Memorandum submitted by the Commission
for Patient and Public Involvement in Health (PCT 50)
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.
It oversees and supports 569 statutory Patient
and Public Involvement (PPI) Forums, made up of local volunteers,
one for Primary Care Trusts, NHS hospitals trusts, mental health
trusts and ambulance trusts. 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. It liaises with national bodies on
patient and public involvement issues, and makes recommendations
to these bodies and the Department of Health.
CPPIH has a remit to make sure the public is
properly involved in decisions about health and health services.
2. The principles and objectives of patient
and public involvement first emerged in the NHS Plan 2000 and
were elaborated on in Shifting the Balance of Power within
the NHS—Securing Delivery.[13]
Derek Wanless' scenario of a fully engaged NHS requires the views
of patients and the public to be built in to the decision making
processes.[14]
Since 2000 the agenda has been given additional impetus.
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.[15]
3. Consultation is pointless unless the
views of consultees are capable of influencing the outcome. CPPIH
takes the view that is important for consultation to feed into
the planning process and should not simply be an afterthought
once decisions are close to being reached. Failure to consult,
or "token consultation", is a source of immense public
frustration and disenchantment with public sector decision-making.
It also provides a disincentive to active citizenship which extends
way beyond the health sector.
Where significant consultation is indicated,
as it is in the case of the major changes to Primary Care Trusts
proposed, significant resources and significant amounts of time
should be made available to make the consultation meaningful.
4. With a dedicated infrastructure in place
to promote involvement in decision-making, funded by the public
purse, it is unfortunate that efforts were not made by the Department
of Health to seek the advice of CPPIH and its network of Patient
and Public Involvement Forums, especially those with primary care
responsibilities, in consulting patients and the public on PCT
reconfiguration proposals.
RECONFIGURATION OF
PCTS—PROCESS
AND THE
NEED FOR
CONSULTATION
5. "Commissioning a Patient-led NHS",
the document issued on 28 July, was an instruction to SHA and
PCT Chief Executives. This and other related proposals are aimed
at creating a decentralised NHS structure, with services delivered
through a range of providers. This represents a very substantial
change in the NHS and should have provided an opportunity to develop
best practice in engaging the public in major NHS reforms.
The Department of Health's review of how health
services are commissioned locally is likely to result in the merger
of Primary Care Trusts (PCTs). Any proposed changes will inevitably
affect service delivery and CPPIH believe the public should be
fully engaged in decisions here too.
6. The Commission would expect Strategic
Health Authorities to consult with PCT Patient and Public Involvement
Forums at an early stage on any proposed changes to the numbers
of PCTs, changes in boundaries, mergers and reconfigurations,
and give them the opportunity to comment. Ideally this would take
place during the pre-consultation stage and prior to proposals
being submitted to the Department of Health.
We would also expect arrangements to have been
put in place to canvass the views of the public, NHS staff, local
voluntary sector and community organisations and other local stakeholders
on possible options.
7. The Commission is concerned that the
Section 11 consultation requirement was ignored when "Commissioning
a Patient-Led NHS" was first announced on 28 July 2005 by
Sir Nigel Crisp.
As a result of this we believe that some NHS
bodies were possibly under the impression that the proposed reconfigurations
fall into the category of administrative changes, and consequently
they were not required to consult. Since Section 11 of the Health
and Social Care Act has been in existence for several years, and
Strategic Health Authorities are aware of their responsibilities,
questions need to be asked about what instructions or guidance
on consultation were issued by the Department of Health.
8. It is also unfortunate that the decision
to make the announcement of "Commissioning a Patient-Led
NHS" at the end of July, and the short-time scale available
for SHA's to submit detailed plans, may have hindered those bodies'
ability to consult widely and involve Patient and Public Involvement
Forums. As stated above, meaningful consultation takes time.
We know from our experience of working with
PPI Forums over the last three years, that volunteer bodies require
substantially longer than other bodies to plan any submission.
Many PPI Forums do not hold meetings in August and early September.
Many Forum members will have been away and have been unaware until
late in the day that any PCT reconfigurations were in the "pipeline".
This removed the opportunity for Forum members themselves to canvass
views from within the local community.
Despite the aspiration in the NHS Plan, the
most profound changes in the NHS since 1948 were initially destined
not to be the subject of public consultation.
9. Following letters and telephone calls
from PPI Forum members with concerns about local consultation
arrangements, CPPIH conducted an on-line poll between 18 and 25
October 2005 to find out whether Forum members had been consulted
about the reconfiguration. We received 353 responses. The general
feeling appears to be that there was inadequate meaningful consultation
of patients and the public in many areas.
