House of Commons - Health - Seventh Report

Select Committee on Health Seventh Report

3. Discussion

17. Reforms to the ways in which patients and the public are involved in the NHS have already been subject to detailed scrutiny by Parliament. We do not wish to use this report to reopen arguments that that have already been comprehensively discussed elsewhere, believing instead that we, as a Committee, can play a far more useful role in scrutinising the ways in which the Government is now implementing the reforms enshrined in the National Health Service Reform and Health Care Professions Act. This was the main focus of our discussion with David Lammy. Mr Lammy implied that members of the Committee might be "fixated" on the old system of CHCs, which is far from the case.[8] However, we feel that it is essential that those changes voted through by Parliament are implemented in a well-managed and logical way, consistent with assurances made in the House.

Implementation and transition

Introducing PALS

18. Patient Advice and Liaison Services (PALS) have been introduced incrementally across the NHS at the discretion of individual trusts. Mr Lammy informed us that at present 96% of NHS trusts have PALS.[9] However, it does not seem to be possible to corroborate this figure with a central list of all the PALS in the country, as in answer to a written Parliamentary Question tabled on 30 October 2002 Mr Lammy told the House that this information is not collected centrally, arguing that it was "the responsibility of strategic health authorities to monitor Patient Action and Liaison Services".[10] We find it astonishing that the Minister was unable to provide information on the extent to which Government policy was being implemented. Moreover we note with concern the recent ACHCEW survey, A Friend in Need, casts considerable doubt on the extent to which NHS trusts have functioning PALS over the country as a whole. We call on the Minister now to collate and publish information on the implementation of PALS as a matter of urgency.

Introducing OSCs

19. Local government Overview and Scrutiny Committees should have been introduced by January 2003, and ministers have made frequent reference to their usefulness.[11] But again the Government appears to have little idea of the number that actually exist.[12] While we appreciate that the machinations of local government are more properly an issue for the Office of the Deputy Prime Minister, we find it totally unacceptable that the Department apparently does not have access to basic information about an element of public involvement in the NHS it clearly views as so crucial, three months after it should have been introduced. This is particularly worrying given the vital statutory function of Overview and Scrutiny Committees with respect to proposed closures and reconfigurations in the NHS.

Introducing ICAS

20. The ICAS pilots will run until the end of July and will spend August closing cases or supporting individuals in preparation for the transfer of service to the new full ICAS provision. This will start across the country from 1 September 2003. During August PALS will also be signposting incoming cases to the new ICAS service. Evaluation of the pilots will inform development of national standards by the Commission for Patient and Public Involvement in Health in the future.

21. ICAS are meant to be the responsibility of PPIFs. However, with PPIFs not yet properly established, the Government has had to step in with an interim measure. The Department of Health is now in the process of establishing an interim system of national or regional ICAS, which will operate until PPIFs are established and in a position to take over responsibility for ICAS.

22. David Lammy gave us a categorical assurance that there would be full coverage, across every NHS trust, by an Independent Complaints Advocacy Service by 1 September 2003.[13] However, his oral evidence appeared to reveal some confusion of PALS with ICAS, and about how advanced the process for setting up ICAS actually was. First he told us that contracts had already been issued, and then later in the session told us that a call for tenders had only just been put out.[14] Given this confusion, it seems to us highly unlikely that Mr Lammy's commitment will be fulfilled.

Introducing Patient and Public Involvement Forums

23. PPIFs form the cornerstone of the new system for patient and public involvement, and as completely new organisations with a strategic function rather than a specific operational role such as information provision or complaints advocacy, they will arguably be the hardest organisations to get right. Furthermore with over 10,000 voluntary members needed to sit on the PPIFs, the establishment of PPIFs is clearly a large scale undertaking.[15] Sharon Grant, Chair of the CPPH, told the CPPIH Board meeting in May 2003 that she felt it would take at least 3-5 years for PPIFs to be fully operational.[16]

24. It is clear that the implementation of such large scale system change is going to require a substantial lead-in time. We believe that with patient involvement, it is also particularly crucial that new arrangements are as clear and simple as possible, so that NHS patients, particularly those from disadvantaged groups, are able to negotiate the system with confidence and ease. It is particularly important that systems work well right from the beginning, as confusion at the launch of a system may erode the public's confidence in it, meaning it has failed before it has started.

