Pontypridd and Rhondda Trust and in a neighbouring CHC, Merthyr Cynon, all of their patients are seen by the North Glamorgan Trust, then it is better to be co-terminous with the trusts. I think there are other instances throughout Wales where you have more than one CHC per local health board in those kinds of areas and it is because of the way patients move. We have given a lot of thought in a place like Carmathanshire (where there are two CHC seats) to the argument for one local health board/one trust, but lots of patients go from Llanelli across to Swansea and probably have distinct community needs. There are places where, very conveniently, the CHC, the trust and the local board coincides and are co-terminous. I think that would be the ideal, but our feeling is that at the end of the day our priority is with patients rather than with the boundaries of local health boards and NHS trusts.
(Ms Theobald) May I add to that. I have a similar experience in Clwydd CHC as one of the CHCs is a single body with area committees rather than being a federation of separate CHCs. We have got three area committees co-terminous with the new local health boards. There is not any one of those where patient services are confined within the LHB borders. The key to that is CHCs themselves being flexible to work across their borders where necessary. For example, our Denbighshire area authority works very closely with Conwy CHC and there are other areas where we will work with Merionedd and Montgomery CHCs where the service is provided from Wrexham Maelor Hospital, and similarly across the border into England. We looked at this very hard last year ourselves where our boundaries should be. I think we came to the conclusion that wherever you draw the boundary you are going to have to cross it at some point. Sticking to the more natural communities and the broadest area of patient flow is probably the most appropriate.
49. Just to push you a little bitand both of you have spoken on thisare you saying you would be happy for the Assembly's discretion as long as you had input into it at an early stage? Is that what you are saying?
(Ms Theobald) Yes.
50. You think co-terminous local CHCs and health boards would be too rigid?
(Ms Theobald) In some circumstances, yes. We find there are advantages in being co-terminous and working closely but with our format we are working with three local health groups within the area. Health organisations change as well and there would be equal arguments for us being co-terminous with the trusts, for example. At the moment we are not quite sure how everything is going to bed down when the LHBs come in and the arrangements come into play. Most of us have got good working relationships both with trusts and the local health groups. We very much hope that they are going to continue into the future. It is that flexibility to work across borders as and when required that I think is most important.
(Ms Jeffs) Can I just add to that. In fact, we nearly are all co-terminous. There are three areas where you have got local health boards with two CHCs but generally it is because they are very large. For example, you cannot expect voluntary patients in North Powys to keep travelling down to Brecon, so in those areas you have got a local health board that has got two CHCs and they generally belong to the same federation and they do work very closely together. All the time we have been flexible to provide exactly what is needed by the NHS. There is only one area where they are not strictly co-terminous which is the one that Clive has talked about. We went into that very carefully. Ultimately we represent the patients and we know exactly what organisations we need to work with and who to speak with. We supported the structure of local health boards because we could see that is the natural theatre in which the CHCs are able to work. We are very clear about how we can be flexible within this and we know that the local health boards ultimately will be the commissioning and provision bodies, but again the CHCs themselves will have to get together when they form their partnerships and then they will be working across a boundary because they will be working in those partnerships and when we start talking about tertiary and specialist services, again, you are starting to look at regional and strategic frameworks, and we feel that we have always been able to adapt and we will continue to adapt to fit the circumstances because our representation is purely for the patients and we will be looking at it from purely which is the best way for patients to go.
51. I am going to ask about advocacy. The new Schedule 7A allows the National Assembly for Wales to provide CHCs to carry out the independent advocacy services which the 2002 Act will require the Authority to provide and the Explanatory Notes suggest 12 extra posts at an annual cost of £480,000. You welcome this and are very pleased that the Assembly is going to resource this in the future. What are your views about the 12 full-time post or 24 half-timers or however it works out? Do you think that is enough?
