Select Committee on Health Written Evidence

Evidence submitted by the Commission for Patient and Public Involvement in Health (Def 28)


  1.  The Commission for Patient and Public Involvement in Health (CPPIH) was established by the NHS Reform and Healthcare Professions Act 2002 and set up in January 2003. It is an independent, non-departmental public body, sponsored by the Department of Health. In June 2004, as part of the Arms Length Body Review, it was announced that the Commission would be abolished in the Summer 2006, which was subsequently postponed until 2007.

  CPPIH oversees and supports 569 statutory Patient and Public Involvement (PPI) Forums, made up of local volunteers, one for each Primary Care Trust, NHS hospitals trust, mental health trust and ambulance trust. It also gathers information and opinion from PPI Forums, in order to ensure that NHS bodies are acting upon patients' and the public's views.

  It is responsible for submitting reports to and advising the Government on how the Public and Patient Involvement (PPI) system is functioning and has a remit to make sure the public is properly involved in decisions about health and health services.

  2.  Members of PPI Forums have a statutory role in monitoring decision-making and service delivery by local NHS bodies. They are in a strong position to comment on NHS deficits on behalf of patients and the public because of their knowledge of local structures and services and their existing relationships with trust managers. PPI Forums are active in every part of England where NHS deficits are occurring.

  3.  PPI Forums began raising concerns about NHS deficits in the latter part of 2005, before the scale of problems and their potential impact on service delivery had been fully recognised. As a result of this CPPIH contacted PPI forum members by email in December 2005 and March of 2006 asking them to take part in "on-line polls" to obtain a more detailed picture of emerging concerns from across England. In addition to answering a series of questions, respondents were invited to provide additional comments highlighting particular local difficulties.

  4.  CPPIH is encouraged that a broad range of PPI forum members responded with detailed comments on a range of issues, and we believe these surveys provide two valuable "snap shots" of emerging problems across England. We also believe that the comments, a selection of which are summarised below, provide an insight into the public's perspective on NHS deficits, revealing a wide range of opinions about why substantial budget deficits have come about. They also highlight genuine concerns about the impact on local services affecting vulnerable members of the community, including the elderly, people with long term chronic medical conditions, and those with mental health problems.

  5.  They provide us with a unique insight into how the interested public at a local level have perceived the handling of the NHS deficits, and are the only channel currently available for doing so. Here we provide the views not of the Government of the day, or PR professionals, or NHS managers and staff—of a serious financial crisis in the NHS. These are opinions from the communities that the NHS is intended to serve, and who pay for it, and whose support is essential to maintaining the consensus surrounding its values.


  6.  The first poll, conducted in December 2005 received 366 responses, with 63% of respondents saying that their Trust was predicting a deficit. Few at that time were able to provide details of the impact on services, with 83% reporting that they did not know whether the trust intended to cut services.

  CPPIH conducted a second poll in March 2006, to which it received 237 replies. The proportion of respondents reporting their Trust faced a deficit had increased to 74%; 58% reported that their trust was planning to make staff cuts over the coming year and 62% reported plans to cuts services.

  7.  Respondents were invited to provide details of projected deficits if they were available. Many sought to do so although in December the picture was far from clear. For example a forum member from Leicester University Hospitals PPI forum commented in December: "the projected deficit is frequently altered to take account of savings achieved and the likelihood of commissioning being adjusted by indebted PCTs to rectify their own projected losses."

  A forum member from Suffolk stated: "The projected amalgamation of the three PCTs to form "Suffolk East" has led to some confusion as to the level of debt and hence projected deficit. The extensive reductions in the service are alarming to patients in the area." (Respondent, December survey)

  An Ambulance Trust Forum Member from East Anglia raised the following concerns: "The Trust is in balance at present but under pressure from the PCT's not withstanding 999 call demand rising annually at a 10% compound rate. Suffolk West PCT & West Suffolk Hospital are both in deficit—some £10-15 million or more. Some of this was inherited from the Suffolk Health Authority. All Forums in Suffolk are now meeting jointly to review the County wide NHS financial situation." (Respondent, December survey)

  A respondent from Yorkshire Wolds & Coast PCT Forum stated "At present another £8m.+ is estimated plus £7.3 million outstanding. It was anticipated to be around £11.5 million. They must make over £1 million. savings before 31st March. This is my understanding as from last week." (Respondent, December survey)

  8.  A former Forum members from West Yorkshire raised a number of serious points about achieving financial balance: "The LTHT Trust (Leeds Teaching Hospitals Trust) in West Yorkshire is projecting financial balance but it is difficult to see how this will be achieved under the current integrated performance reporting. Great progress has been made into the underlining [underlying?] reported deficit, but recovery is in the hands of the business managers at the Trust. . . . managers have experienced great difficulty in producing business plans for this last year and for 2006. . . .