25. However, there has been considerable confusion about the lead-in time for setting up PPIFs. From an initial commitment of early 2003, their expected start date has now been put back to 31 December 2003.[17] When we put it to Mr Lammy that the difficulties in establishing a new system would leave a considerable hiatus when patients and the public would have access to neither a CHC or a PPIF, he responded repeatedly that this would not cause problems, as other systems, such as ICAS, PALS and OSCs would already be in place to bridge the gap.

26. For the reasons outlined above, we felt unable to share his confidence that there would be sufficient coverage from each of these organisations by 1 September 2003. But perhaps more worryingly, we felt that Mr Lammy's arguments demonstrated a misunderstanding of the important functional differences between each type of organisation within the new system for patient and public involvement. PALS' primary function is to provide advice on accessing hospital services, including complaints advocacy, and they are a service provided by, and firmly located within, the NHS. ICAS have a narrow remit focused exclusively on providing advocacy services for patients who wish to pursue complaints. OSCs, based within local councils, allow elected local councillors to scrutinise the delivery of healthcare in a given locality. But none of these organisations has the overview, independence, or direct means for patients to input into local services which is promised from PPIFs, and so they cannot, in our view, be described as an adequate replacement for CHCs, even as an interim measure. For a Minister charged with securing better patient and public involvement in healthcare, we are dismayed that at our evidence session Mr Lammy apparently failed to grasp the subtle but extremely important distinctions between the organisations which his Government is currently setting up.

27. Three weeks after giving evidence to us Mr Lammy announced that "to make the position absolutely unassailable" CHCs would remain in operation until 1 December 2003, "at which time all patient forums will be in place to take up this role".[18] We welcome this move in as much as it acknowledges the necessity of ensuring that adequate provision is made for patient and public involvement at all times. However, several concerns remain. Firstly, the need to extend CHCs' period of operation will no doubt have placed those CHC staff who have not already left for alternative employment under great strain and created uncertainty. This extension will also give rise to widespread logistical problems. For example, many CHCs will have already had to give up the leases on the premises from which they operate, effectively rendering them homeless from 1 September 2003. This last date has been widely publicised as the date at which CHCs will close down, and any revision of it will no doubt lead to confusion amongst patients and the public as to where they should go to from September. We welcome the Commission for Patient and Public Involvement in Healthcare's decision to set up a telephone helpline to help people negotiate the complex and confusing arrangements that will be in place from 1 September, but we feel strongly that with a little more foresight from the Government these problems could easily have been anticipated and avoided. The fact that these reforms have been under discussion for almost three years makes this lack of simple planning even harder to justify.

28. Furthermore, we have seen nothing as yet to support Mr Lammy's promise that all PPIFs will be in place by 1 December 2003. Information previously published by the CPPIH suggests a date of 31 December 2003, which was the date that Mr Lammy referred to himself when giving evidence to us.[19] There have also been reports of numerous difficulties in establishing PPIFs, including a greatly truncated deadline for applications of interest, suggesting that if anything, the date at which PPIFs are fully operational is more likely to be put back than brought forward. We urge the Government to ensure that the establishment of Patient and Public Involvement Forums is fully completed by 1 December 2003, to avoid further confusion and uncertainty for patients and NHS staff.

29. Equally, setting up new organisations is a difficult process, and it often takes several months before they are operating at full capacity. With this in mind, it may be prudent to allow a period of overlap between CHCs and PPIFs, as was originally promised in Parliament.[20] We urge the Government, in line with commitments made in Parliament, to extend CHCs period of operation until 1 July 2004, by which time PPIFs will have had sufficient time to develop their own systems and will be operating at full capacity.

Unexpected changes

Appointment of staff to Patient and Public Involvement Forums

30. We were also very surprised to learn that, again contrary to commitments made in the House of Commons, the CPPIH, rather than appointing staff to PPIFs directly, is now delegating this function to local voluntary organisations. In evidence to us, Mr Lammy told us he felt that this distinction was not important in the least, and was in fact no different from a Member of Parliament delegating the appointment of junior office staff to an office manager. However, we feel that the delegation of appointment to PPIFs from the CPPIH to local voluntary organisations represents a significant departure from the policy originally discussed in the House.[21] The CPPIH is an independent body charged with representing the interests of all NHS patients, and also, crucially, the interests of the wider public. Local voluntary organisations have typically sprung up to represent a particular group of patients or the public, for example people suffering from a particular medical condition, and as such their previous work has been narrowly focused on securing access and benefits for one very particular group of the population. To charge such organisations with appointing staff to PPIFs, which are intended to represent all types of service users as well as the wider public, certainly risks, at the very least, giving the impression that only a small group of users will be having an input.

