Examination of Witnesses (Questions 1-19)
ROSIE WINTERTON
MP
26 JANUARY 2006
Q1 Chairman: Good morning, Minister.
Could I welcome you to the Health Committee. I think you are the
second Minister from the Department now that we have had in to
discuss your responsibilities. You will be pleased to know that
we are just looking at two areas this morning, although we will
be looking in depth, which you may not be pleased to know. We
are going to start looking at the issue of public and patient
involvement in the National Health Service. I wonder if you could
just tell me, what do you think the Government hopes to achieve
through public and patient involvement in the NHS? What are the
goals, as it were, as far as you are concerned?
Ms Rosie Winterton: Well, I think
there are two issues really. One is that I think all the evidence
and experience of service-users, carers and, I am sure, MPs as
well is that if patients and if the public are involved in a sense
in the design of services, then they are very much more effective.
I see that particularly, for example, in mental health services,
which is one of my areas of responsibility, where traditionally
it has perhaps been quite difficult to get people involved, but
where you see the health services themselves making a real effort
via clinicians and local interest groups and service-user groups
actually to say, "How can we deliver these services better?",
and, when you see some of the shaping of services within the community,
then frankly service-users find them easier to access and they
are more relevant to their needs, so in a sense the outcomes are
better. I think that is the first thing, which is in the design
of the services themselves. I think there is then an issue about
looking at local priorities and local needs and in a sense, for
me, when we say nowadays that the NHS devolved budget, if you
take out the kind of passporting of education payments through
to schools, is likely to be twice as much as the budget for local
government, in a sense do local people feel that they have had
an input into deciding the priorities for spending? Do they feel
that the priorities that perhaps a primary care trust has given
reflect local health needs? Also do they feel that they have any
input into that and do they have any input into how some of those
services are provided and in the future there will be a big debate
about whether services might be provided, for example, in hospitals
or in the communities? That is where I think that the challenge
is for the future and, if we can build on the very successful
work that has taken place so far, then we can have a Health Service
which is more personalised to patients, which is not being done
to them, but is being done in conjunction with patients, service-users
and carers and that, in a wider sense, at the local level people
understand the decisions and priorities that are being arrived
at.
Q2 Anne Milton: I would just like
to say that I could not agree with you more about the involvement
of the public and service-users and I think mental health services
are one very important area, but I think there is a danger that
it becomes simply a tick-box exercise. I think the public are
somewhat cynical about the whole business of public involvement,
ie, that the public can be involved until local health service
providers want to do what they want to do and then they will not
take any notice of them.
Ms Rosie Winterton: Well, I think
that you are right to say that that is where the challenge is,
but, as I said, building on some of the best practices that are
in place at the moment. Perhaps one example would be to look at
some of the work of overview and scrutiny committees whereby they
have done some very interesting reports into local provision,
very often in conjunction with patient forums they have taken
evidence from, and at the same time they have a real role in reconfiguration.
We sent out some guidance recently, which I would be more than
happy to send on to members of the Committee, which is about overview
and scrutiny committees being able to look very closely and where
they can refer on to the Secretary of State if they feel that
either any proposed service changes are significant and they do
not agree with them, or they feel that the consultation process
has not been adequate. That is a very important safeguard for
saying to people that there is a system in place which means that,
if they do not feel their views are being taken into account,
there is a process through which they can make referrals onwards.
Again there are some very good examples of where patient forums
have conducted inquiries and, as a result of that, local health
services have changed. I think in mental health services again
there are some very good examples of where patient forums have
said, "We don't believe that these services are being delivered
adequately. We would like another look at it", and there
has been a response to that, and there is a duty for health authorities
to respond to the views of the patient forums and overview and
scrutiny committees.
Q3 Anne Milton: Just to come back
a bit, and I do not want to talk about overview and scrutiny committees
because I know that others on the Committee will want to pick
that up later, but, as an example in my own local area where the
overview and scrutiny committees have referred something to the
Secretary of State, they referred it in October and they still
have not heard back. That is the problem and that is why people
think it is a box-ticking exercise. Just to go on, have you ever
considered looking at other ways of involving patients and the
public, maybe some of the methods that the retail trade use? There
are lots of organisations out there, collecting the public view
and trying to respond to their clients, the consumers.
Ms Rosie Winterton: Well, I think
the way that we would want to see that working is obviously people
decide what is most appropriate at the local level. What we can
do, and what the Commission for Public and Patient Involvement
has been able to do, is to look at the most effective practice
that has taken place and pass that on to other forums. We have
tried, through the Centre for Public Scrutiny, through government
funding, to get them to put together ideas and best practice from
areas where they have perhaps conducted more wide-ranging exercises.