  ". . . In line with the quality sub group terms of reference there should have also been quality plans backing up these business plans, which to date have not been available. . . . Having been in finance most of my working life I find the concept of doing a budget then having a deficit as large as some of the Trusts report a real concern, it all comes down to good management and accountability". (Respondent, December survey)

  9.  A respondent from Central Manchester PCT Forum wrote: "It's complicated—the finances seem to be in order and operating normally the PCT is not running at a deficit. However, due to the actions of the Central Manchester and Manchester Children's Hospital NHS Trust, a significant amount of money had to be allocated to the CMMC to cover their deficit. As a result, Central Manchester PCT has put in place their own, voluntary, recovery plan. In the medium term, things remain uncertain. However, it is possible that a large sum of money will come its way through PBR (Payment by Results) and the acceleration of the catch-up of historically owed resources." (Respondent, December survey)


  10.  A number of respondents raised similar concerns about trusts having to take on the burden of deficits from neighbouring trusts:

  A respondent from East Hants PCT Forum commented "it began at about £5 million but for some odd reason they had to take on more from other trusts and I think they are up to about £23 million" (Respondent, December survey)

  A Billericay Brentwood Wickford PCT Forum respondent added "This is an odd one as the Trust has budgeted to balance its books and strives to do that but has had imposed on it a requirement to provide £2.2 million savings to help the SHA balance its books. I think that this will be hard to achieve in the next five months without cuts." (Respondent, December survey)

  A member of Croydon PCT Forum: "The Trust is expected to breakeven this financial year although a £2 million deficit was carried forward from last year. However a further concern is that existing deficits will be shared across sectors so Croydon services may be curtailed as a direct consequence of the financial deficits created elsewhere." (Respondent, December survey)

  11.  Similar concerns featured in the March survey: "This year has seen the SHA call in money for a bail out fund for less well managed trusts and the £2.5 million called for cannot be achieved. The Chancellor's insistence that the new merged PCTS must take forward the deficits precludes a balanced budget in most cases without reduction in services." (PCT Forum member, March survey)

  "The PCT has been asked to contribute 3% of its income to a fund held by the SHA to plug the debts made by other trusts in London. This will amount to £11 million which the trust can ill afford to lose. It seems that the trust is being penalised for not being in debt—no question that this amount will mean cuts of some kind, either staff or services or both." (Forum Member, Westminster, March survey)

  "The trust manages its finances well. However, due to issues with other trusts the goalposts are constantly being moved. In 2005-06 they had their budget cut by c. £700k mid year. 2006-07 year budgets have been scrapped and they are about to start the year not knowing what their budget is! SHAs should abide by the budgets set and ensure new budgets are approved 2 months before the year starts, to allow for planning." (Respondent, March survey)

  12.  A respondent from Bromley Primary Care Trust Forum provided detailed comments on possible reasons for growing deficits "I am the Forum's elected Observer on the PCT Board, and I am very much aware of the financial situation. Last March the projected deficit was 2.7 million which was largely caused by the sudden introduction of Payment by Results using the National Tariff charges, of which some new Foundation Trusts were early implementers. I learnt eventually that there was a wholesale cull of the senior management team: some Directors were not re-appointed, some were re-appointed to their job at a lower grade (eg Assistant Director), and others eventually left for jobs elsewhere. Such a `solution' can be applied only once." (Respondent, December survey)


  13.  Other respondents, however, reported a different understanding. Respondents cited a range of reasons for budget deficits:

  "Our trust has poor financial management. Does not know what services it is paying for in the various hospitals used in our area, May be paying for some services twice." (Respondent, March survey)

  "Currently no-one can explain why they are in such a mess and exactly what is being proposed. The financial problems in Worcestershire are historical and currently running at £20 million." (Respondent, March survey)

  "I think the NHS finances are not properly profiled, recorded, monitored or QA'd for Value for money, certainly not in the way Civil Service public expenditure is. I have never before heard of an organisation that asks people it is giving money to to explain what service they are paying for!" (Respondent, March survey)

  "Most of the deficit has arisen because our hospital has carried out work to meet patient needs which the PCTs have not paid for due to their own financial problems." (Respondent, March survey)

  "Central NHS directives mean that my trust does not have financial control. An inherited deficit has caused major problems." (Respondent, March survey)