Only 39% of PPI Forum members said their Forum
had been consulted and only 22% said they had found the consultation
meaningful. 52% of respondents said that patients and the public
had not been consulted over the proposed changes.
We suggest these figures are a cause of concern,
particularly as only 14% of Forum members said patients and the
public had been consulted and only a minority were aware of any
opportunities available to the public to express an opinion.
10. We invited comments as part of the survey.
Here are just a few examples;
"We were actually consulted after the cut-off
date for written submissions . . . This means that I have not
been able to discuss the proposals with my Forum or for us to
have time to submit any kind of proposal. This seems to be a frequent
occurrence where consultation/information by the SHA is withheld
until the last possible moment." (East Staffs PCT PPI Forum)
"Re-organisation has been explained to us
. . . However, to me, consultation means the opportunity for discussion,
to put forward opinions and to question the proposals prior to
decisions being made. We have not had the opportunity to do this."
(North East Region)
"Our PCT has told us about the process but
has made the point that is not their duty, or the duty of the
SHA, to ask our views." (South East Region)
"There has been no official consultation
with the Forum or its members or with members of the public .
. . We have strong views on the matter, but meetings with the
PCT are cancelled by them at the last minute. Comments from the
DH indicate that there is no consultation requirement as this
is merely an administrative change." (East of England)
Since the survey was conducted, the government
has announced that there will be a three month formal consultation
exercise on the reconfiguration of PCTs. This consultation will
begin in early December 2005. CPPIH welcomes this announcement,
but again regrets that its representations were not heeded at
an early stage.
11. Sharon Grant, Chair of CPPIH wrote to
the Secretary of State for Health on 3 October 2005 urging greater
clarity about how communities are able to share in local decision
making about health services, as the effects of current policies
begin to emerge.
12. CPPIH's view is that in areas where
there are already good arrangements for patient and public Involvement,
PPI Forums are more likely to have been kept informed and involved
in meaningful discussions. Some Forums members have told us they
were happy with the information and consultation arrangements
in place. It is clear that some sections of the NHS give much
greater priority to Section 11 than others. The level and quality
of consultation differs substantially between different areas
and different NHS bodies.
13. CPPIH is aware of some encouraging examples
of good practice in involvement and consultation arrangements.
One such is the Avon Gloucestershire and Wiltshire Strategic Health
Authority which informed stakeholders, including Forum Chairs,
at an early stage, held stakeholder meetings and produced regular
newsletters sent to staff, unions, MPs, Overview and Scrutiny
Committees, Forum Members and voluntary and community sector organisations.
PPI Forums were invited to complete the assessment framework document,
the whole process was publicised on the SHA's website and the
final decision was made at a meeting held in public.Conclusion
and recommendations.
14. Patients and the public deserve an explanation
as to why such momentous change in the NHS was intended to be
implemented without reference to Cabinet Office guidelines on
consultation and Section 11 of the Health and Social Care Act
2001. We believe Cabinet Office guidelines were breached and Section
11 requirements were overlooked.
15. We recommend that in future Section
11 consultation requirements are made explicit at the beginning
of any process involving changes to the mechanisms by which services
are delivered as well as changes to the services themselves.
16. We would also recommend consideration
be given to strengthening Section 11 to introduce sanctions in
cases where NHS bodies are failing in their statutory duties.
17. We note the Secretary of State's recent
announcement of a 3 month formal consultation period in respect
of changes to PCT boundaries and we welcome this. However, the
proposed changes in PCT functions will also require consultation
and we recommend the White Paper on healthcare outside hospitals
be used as a springboard for further public debate to ensure the
changes proposed for the NHS are what the public want. There should
be a major public debate on the principles enshrined in Creating
a Patient-led NHS. If resource constraints are a key driver in
this process then this ought to be openly and honestly be shared
with patients and the public.
18. We recommend that the Department of
Health should heed early warnings that indicate consultation mechanisms
are not working. PPI should be part and parcel of Department of
Health and NHS practice at every stage in the future.
19. We recommend that consultation arrangements
are properly resourced and that adequate time is set aside to
allow patients, members of the public and PPI Forums to have a
meaningful input into the decision-making process. Existing systems
for PPI should be supported.
20. We recommend an effort be made to reach
uniform standards in patient and public involvement and where
there is good practice this should be captured and used to set
standards that are universally applicable.
The Commission for Patient and Public Involvement
in Health
24 November 2005
13 Chapter 10 "Changes for Patients" of
the NHS Plan (2000). The Plan called for PPI Forums and Citizens
Panels as a mechanism for citizen empowerment and encouragement
for the involvement of citizens in redesigning the health service
from the patient's point of view. Shifting the Balance of Power
Department of Health July 2001, p 26. Back
14
Securing our Future Health-Taking a Long-term View Final
report 2002. Back
15
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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