It is a balance in a sense because within health, for obvious
reasons, you can get special interest groups and it is important
to involve those interest groups, and it can be around particular
conditions, and I think we all know, as Members of Parliament,
that there will be groups within our constituencies where they
will be pressing for more attention perhaps for services in their
area. Beyond that, I think it is important to make sure that that
is balanced with the wider views and it can be quite difficult
to involve people, but I certainly know that when you get, for
example, quite big reconfigurations, people do get very interested
and do get very involved, whether it is via petitions or making
representations. It is something that does capture people's attention
locally and I think the challenge is how you use some of that
interest to take it forward in the future, and, when people say,
"Well, actually I feel quite strongly about this reconfiguration",
or "that change to service", how we say, "Okay,
but stay involved with the process". That is where I think
public involvement can become a reality. It is a challenge. I
am not saying that it is easy, but what we do try to do is, through
the processes that we have got, exchange good ideas and see if
we can spread some of the best practice into different areas.
Q4 Anne Milton: Are you satisfied,
therefore, that the systems we have got in place actually have
the credibility of the public and do you believe that they are
reaching out to the hard-to-reach groups which are so very hard
to reach actually?
Ms Rosie Winterton: I think what
we are seeing is a much greater recognition of the processes now.
I know that, when I have talked to patients, patient forums and
sometimes to overview and scrutiny committee representatives,
they will say, "People don't know we're here. How can we
improve that?" I have always said, "Well, what I think
will happen is that, when you do produce reports, when you do
start to make a difference, people will understand that".
There are, as I said, many examples in members of the Committee's
own constituencies where some of those changes have taken place,
but it is about a self-confidence that needs to be built up, and
I think it is also about the fact that, when overview and scrutiny
committees publish their reports and when patient forums publish
their reports, it does receive attention locally and people start
to say, "Ah, right, it is making a difference, it is worth
getting involved". I have always tried to encourage Members
of Parliament to get involved with their patient forums to help
them publicise the work that they are doing in order to in a sense
give them the confidence, but also to give the public confidence
to get involved so that they know, if they do go along to see
their patient forum representatives, they can say, "Look,
I'd really like it if you did a report into X, Y and Z",
and make that process, which will take time. I think, as with
anything, it does take time to bed down, but I am encouraged by
a lot of what is happening. I think there are improvements and
we are reviewing, as I am sure members know, the system of how
the patient forums are operating because some of my worry is:
are we getting enough front-line support through to them? Sometimes
there are questions about whether in a sense at the moment we
could realign some of the patient forums, so the 572, which is
quite a task, and the Commission for Patient and Public Involvement
did a very good job in recruiting members, but some of them feel
a bit isolated. When I have spoken to them, very often they have
said, "Could we have a closer relationship with the overview
and scrutiny committees? Could we combine more?", and with
some of the Primary Care Trust (PCT) reconfigurations there is
an opportunity and that is why we have wanted to review them in
the light of some of those changes to see whether they might feel
that they could operate more effectively, if, for example, instead
of always being aligned to every specific trust, whether they
might look at the patient journey. As a quick example, in mental
health services, very often you will have a patient forum for
a mental health trust and some of the complaints about mental
health service-users is that they may have their mental health
needs looked at, but sometimes their physical medical needs are
not always attended to. What I want us to get to a position of
is where the patient journey is followed right from primary care
through to more acute care, how we look at the patient, not necessarily
a look at the buildings, but a look at the patient and how the
services react to the patient, which is very important in terms
of as we look to the future and see services delivered perhaps
more in the community than necessarily in-patient care as well.
Q5 Dr Taylor: Minister, you have
been very good, coming to meetings of the All-Party Group on Patient
and Public Involvement, and you know how hard the Commission are
working to get things right for the future. One thing they are
very worried about with their current role is that there appears
to be confusion between service improvement and accountability.
They say in their paper to us, "This accountability function
must not in future be confused, as it has been in the past, with
the service-user advocate involvement function". What are
your comments about that?
Ms Rosie Winterton: Well, as I
have said, I feel very strongly that we do have to look very closely
at what we can do to make sure that services are delivered in
a way which is responsive to service-users' comments and others'.