  "Balanced finance depends on demand, expenditure and funding. Demand from patients seems to go up year after year. Expenditure: a lot of this is outside the control of the trust; wages, government targets etc. Funding: there is little transparency in how the level of funding trusts is arrived at." (Respondent, March survey)

  "Resourcing and Allocation Budget (RAB) is, it seems to me, at the root of many Trusts problems because of the way it ratchets up indebtedness. In this area Trusts have had budgets top-sliced by 3.5% presumably increasing their indebtedness by several million pounds." (March Survey respondent)

  "Blame is being placed on central government when locally it can be shown that the overspend has been going on for many years and has not been addressed." (March Survey respondent)


  14.  The March survey also revealed considerable pessimism about the future, with 70% of respondents saying they did not expect the situation locally to improve.

  "All trusts will struggle unless there are changes made. Those who will not suffer a financial deficit have managed well, but we all know that changes will be made in many things including the amalgamation of Trusts and it is impossible to forecast what the future holds for each trust." (Respondent, March survey)

  "With the introduction of Commissioning a patient-led NHS, choose and book, patients might see a fluctuation in services as a direct result, this is unknown territory for many even those with financial balance. Nobody really knows the fallout from choice, where money follows the patient, can existing standards be maintained or even improved upon? These are questions and answers that only with time we will know." (Respondent, March survey)

  15.  Several respondents were concerned about the impact of other departmental policy initiatives on trust finances, particularly on Foundation Trusts:

  "Leeds Mental Health Trust is proposing to become a foundation trust. The main threat that it sees to achieving this is that the PCT(s) in Leeds will not be able to pay for the contracted services over the coming and future financial years. For FTs the lack of confidence about cash flow is of particular concern—if major contractors cannot guarantee payment for the services they commission then vital resources will be taken up in legal challenges." (Respondent, March survey)

  "The DOH policy in introducing and expansion of Independent Treatment Centres will adversely impact on Foundation Trust's ability to generate income from the number of patients treated. This was coupled with the DOH proposal to offer minor surgery in the Community without adequate compensation for loss of revenue to the acute trust sector will in my view entrench the foreseeable financial difficulty and subsequently adversely affect the future development of acute trust services. Having said that, improving local community services including the ability to offer minor surgical remedies can only benefit the service to patients. However this should not be done at the expense of improving services in local district hospitals." (Respondents, March Survey)

  "With PCT Commissioning and patient choice via choose and book, the planning by acute hospital trusts is very difficult. Also tariffs for services are not complete or seemingly `unfair' eg same tariff for single and dual bypass heart ops. Lastly with our PCT not being amalgamated with others, yet predicted savings targets the same as those which will amalgamate and have economies of scale, plus the assumed wage geographical reductions for trusts in the south west, there is bound to be further pressure on our local PCTs finances compared to South East/and or urban areas of the UK." (Respondent, March Survey)


  16.  Respondents were invited to provide details of services they believed might be affected. In December, of those that could report an impact on services, 32 said beds and wards were being closed; 9 raised concerns about loss of beds in Community Hospitals, the same number said Out of Hour services would be reduced; 6 suggested operations were being delayed; and 10 said mental health services could be cut back.

  17.  By March respondents were reporting a very wide range of services affected, but community services and community hospital and intermediate care services were mentioned particularly by various forums.

  A Forum Member from North East Yorkshire reported reductions in the availability of "consumable items, such as the Pain Clinic cannot send out pads for TENS Machines, [Transcutaneous Electrical Nerve Stimulation] and some sizes of Acupuncture needles are not available." (Respondent, March survey)

  An Oxfordshire Forum Member reported: "The proposed dental services have not materialised due to lack of finances. There are consistent threats of closure to local Community Hospitals and community midwifery services." (Respondent, March survey)

  A Forum Member in North Devon reported: "HCT [Healthcare Trust] has 4 areas of out of hours service cuts and children's services including paediatrics unit bed reduction from 22 to 16 and possibly more to be cut in future. oral surgery/maxillo facial out of hours services ophthalmology out of hours services ENT out of hours services clinical & support services." (Respondent, March survey)

  A forum member for University Hospitals Coventry and Warwickshire reported: "The Elective Care Unit (set up to reduce waiting times) was closed overnight and the Oncology Day Centre (which had regular patients for palliative care) was closed with a month's notice." (Respondent, March survey)

  A member from High Peak and Dales reported an estimated £3 million deficit, saying that the following services were under threat: "MIU [Minor Injuries Unit] hours cut: Postponement of reopening of refurbished mental health ward for older people. Closure of nursing ward for older people. No vacancies being filled." (Respondent, March survey)