(Ms Theobald) It is a good question and I think it is something that as CHCs we are going to have to look at more closely bearing in mind the different factors of population size, travelling distance and so on that are workload generating factors, it you like, within the CHCs. Looking at the first 12 posts at that level of funding, it is probably a reasonable guesstimate. It is important with this to think that CHCs are already providing this service. All CHCs have developed this to a greater or lesser extent since they were set up in 1974. A number of us have had a dedicated complaints advocacy service in place for a number of years. In Clwydd it is funded by the North Wales Health Authority at the moment and I believe Merthyr has an advocate funded by a trust. We have found that it has made an enormous difference having those extra people on board who can provide that as a dedicated service. It frees up the chief officer and the other CHC staff for dealing with all the other statutory functions of the CHC, but what we have found is that once you have a dedicated service in place and you publicise it, the complaints workload starts to increase. We have found that bringing the two part-time advocates together and providing them with some extra hours from within our own budget and providing some publicity, that the advocacy is starting to find that they become involved within the health trust and so on in their own complaints monitoring processes and actually informing the process, if you like, from the beginning in terms of good practice within the health organisations. It has made a huge difference to the service that we can offer. I might be wary about the numbers but I know that in our area, as I say, we have got just over one whole-time equivalent who is struggling a bit in terms of time. If we could have somewhere of the order of one and a half and some clerical support that would probably be about the right level. We could perhaps extrapolate from there. On that basis 12 is probably in the right region but it would need more careful examination according to the workload generating factors.
52. Are these 12 posts in addition to the ones that have already been agreed by the trust fund?
(Ms Theobald) I think they would be replacing them because one of our issues, of course, is having health authority funded posts when the health authorities are disappearing next year. We would see it as replacing the discretionary funding that we are getting at the moment from outside.
(Ms Jeffs) The North Wales Health Authority was the only one of five health authorities that did provide any funding so it was great for the CHCs in the north that got that support. The only other organisation, as Carolyn said, was Merthyr, and in all the other areas in Wales the chief officers had been providing that service and had been doing it that as overtime or using their own time to provide that service. As Carolyn has said, it is replacing the ones that will go when health authorities come, but it is all about improving the quality of health care because of the information that we get from complaints. The reason CHCs started to do it wasand I need to say that the advocacy is about advocacy in the complaints system and support patients against the NHS it is not a broader advocacy roleis that is what we have been using to feed into the clinical governance agenda and what we have been using to explain to the trusts (and primary care where we can) that this is how to improve the services and it is that patient feedback that has been so useful and has been generally helping us.
53. Obviously as Members of Parliament we have a lot of individuals coming to us with complaints about the Health Service and you do learn an enormous amount. I have had good experience of working with a CHC without any dedicated resources. I think it is tremendously important and one of the most important bits of the Act. Your general view is that 12 is okay to start with?
(Ms Jeffs) Yes.
(Mr Hall) If we could have some more we would be very grateful!
54. Thank you. The other issue is do you think other bodies could be given the advocacy role by the CHCs? Have you had any discussions about this?
(Ms Theobald) In what sense?
55. A voluntary body, for example, could carry out the advocacy role for the CHC.
(Ms Theobald) I do not think that they could easily carry out the advocacy role in terms of the NHS complaints process. They obviously provide some very important specialist advocacy services and CHCs will regularly refer patients to specialist services such as the mental health advocacy and other forms of advocacy. The CHC's advantage in the NHS complaints procedure is that we are the only organisation that has a total overview of the NHS through primary care, secondary care, tertiary care and increasingly an input with social services and the private sector. I think that is important because many complaints have more than one element to them. Patients do not recognise the divides between the different parts of the NHS and very often do not recognise the divides between health and social care. Though our role has never strictly been a statutory dutyit has been accepted by custom and practiceit is to do with the NHS but we find very often that social services are willing to deal with us as well where there is a social service element in a health service complaint, and similarly in the private sector. We cross all the boundaries and we have got the overview. As Jane said, that is very important for service monitoring. It will often inform our CHC visiting programmes as well.
56. That has come up because when we had the joint meeting with the Assembly's Health and Social Services Committee, one of the things being discussed was whether a voluntary body should or could take over this role and be more independent. It would not be taking the power away from the CHCs but could they task a voluntary body to do it? Have you got any views on that?
(Ms Jeffs) Can I chip in here. In England they were saying that CHCs were too variable. I think the most important thing is that we should be offering patients a consistent service. If they walked into the CHC in Cardiff they should get exactly the same assistance with their complaints or problems as they would if they walked into the CHC in Carmarthan. I am not sure there is another organisation that has a Wales-wide view that you could commission the service from that would be able to provide it all the way across Wales. One of the advantages of CHCs providing it is that they have the expertise and experience. The second one is that they should be able, one hopes, to make sure that the training is consistent, that the standard of delivery is consistent to the patient. The third advantage, as Carolyn said, is that it feeds into the representation and the monitoring role. I am not aware of another single organisation that is extant all the way across Wales. When we deal with mental health advocacies, for example, you find there is one in South West Wales. There are different organisations across Wales and frequently we work quite closely with them, but I am not really aware of one that is there all the way across Wales through which you could do this.