I think that there should be a role for patient forums and there
is a duty on the NHS as well to make sure that there has been
that kind of service-user input. I would like to see the Healthcare
Commission, which does look, because of the section 11 requirement,
at how effectively there has been patient and public involvement
in the design of services, I would like to see how the Healthcare
Commission takes into account very closely the views of patient
forums as to their experience of involvement. It is true to say
that in some areas the trusts and health authorities can be very
good at involving patient forums in some of the decision-making
processes and in others it is not so good, but that is something
that the Healthcare Commission would want to look at. At the same
time, I think the issue of accountability is important in a devolved
NHS because you do have to look at how local priorities are being
decided and how money is being spent locally. My constituency,
I am sure, will be very different from your constituency, and
the Chairman's constituency is similar to mine where we have a
lot of problems which have come from the kind of industrial base,
from a mining community, but it is going to be different in different
areas and I think it is only right that there should be a much
greater understanding of how decisions are made about the priority
given to different local services, so I think the two are important.
There is an element of accountability and there is an element
of making sure that trusts design services around the input from
service-users, carers and the public as well.
Q6 Dr Taylor: So you think they have
got a duty with both of those things, accountability and representing
the patients' views on service changes and improvements to services?
Ms Rosie Winterton: I think there
should be, yes. It would be quite difficult, and I think this
is where we need to go because these are all issues that we are
looking at in our review, but I think in terms of the design of
services, it is important the patient forum helps the trust and
encourages the public to get involved in the design of services,
reflecting the duty that there is on the NHS itself to involve
the public. At the same time, because so many of the people on
patient forums are experts, they do have a kind of holistic view
of how services are being delivered, so one would expect them
to have a view as to what is achievable within the priorities
that the trust, for example, let's say a primary care trust, has
decided upon. I think in the future we would want to see them
having an all-round view in that sense.
Q7 Dr Taylor: Are there going to
be enough of them left to do this?
Ms Rosie Winterton: Enough patient
forums or enough members of patient forums?
Q8 Dr Taylor: Enough patient forums.
Ms Rosie Winterton: Yes, of course.
What we are looking at at the moment is a whole range of ideas
which have come forward as to how we can give greater support
to patient and public involvement. Now, the patient forums have
played an incredibly important part in taking forward that agenda
at the moment, and it can be quite difficult because, when I have
talked to members of patient forums, I have said, "Are you
getting enough support from the forum support organisations?",
and in many cases that has worked really well, but in some areas
it has not and we had to make some changes recently where they
felt they were not getting the proper support. However, as I have
said, many of them said, "We might find it more effective
to combine together", some have said, "We would like
to have more of our own budgets", and others have said, "We
don't want that sort of responsibility", and I have felt
that sometimes they would maybe be able to work more effectively
if they had more of their own budgets. However, it is also true
to say that many of them have said, "We're a bit worried
about that because we like what we are doing, but we would rather
have the support given from in a sense somebody else who was taking
responsibility for managing the budgets", so I think we have
got to look at a way which allows more discretion over funding,
and we have allowed some of that so far. Legally, at the moment
it is impossible for them to do that, but we have been able to
make, I think it is, £500 per forum available for things
like training and so on, so they have got that discretion, but
beyond that it is a little bit more difficult. What we have to
do is look at a system which builds on the best that the patient
forums have had to offer, looks at the role of overview and scrutiny
committees to make sure we are not duplicating some of that work,
but which responds to many of the comments that have been said
about bringing together some of the work. Sometimes people have
said to me, "Why can't we join together?", to which
I have said, "Well, it's interesting. Make sure that you
are, within that, preserving the independence that you want to
preserve", and it is getting that balance right because Parliament
was very clear that it wanted forums to be very independent of
the NHS and we have to be clear that the relationship with an
overview and scrutiny committee allows for that continuing independence.
At the same time, if at the end of our review it is very clear
that people want to have a much closer relationship, it is how
we get that balance right.
Dr Taylor: Thanks for emphasising the
independence because that is absolutely crucial.
Q9 Mr Burstow: I want to pick up
on something which, when the Committee produced its own report
into the whole issue of public and patient involvement a few years
ago now, was surprising to members at that stage which was the
decision by the Commission, despite commitments which had been
given by ministers at the time, rather than directly to provide
support services to Patient and Public Involvement (PPI) forums,
instead to set up the arm's-length operation with the forum support
organisations. What sort of evaluation have you made, and what
sort of lessons have you drawn from that evaluation, of the way
in which the forum support organisations have worked? For example,
is scale a factor in their effectiveness and the way they are
operating?