  18.  A Sussex Forum Member reported "We in Littlehampton have been told our new Arun Community Hospital is put on hold. It has been deferred twice now and the SHA has not assured us the new hospital will ever be built. Our old one was demolished and the land is just waiting to be built on. All planning applications have been approved. We are at a loss to what will happen next. We desperately need a hospital here. The public deserve this as they are migrating to Worthing for treatment." (Respondent, March survey)

  19.  Another area of concern is the impact on mental health services. For example the Hertfordshire Partnership Trust, which serves those with mental health and learning difficulties, had been asked to make savings because of deficits by the acute trusts. It was reported in April 2006 as having to reduce expenditure by £5 million, to help reduce the overall £100 million deficit in health service spending in Bedfordshire and Hertfordshire. Amongst the services likely to be affected were specialist care for children with behavioural problems, reductions in day care services, reduction in access to community mental health teams and community drug and alcohol teams and the closure of a mental health ward.

  Hertfordshire Partnership Patient and Public Involvement Forum commented that service reductions may increase the burden on GPs and would run counter to the Government's National Service Framework for Mental Health as well as to local proposals for investment in mental health services, approved in public consultation in December 2005. (Herts Advertiser, 13 March 2006)


  20.  A particular issue of concern to CPPIH is what the results of these surveys reveals about the lack of openness and transparency within many trusts and PCTs around the impact on service provision.

  21.  NHS Trusts, Primary Care Trusts and Strategic Health Authorities have a statutory duty, under Section 11 of the Health and Social Care Act 2001 to consult patients and the public in service planning and operation, and in developing proposals for changes. This includes consulting on:

    —  ongoing service planning, not just major proposed changes;

    —  not just in the consideration of a proposal, but in the development of that proposal;

    —  decisions about general service delivery, not just major changes.[20]

  22.  It is a regular complaint from forum members across England, that many NHS staff with responsibility for making major decisions affecting patients and the public are still resistant to providing information about service changes and the reasons for them.

  23.  Responses to both surveys reveal this continuing lack of transparency about decisions made and a lack of consultation. CPPIH believes the scale of service changes identified by forum members clearly fall under the remit of Section 11, yet only 40% of respondents said their PPI forum was being consulted and in March, in response to the question: "In your opinion do you feel your NHS Trust is accountable enough to its patients and local community on the issue of NHS Finances?", 33% of respondents said yes and 67% said no.

  24.  Yet when respondents who reported their forum had been consulted were asked whether they had found the experience useful, 53% reported that they had. A minority of forums were able to involve themselves in detailed work with their associated trust on finding solutions, in areas such as obtaining public reaction to proposed service cuts and helping develop consultation methods, as well as helping identify areas of small saving and investigating local provision of services as an alternative to providing services in hospitals.


  25.  Patient and Public Involvement Forums have been able to offer an insight into the patient and public perspective on NHS deficits and their impact on services, and on the process by which they have been dealt with. They report substantial concern about trusts' ability to reach financial balance in the short-and medium term without reductions in services, particular as these deficits have arisen as the NHS is undergoing substantial reform, the real impact of which is unknown.

  26.  Lack of transparency in matters relating to NHS finances and an apparent failure of many trusts to consult on service changes has a negative impact on public confidence in the National Health Service.

  27.  CPPIH also has serious concerns that an admittedly very complex situation has been rendered even more difficult for patients and the public to understand by the deliberate opacity of many trusts financial decision-making processes.


  28.  Such a position can only be exacerbated in the future by the growing impact of Choice and the complexities surrounding the "market place" philosophy of the PBR tariff. Choice can only work well, both for communities and individuals if clear and unambiguous financial information is available about available policy and treatment options. The NHS will need to raise its game significantly in this area.

  29.  At the very least all trusts should, as a priority, provide clear and accurate information about the cost of services, their financial positions, the potential impact on services and how decisions are arrived at, so that the public, or at least PPI Forums, could participate in decision-making, and make choices. We recommend there should be national guidelines that all Trusts should observe, so that transparent and meaningful financial information is publicly available for scrutiny. Public willingness to participate and become engaged in local decision-making on policy and priorities will continue to be undermined if prompt action is not taken along these lines.

Sharon Grant

Chair, Commission for Patient and Public Involvement in Health

5 June 2006

20   Section 11 (1, a, b and c); see also Policy Guidance Strengthening Accountability-Involving Patients and the Public February 2003. Back

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