57. So you have not really considered this as a possibility?
(Ms Jeffs) No, but also because that is what we have been doing over the past 26 years so we feel we have the expertise that is necessary. If you were dealing with somebody with a mental health problem or children's advocacy for learning difficulties, frequently we find we work together with that advocacy group. While we provide the expertise in dealing with the NHS, they provide the expertise for that particular condition, and it can be properly taken forward either jointly or with just one organisation advising the other. I do not know of another organisation that is better placed to provide it than the CHCs. We would be quite happy to consider the possibility if it came forward, but I am not sure where it would come from.
(Mr Hall) There is always a danger that CHCs try to do too much. I think in the past we have tried to do too much. What I like about this Bill is you are focusing the activities of the CHCs. Complaints is something we have dealt with so the expertise is already there and we do not need further training. This is an organisation in place that has been doing it since 1974 and I think we do it very well. I am not totally in agreement about the independence. I think the way they are selected through local authority representation, voluntary sector representation, members of the public and Secretaries of State means that you have the overall spread and understanding of all sorts of complaints in the CHC, but I would agree with what Jane has said, if it is a specific type of complaint we would pass it on and look for liaison so we would work together. I think it is important that the public have one point of contact for complaints. That is the beauty of this Bill; we are given statutory responsibility for complaints.
(Ms Theobold) It is also important to note as well backing that up that very often we get referrals from the voluntary organisations to our service and from citizens' advice bureaux and other help agencies because they recognise that the CHC has the expertise to deal specifically with the health-related complaints.
Julie Morgan: Thank you.
58. Before I ask any questions if I could pay tribute to the work CHCs do. Ann Jones, the Assembly Member, and myself have a very close relationship with Carolyn Theobald and they do an excellent job up in North Wales.
(Ms Theobald) Thank you.
59. If I can refer you to paragraph 2 of the new Schedule 7A; is this Bill erring too far on the side of caution? Why not give the CHCs some right to be consulted and to advise any public body engaged in providing health services, for example a local prison?
(Ms Theobald) We would be happy to do that. On anything that has to do with the health of any individual we would be happy to give advice to anyone who needs it. I think that we have looked at the Bill and tried to see where it is going to change our role, and the most important thing was to give us rights of access into primary care and where, increasingly, services are not just delivered in secondary care, they are delivered in a number of other places, we need to be able to support patients wherever they are. With regard to going into prisons, that is one of things we had thought about beforeit is back to what Bob saysbut we have not been resourced to the extent that we could do a huge amount and at the moment we know what we can and what we cannot do. We need the extra resourcing if we are going to provide complaints advocates all the way across Wales. We are going to need extra resources if we start to visit private nursing homes and then if we start looking at not just nursing but maybe local authority residential homes and all sorts of other services. We are happy to provide advice to any health organisation that asks for it but the actual capacity for visiting a number of organisations, really impinges on our members. We looked at the expense of travelling to all these different places but it is alsoand I think Pat can endorse itan issue around members' time. That is why we have asked, if possible, if we could be included in the public bodies which have the right to have time off if they require it because we have never had that before. If you have got working members of CHCs you can only do things in the evening. That limits what you can do and we have a problem at the moment in that in some areas the more we are asked to do, it is a question of how much our members can do.
(Ms Cadwallader) Yes, that is a very important point, that if people are working and they can only go in the evenings that is not a good time to go visiting nursing homes or community hospitals from the staff's point of view. Apart from the scheduled meetings which we do a couple of times a year in Anglesey where we go to the two community hospitals around 10 o'clock at night to see what is happening and how things are going on there, in the normal course of events these inspections or visits are done during the daytime. So once again you are down to a small core of people doing them. There is the questions of the right to go into wherever there are NHS services being applied. I have got experience of one home I am worried about on the island at the moment. We know they doll everything up for when we are going because it is a scheduled visit. I have had several things told to me about, for example, there having been no rubber gloves in this home for well over a fortnight and staff have been buying their own. It is a private nursing home but they have got some NHS people in. If I were to say, "I will be coming along on a visit", those gloves would be there. I know they have got six cases of MRSA at the moment in that home. It is little things like that. We have not got the power to go in at the moment at any time and say, "Can I have a look at your stores? Have you got this? Have you got that?" And that is essential for CHCs to have because if the NHS is providing the service within that home that people need, we need the power to go in, which we have not got at the moment.