Ms Rosie Winterton: The forum
support organisations?
Q10 Mr Burstow: Yes.
Ms Rosie Winterton: Well, because
we have extended the contracts for a further year in terms of
the forum support organisations, that gave us a very good opportunity,
as I have said, to evaluate the ones which were working well and
the ones which were not. It was not necessarily, as I recall,
although obviously this was done by my officials in the detail
of it, dependent upon the size of it, but more it was dependent
upon the effectiveness of the organisation in supplying the service.
Certainly, because I could tell from letters from Members of Parliament
where there were difficulties, it was fairly clear that they did
kind of match the evaluation that was done.
Q11 Mr Burstow: The reason I asked
the question is partly because of local experience, that it has
certainly been very much a cause of concern to the PPIs in my
area, the issue being that a contract was let and various organisations
were invited to bid and, for example, the local volunteer organisation
in my constituency, the Local Volunteer Council, had made its
application and was turned down on the basis that it was not prepared
to do lots of PPI forums. In the end, an organisation was appointed
covering most of south-west London and within a very short space
of time that organisation was being performance-managed by the
Commission, lost its contract and now the service is being provided
directly by the Commission. It has left those local PPI forums
in a sense of limbo really almost since their inception. Many
of them do not have their full membership and part of the reason
for that is because they do not feel they have ever actually had
adequate support to do their job.
Ms Rosie Winterton: Well, as I
said, it was the Commission and officials who looked at the performance
of individual organisations and I think that the Commission did
respond well to the points that were made, if there were felt
to be problems in terms of how the forum support organisations
were working. Where they have decided that it is more effective
to directly assist the forums, then I do not see a problem in
that, but I think where you are right in many senses is to point
to the fact that some patient forums did feel a bit isolated and
that could be to do with all sorts of issues. As part of the review,
we are looking at how to improve the sort of support, but, within
that, saying that if a forum is going to get adequate support,
does it mean that it may be more effective to have combinations
of forums that join together and who work perhaps more closely
with overview and scrutiny committees because that may assist
them in working effectively? I do understand. Remember, the Commission
very effectively found nearly 5,000 people who joined the patient
forums, but inevitably, because there are 572 of them, some of
them have felt, I think, a little bit isolated and we need to
look at how we can improve that and make sure that they are getting
the support that they need. That is why we have been very keen
in the review that we are undertaking to ask what kind of support
people feel is going to be most effective in the future.
Q12 Mike Penning: Minister, can I
just clarify one thing you said very early on to do with the new
guidance to scrutiny committees. There are different sorts of
scrutiny committees at a county level as well as at district and
borough, but can the district and borough scrutiny committees
refer things of concern about facilities as well as the actual
methodology to the Secretary of State?
Ms Rosie Winterton: What tends
to happen is that, if there is a large reconfiguration that the
local health authorities are looking at, there will very often
be a combined overview and scrutiny committee to look at that,
so your county, district and boroughs will join together.
Q13 Mike Penning: What happens when
they do not agree? If you look at somewhere like Hertfordshire
where there is a big problem in one part of Hertfordshire which
does not affect the others, so on the Hertfordshire Scrutiny Committee
half of the members are not fussed because they are not worried
about it, whereas in the south-west of the county all the districts
are very, very worried, can the districts ignore the county and
refer it?
Ms Rosie Winterton: The districts
can refer separately if they wish to.
Q14 Mike Penning: On the reconfiguration,
not just the methodology?
Ms Rosie Winterton: On reconfigurations,
but the reconfigurations can be linked, if you like, with the
methodology because part of it is to show that, if they believe
that consultation has not taken place effectively, then they can
refer them on as well.
Q15 Mike Penning: Some district authorities
do not feel they have those powers and there is legal advice which
has been given to some districts that they do not, so your guidance
is going to help there.
Ms Rosie Winterton: Yes, I am
very happy to send this round to members of the Committee if that
would help.[1]
Q16 Mike Penning: I know we will be coming
on to the overview and scrutiny committees later, so I do apologise,
but I just wanted to clarify that point because it is very important
to district and borough authorities. Can you give the Committee
any evidence as to whether the new system is better than the old
community health councils in delivering the objectives to which
we are all aspiring for our constituents?
Ms Rosie Winterton: Well, I think
that the community health councils did a very good job in many
areas. The difficulty was that there was a certain patchiness
of service because there was a whole range of activities that
they undertook from monitoring local health services through to
taking up complaints and to looking at individual service development.
