APPENDIX 13
Memorandum by the Association of Community
Health Councils for England and Wales (FT26)
BACKGROUND
Community Health Councils (CHCs) were established
in 1974 and operate under the provisions of the National Health
Service Act 1977 and Community Health Council Regulations 1996.
They have a statutory responsibility to represent the interests
in the health service, of patients and the wider community.
The Association of Community Health Councils
for England and Wales (ACHCEW) is the statutory body, which represents
the interests of Community Health Councils (CHCs) in England and
Wales. It is an unincorporated body established by the Secretary
of State for Health by Order dated 1977. Its membership is made
up of individual Community Health Councils who direct its work.
The Association is funded by annual subscription from those Councils.
The Association provides advice and support to individual CHCs
and represents their interests at national level. In the process
its members and staff have gained an overview and expertise in
the issues of concern to patients across the country. No other
body is so uniquely placed to represent patients and the interests
of the wider community in the National Health Service.
ISSUES
Patient and Public Involvement
The system prefigured in "Shifting the
Balance of Power" sees responsibility for three quarters
of total spending by the NHS in England in the hands of three
hundred primary care trusts. These will commission services from
secondary and tertiary providers such as acute trusts, mental
health trusts and specialist trusts; also from providers outside
the NHS and England.
The system of patient and public involvement
in England agreed finally in June last year was designed to match
the system of commissioning and provision set out in "Shifting
the Balance of Power". Statutory Patients" Forums relating
to primary care trusts will have a wider role with regard to the
health of the local community not just health services, will work
together and contain representatives from the Patients" Forums
of relevant NHS trusts. They will be expected to provide, or at
least, commission a complaints service demonstrably independent
of providers. Patients" Forums will be represented in some
form on trust boards (as Community Health Councils are at present);
these will continue to meet in public.
It is envisaged that foundation hospitals will
have stakeholder councils, that will include representatives of
staff, patients and the wider local community. These will elect
non-Executive Directors to the Board.
While any move to increase patient and public
involvement in health care provision is to be welcomed, there
remain serious concerns both about how these proposals will work
in practice and how they will mesh with the roll out of the new
Patient and Public Involvement system.
1. Given the shift towards primary care,
a hospital unit seems the wrong level at which to increase the
democratic participation of the local community. A primary care
trust serves a given local community and has an interest in all
local services. This would therefore appear to be the most appropriate
level at which to increase public accountability.
2. Foundation hospitals will not have Patients
Forums and will instead have a stakeholder council. This will
represent a somewhat anomalous situation in the local structure
of patient and public involvement. It is also unclear whether
it is anticipated that the stakeholder council will perform the
same monitoring and scrutiny functions as would be expected of
a Patients Forum.
3. There is no clear catchment area for
a given hospital; this is especially true of large teaching hospitals.
If stakeholders are drawn from a given local community there is
a danger that specialist units will be deprived of resources as
stakeholders seek to refocus Trust resources to meet local needs.
4. There is a danger that stakeholder groups
will be dominated by the more vocal and better organised sections
of the local community. This may result in distortion of provision
in favour of such groups, while other groups in the community,
including ethnic minorities, who may have specific health needs
are under-represented. Specific provision would need to be made
to ensure that this problem did not arise.
Health Inequalities
It is envisaged that foundation hospitals will
have privileges not accorded to other hospitals. These include:
greater freedom to borrow and make capital investments; freedom
to vary national pay deals; and freedom from legal direction from
the Secretary of State. It is the Government's intention to legislate
in order to enshrine these freedoms in statute. Determining which
hospitals are granted foundation status will be based on "earned
autonomy". Those hospitals that pursue Foundation status
will therefore be those that are the most successful under the
current system. There are serious concerns that, although foundation
hospitals may benefit from additional freedoms, the affect on
the entire system will be to increase inequalities.
1. There are widespread staff shortages
throughout the NHS. Allowing individual hospitals to opt out of
national pay deals is liable to result in "poaching"
of staff by Foundation hospitals from non-foundation hospitals.
This will increase the recruitment problems of non-foundation
hospitals in the same area as a Foundation hospital. It is also
likely to have a negative impact on the morale of staff in a non-foundation
hospital.
2. Allowing greater financial freedom to
foundation hospitals, including borrowing and profit from land
sales, will increase their available resources. Non-foundation
hospitals in a given area with fewer resources will have less
to spend; this may be reflected in any number of areas eg older
equipment, less hospitable conditions for the public and more
poorly paid staff.
3. Research suggests that increasing "patient
choice" disproportionately benefits the middle classes. This
tendency is likely to be exacerbated by the creation of foundation
hospitals. Non-foundation hospitals are liable to end up dealing
with a greater proportion of the poorer and sicker sections of
the community as the middle classes opt for foundation hospitals
for their treatment.
4. A further distortion could also occur
if foundation hospitals do not have to pay charges on the public
capital they are vested with; it is difficult to see the equity
in this if struggling "zero star" and "one star"
trusts continue to be obliged to do so.
5. There is a real danger that as a result
of the above factors some non-foundation hospitals could enter
a spiral of decline.
CONCLUSIONS
A number of details on the proposed foundation
hospitals remain unclear. Furthermore there are considerable doubts
about how the foundation hospital proposals will mesh with other
policy priorities being pursued by the Department of Health, most
notably: the integrated and seamless system of care driven by
the "front line" through primary care envisaged by "Shifting
the Balance of Power; the new system of patient and public involvement;
and the government's general commitment to equity in health care
provision.
3 February 2003
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