Select Committee on Health Seventh Report

2. Background

4. Allowing patients the opportunity to have an input into the delivery of local NHS services, as well as enabling them to make complaints, has long been recognised as an important aim. Local Community Health Councils (CHCs), which have a statutory responsibility to represent the interests of patients and the wider community to the health service, were first established in 1974. However, in recent years, the needs, views and rights of NHS patients have rapidly ascended the political agenda, with the Government announcing in 2000 their "vision" of "a health service designed around the patient".[2] While measures to improve access, convenience and quality of care for NHS patients form the mainstay of government policy, there have also been significant developments in terms of securing direct patient input into NHS services, and providing enhanced support to patients negotiating the NHS system.

5. CHCs were established in 1974 and have their statutory basis in section 20 of the National Health Service Act 1977, and schedule 7 to the 1977 Act. CHCs have a statutory duty to represent the interests of the public in the health service, to monitor the local operation of the health service, to give advice to health authorities, and to be consulted about substantial service changes. They also have the right to inspect health service premises, but not those premises belonging to GPs without obtaining the owners' consent. About 500 people are employed full time by CHCs and 5,000 act as unpaid volunteers.[3] CHCs have been instrumental in exposing several major NHS failures, including the actions of the disgraced gynaecologist Rodney Ledward in 2000. However, in recent years attention has also been directed towards the perceived weaknesses in CHCs, including: problems associated with the fact that they deliver three distinct functions (advocacy, advice and representation) from within one organisation; their failure to secure adequate representation from minority and young age groups; and the fact that they are located outwith local NHS organisations, potentially creating an unnecessarily adversarial relationship; and the fact that they had historically been unable to cover primary care services. All this formed the backdrop for significant reforms proposed in 2000.

Proposed government reforms

6. Speaking at the launch of the NHS Plan on 27 July 2000, the then Secretary of State announced the abolition of CHCs, but very little detail was given about the system that would replace them, causing concern amongst many MPs. The alternative arrangements came to light in a series of other announcements, and included the creation of Patient Advice and Liaison Services (PALS) and Patient and Public Involvement Forums (PPIFs); the establishment of Overview and Scrutiny Committees (OSCs) in local authorities, with the remit of holding the NHS locally to account; and the formation of an Independent Reconfiguration Panel to consider the merits of major reorganisations of services which have been contested locally.

7. Provisions to abolish CHCs, to establish a duty on NHS bodies to secure public involvement in the planning of services, and to create OSCs and PPIFs were included within the Health and Social Care Bill in the 2000-01 Parliamentary Session. However, the idea of abolishing CHCs proved exceedingly controversial, and the clauses dealing with the abolition of CHCs and their replacement by PPIFs, Patients' Councils and a national patient body were all dropped when the Bill returned from the Lords to the Commons.

8. In September 2001, the Department of Health put forward new, more detailed proposals on patient involvement in the NHS in the form of a consultation document Involving patients and the public in healthcare: a discussion document, reiterating the Government's intention to replace CHCs with PPIFs in every NHS trust and PCT, and to create a national organisation to co-ordinate patient and public involvement in the NHS, the Commission for Patient and Public Involvement in Health (CPPIH).[4] These reforms, in amended form, were finally implemented through the National Health Service Reform and Health Care Professions Act 2002.

Commission for Patient and Public Involvement in Healthcare

9. The Commission for Patient and Public Involvement in Healthcare, which was established as a statutory non-departmental public body on 1 January 2003 under the leadership of Sharon Grant, sees its own role as:

• Ensuring that NHS services take proper account of the views of the public;
• Providing and facilitating a framework for public involvement; and
• Acting as a champion for patients nationally.

10. The Commission will also channel and co-ordinate all information provided by the individual PPIFs, disseminate good practice to other PPIFs within England, and make representations nationally on key health issues.