Now, one of the difficulties, therefore, was that in different
areas of the country they might give priority to different subjects,
and complaints is a classic one. Many community health councils
would, if you like, specialise in complaints, which provided a
very good service, but in other areas they would not necessarily
do that, which left people a bit confused about the role and a
bit worried about whether they were really reflecting an overall
service. One of the things which has been a big success, although
I think there have been quite a few big successes, but particularly
I think is every trust now having a Patient Advice and Liaison
Services (PALS) where people are able to go very often for clarification
for things where they may not wish to make a formal complaint,
but which, for goodness sake, should be able to be sorted out.
If somebody requires a special meal, they are in hospital, but
they are not getting it, they do not want to be involved in a
formal complaint there, but what they would like to know is that
they can go somewhere and say, "Look, I really would like
to get the diet sorted out". Now, if they have somewhere
they can go which is relatively informal and get some advice,
or get some advice about benefits, whatever, that is accessible,
it is on the spot. Beyond that, we have ICAS, the Independent
Complaints Advisory Service, which I do think again has been a
success because people know now that they have a service across
the whole country where they can get assistance in making perhaps
a more formal complaint if they wish to. Therefore, in both of
those aspects we have a very clear strategy in place now for dealing
with two issues which are very important for the patients and
for the public. We have the patient forums which are now very
clear in terms of how they can make sure that local trusts, local
health services are responding to the patients and the public
in terms of the way that they involve them, but which also have
a monitoring role in terms of looking at how individual services
are developing, and we have the overview and scrutiny committees
which, as I said, have an important role in reconfiguration, but
which can also carry out inquiries into local service development.
Coming on to one later, I know the Overview and Scrutiny Committee
in the Chairman's area next month is carrying out an inquiry into
local dentistry. Now, as I have said, there have been some very
important ways that this is operated to improve local services,
so I think it is more transparent and there is greater consistency
across the country in terms of some of the separate duties that
different community health councils were undertaking which has
actually translated into perhaps a more coherent system. As I
have said, that is not to undermine the work that the community
health councils did which I think was very good, but, as I said,
it did vary in different parts of the country.
Q17 Mike Penning: Can you give any
examples then, Minister, as to how these new forums have designed
and helped in planning NHS policy? If they are so good and we
have got so much involvement and you are listening to them, have
they actually changed the planning or the policy in the NHS?
Ms Rosie Winterton: They have.
I have got some examples and, if it is all right, may I refer
to some examples that we have had in different areas, and I think
in Mr Amess's constituency.
Q18 Jim Dowd: He has woken up now!
Ms Rosie Winterton: This looked
at a review of A&E services, particularly for people in mental
health services. They have been very good at going out to local
schools and talking about stigma and mental health. It is a very
important role in the local community that that plays and, as
I have said, looking at particular services in terms of A&E.
In the Chairman's constituency, the PPI forums looked at the accessibility
of health services in Rotherham for wheelchair-users and that
meant that the local trust allocated another £30,000 to improve
access for wheelchair-users. Those are some of the examples as
to how it has made a difference, but overall it is about, I believe,
focusing trusts' attention on the need to involve the patient
and the public in service design and delivery. When each trust
does have to involve the forum in the decisions that they are
making, it sends a very important overall message that I think
we need to get across which is that the National Health Service
is the community's health service as well and it does not belong
to any one group, whether it is clinicians, managers or others,
but it is a community service that should involve those who use
it and the wider community in it. As I have said, as we look at
how increasingly reviews are undertaken, whether by patient forums,
the overview and scrutiny committees or others, then it is developing
that local input which I think is quite vital for the future.
Q19 Mike Penning: You are obviously
quite proud of this local input, but I am conscious that you did
not quote my constituency where the whole of the local community
is completely against the proposals by the Trust, the forums have
opposed it, the scrutiny committees oppose it, thousands and thousands
of residents have written to the Secretary of State and to the
Trust, there have been petitions coming in for years and years,
yet the community is completely ignored, so what happens then?
The forums have clearly not been listened to, the scrutiny committees
have not been listened to and there is no elected person between
the ministers, the Secretary of State and the delivery for the
patients, so where does the buck stop then?
Ms Rosie Winterton: Well, if we
are talking about a major reconfiguration, as I have said, the
overview and scrutiny committees, which clearly do comprise elected
members, do have the ability to refer it on to the Secretary of
State for further—
1 See Ev 21, supplementary memorandum from the
Minister. Back
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