The 'one-stop shop' approach

31. The idea of a 'one-stop shop' has attracted considerable support in the NHS in recent years, offering, as it does, an opportunity for patients and the public to gain quick and easy access to the services or information they want without the need to negotiate a multiplicity of different systems, organisations and individuals. Supporters of CHCs have argued that CHCs provided precisely that, and that the new system risked fragmentation of a previously seamless service. Ministers have strongly refuted this claim, promising that the new system will indeed provide a 'one-stop shop'.[22]

32. However, the confused transition arrangements surrounding the implementation of the new system mean that over the coming years, a time when it is crucial for patients to exert a strong force for change in the NHS, there may in fact be up to seven different types of organisation over then next two to three years. PALS or, in the short term, CHCs, will be the first point of contact, with PPIFs being established in December. A patient with a complaint may then be referred to an ICAS pilot (up until July 2003), then be transferred to a new national ICAS service, and then finally to a new ICAS service implemented by the PPIF at some date in the future.

Patient and public involvement in Foundation Trusts

33. Another complication to the system is that, if the Government's plans for introducing Foundation Trusts come to fruition, a growing number of NHS organisations will not be directly served by a PPIF at all. If, as the previous Secretary of State hoped, within four to five years all NHS trusts will have moved to Foundation status, the PPIFs planned to be established by December 2003 could be in operation for a total period of three years, about the same amount of time that the Government has spent preparing and introducing the policy of PPIFs. In answer to a Parliamentary Question tabled in April 2003, Mr Lammy said that he was unable to provide an estimate of the redundancy costs associated with the abolition of CHCs.[23] However, as CHCs across the country employ around 700 staff these are likely to be considerable. It is now possible that the public purse will be facing costs of the same order over the next five years as PPIFs are scrapped when NHS trusts attain Foundation status.

34. We were told by the then Secretary of State that the new arrangements proposed for Foundation Trusts represented a far better form of public involvement than PPIFs, a conclusion we were not able to accept in our report on Foundation Trusts.[24] While we explored this issue at great length in our inquiry on Foundation Trusts, we feel it is necessary again to register our amazement that throughout the arduous and comprehensive discussions that preceded the introduction of the new system for patient and public involvement, the Government's plans for a second, more radical overhaul of patient involvement, through the establishment of Foundation Trusts with elected Boards of Governors, were never brought to light. Had the connections between these two divergent and conflicting policies on patient and public involvement been drawn out before the new system began to be implemented, the issue of how Boards of Governors and PPIFs might relate to each other and work together could have been very profitably explored, and perhaps a coherent policy involving the best elements of both could have been developed. As it is we are left with the impression that some policy within the Department of Health is formulated in total isolation from other policy, leading to the ridiculous situation the NHS and its patients are now faced with the introduction of two parallel but entirely different systems of patient and public involvement within the NHS within one year. [25]

8 Q7 Back

9 Q2 Back

10 HC Deb. 30 October 2002 Col. 834W Back

11 Q4, Q7, Q15, Q27 Back

12 HC Deb. 8 April 2003 403 Col. 237W Back

13 Q7, Q39 Back

14 Q4, Q15, Q17 Back

15 Commission for Patient and Public Involvement, 'Patient and Public Involvement Forums Frequently Asked Questions', www.cppih.org Back

16 Private correspondence from Association of Community Health Councils for England and Wales (not printed) Back

17 Department of Health, Involving Patients and the Public in Healthcare: Response to the Listening Exercise, June 2001, p24; Department of Health, Local Authority Health Overview and Scrutiny-a Consultation Document, January 2002, p21; 'Commission invites independent voice to shape the future in Health', Commission for Patient and Public Involvement Press Release, 7 March 2003, www.cppih.org Back

18 HC Deb. 4 June 2003, Col. 23WS Back

19 'CPPIH moves to next stage on appointment of Local Network Providers', Commission for Patient and Public Involvement Press Release, 25 June 2003, www.cppih.org; Q4 Back