PALS

11. According to Involving patients and the public in healthcare, PALS should have been established within each NHS Trust by April 2002, to provide on the spot help and information about health services and to act as a gateway to an independent complaints advocacy service (ICAS) where people would be able to obtain help in pursuing formal complaints. PALS are run internally by hospitals and accountable to the Trust Board. The remit of PALS is to:

• resolve problems on the spot;
• provide information to patients, carers and their families about local health services and put people in contact with local support groups;
• tell people about the complaints procedure and direct people to independent complaints advocacy support;
• act as an early warning system for trusts and PPIFs by monitoring trends and highlighting gaps in service and making reports for action to trust management. These recommendations and the trust/PCT response will be included in the annual patients' prospectus for the trust/PCT in question.

Independent Complaints and Advocacy Services

12. The Health and Social Care Act 2001 places a duty on the Secretary of State for Health to make arrangements for advocacy services to be provided to people wishing to make a complaint about their NHS care or treatment. The delivery of ICAS across the country is to be managed by the CPPIH, through Patient and Public Involvement Forums. A trial ICAS scheme is currently being piloted around the country, but these pilots are due to come to an end at the end of July.[5]

Patient and Public Involvement Forums

13. Patient and Public Involvement Forums (PPIFs), which have a different role, are now being introduced across the NHS and they are due to be introduced in every NHS trust and Primary Care Trust (PCT) by the end of 2003. The role of PPIFs is to influence the day to day management of health services by the Trust, and to monitor the effectiveness of the PALS and ICAS in their area. PPIFs will be run by independent organisations under contract to the CPPIH, to which they will be directly accountable, reinforcing their independence from the trust whose patients they serve. Each PPIF will have the right to appoint a member appointed as a Non-Executive Director on the trust board. The CPPIH will support and facilitate the co-ordination of PPIFs at a regional and a national level. According to the CPPIH:

the public, through the PPI Forums and with access to high quality information provided by the CPPIH, will be able to engage in decision making as never before. This will include the monitoring and shaping of the range and effectiveness of services provided by every Primary Care Trust and NHS Trust in England, as well as influencing the health related decision making of other public bodies. Our strategy is to establish a de-centralised system which provides support as close to the public as possible, and ensures local sensitivity. In this the regional offices will play a major part.[6]

14. The PPIFs will each comprise volunteer members, recruited locally and trained appropriately. The forums once established will:

• be the main vehicle for the public to influence strategic priorities and day-to-day management of health services in their local area;
• be an independent critical friend on wider health matters in their community such as environmental health;
• review services from the patient perspective and monitor responses from local health services to complaints from patients.

15. The PPIFs' legal powers will include:

• the right to go where patients go, entering all buildings NHS patients use;
• the right to a response from the NHS to their recommendations;
• the right to refer concerns to local authority Overview and Scrutiny Committees;
• the right to a PPIF member as a non-executive director of the Trust;
• the right to raise concerns with more senior NHS management or a national body.

16. It is anticipated that there will be a total of 571 PPIFs, representing each of the 301 PCTs and 270 NHS trusts.[7]

---

2   Department of Health, The NHS Plan: A plan for investment, a plan for reform, Cm4818, July 2000, p 17 Back

3   Improving NHS Performance, Protecting Patients, Modernising Pharmacy and Prescribing Services: the Health and Social Care Bill, Research Paper 01/01,House of Commons Library, January 2001 Back

4   Department of Health, Involving Patients and the Public in Healthcare-a Discussion Document, September 2001 Back

5   Patient and Public Involvement (PPI): the Future Picture, Department of Health Position Paper, www.doh.gov.uk/involvingpatients Back

6   'Milestone achieved towards increased patient and public involvement', Commission for Patient and Public Involvement Press Notice, 1 May 2003, www.cppih.org Back

7   'Milestone achieved towards increased patient and public involvement', Commission for Patient and Public Involvement Press Notice, 1 May 2003, www.cppih.org  Back

---

Prepared 16 July 2003