House of Commons
|Session 2006 - 07|
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General Committee Debates
Local Government and Public Involvement in Health Bill
Local Government and Public Involvement in Health Bill
The Committee consisted of the following Members:
John Benger, Committee Clerk
attended the Committee
Councillor Gordon Keymer, Chair of Conservative District Councils Group, Local Government Association
Councillor Merrick Cockell, Chairman, London Councils
Martin Pilgrim, Chief Executive, London Councils
Elizabeth Manero, Director, Health Link
Sally Brearley, Chair, Health Link
Public Bill Committee
Tuesday 30 January 2007
[Mr. Joe Benton in the Chair]
Written evidence to be reported to the House
LGPI 01 Centre for Public Scrutiny
LGPI 02 London Councils
LGPI 03 Commission for Racial Equality
The Chairman: Good afternoon, Councillor Keymer. Thank you for coming. We shall go right into the question session.
Q38 Mr. Robert Syms (Poole) (Con): We will start off with first principles. Why do we need district councils?
Gordon Keymer: I do not know whether hon. Members are aware, but in the whole of Europe we have the lowest number of councillors per 100,000 people. They will be amazed to know that the second worst country is Denmark, which has twice as many as we have per 100,000 people. A Danish councillor said sadly that his Government were following the example of the UK Government and reducing the number of councillors. It is my view that we need more councillors, not fewer, and that important point relates particularly to the unitary proposals.
Q39 Alistair Burt (North-East Bedfordshire) (Con): Good afternoon, Councillor. Clause 3 states that the Secretary of State may direct an authority to make a proposal for a single tier of local government, only where he believes that it would be in the interests of effective and convenient local government. How do you feel about that and what do you think of the implications of that approach for district councils?
Gordon Keymer: The whole exercise for inviting bids for unitary authorities has been most unfortunate. It has been costly. There have been no proven records of savings through unitary as opposed to two-tier authorities. It has caused serious division within the two tiers of authority, which will take a long time to recover from. It is a shame because we have just recovered from the experience of Banham and now we have this. However, it produced a couple of very important points about districts.
First, districts possess service provision and run an extremely tight operation on that. Secondly, districts must be given every encouragement to get their services from the most cost-effective source they can. Thatmay be from the upper tierthe county councilor it may be from their neighbours. In Tandridge, we are
To take your specific point, I am concerned about it. We were promised that 25 January would be a deadline for such matters, and that that would be the end of it. Mr. Woolas assured us of that, and I am sure that he did so with the best of intentions. However, we must be worried by the proposal. It suggests that what has not been achieved by stirring will be achieved by the Secretary of State, which is regrettable. If you would like me to propose a change to the Bill, I can say that the first thing I would hoick out of it is that proposal.
Q40 Alistair Burt: You mentioned that there was no evidence of long-term savings through reorganisation. Would you be able to supply that information in written form to the Committee during its deliberations? Can you provide evidence from your past experience or the evidence of district councils from their past experience?
Gordon Keymer: I would love to. The difficulty is that there is no evidence of there being savings. It is a difficult situation. I have discovered no exercise that has shown that a change from a two-tier to a unitary basislet us forget about what all the consultants are suggesting and the huge savings therehas produced major savings. To me, that is a very important point. I understand that councils remain that have still not made up the cost of the Banham change.
Gordon Keymer: Since 1987.
Gordon Keymer: You are right in that I have not, no. It is not just a matter of saving money. We are here to provide services. I know that we are supposed to be place shaping. I like place shaping as much as anybody else, but in the end we are here to provide services. That is what we are elected for. Services do not get improved by reorganisation. One of my big worries about the whole process is connected with the fact that, as districts, we are in the forefront of service provision, of which refuse collection and planning are examples. A unitary authorityparticularly a large onecauses that front line to be lost, and my fear is that one is then left with the lowest common denominator for services in that area.
My electorate believe that weekly refuse collection is important. In Tandridge we still run refuse collection from the back door, and people value that toowe have just started a new 14-year contract. However, I can envisage a nightmare scenario in which, had we become unitary, all that would have gone.
The Government proposed not a referendum but a conversation with the movers and shakers. So I went off to find the movers and shakers, of whom I assumed the vicar was one, in Government terminology, and I mentioned the problem. He was horrified. I thought,
Q43 Alistair Burt: My last question is whether you or your colleagues have any evidence of a tremendous pressure for change in district councils. When the Bill was proposed, were not you and your colleagues absolutely spitting at the sheer waste of time and effort that it would involve? You can be honest.
Gordon Keymer: The answer is yes, but I should like to say slightly more than that. Earlier, I mentioned that districts are incredibly tightly run. I do quite a lot both within and outside my district, though I am leader of it. I have no support at all, and I am happy about that because I learn a lot, but the distraction that the Bill would present was therefore of great concern.
What particularly bothered us was that the game was unfair. The dice were loaded such that the counties could put in bids, and the districts had to wait to see whether they were going to have their heads chopped off. The alternative, of course, was for districts to get together and make counter-bids, but that would have meant walking right into the trap, because it would immediately have been attacked by the countyI am sorry to use emotional words like attacked, but it shows the damage caused by that type of thing.
In my own county there was a proposal for three unitary bodies, which copied our current area working. I stood out against it, and as soon as the invitation was issued the other districts withdrew, and no bid was put in. Nevertheless, I felt that it was a particularly damaging operation. We have to get on with our counties, and the counties have to get on with the districts, and that sort of approach is not helpful. All in all, I really do not understand why the Government took that line. I hope that they keep to their assurance that the number will be limited to eight. I would prefer none at all, given the unproven benefits of unitary authorities.
Q44 The Minister for Local Government (Mr. Phil Woolas): Thank you, Mr. Benton, for this historically unique opportunity for a Member of Parliament in my position to quiz the leader of the district councils. I promise to be briefer than when the situation is the other way round. The Government have a good relationship with the District Councils Group and we value its input.
Do you accept, Gordon, that there are districts that have made proposals for unitary authorities and that the Government were under significant pressure to make a decision on process? Do you accept that, in the case of SurreyI think that you confirmed itthere is no proposal? Do you also accept that districts as well as counties can make proposals? Do you accept that the bid that I understand was considered by Surrey county council would, according to that council, have saved it £40 million? That is the councils figure, not mine. Given the process, do you accept that the Government do not have a predilection and that the power to direct cannot and could not apply in Surrey and in Surrey districts?
Gordon Keymer: I said that at the beginning, andI take your assurance that that is right. On the£40 million savings, they would say that, wouldnt they? I was concerned that we did not enter a situation in which further council tax payers money was wasted in going through the figures that had been put through by the county. The main point is that the county decided not to put in a bidthat is very important.
I have to take your word, Minister, as regards the pressure that you were under. I came to a meeting in London with David Miliband. The meeting was very useful and well represented and we had an interesting debate. However, I saw no great pressure there, but you may have been subject to separate approaches of which I am not aware.
Q45 Mr. Neil Turner (Wigan) (Lab): To follow what the Minister said, why is it that if districts are such a good thing, some of them want to become unitary?
Gordon Keymer: I think that it is very important that every district, county or whatever is free to choose. I can only speak from my own experience. An authority may wish to change for a number of reasons. It could be concerned about service delivery, but I do not want to enter into a debate about the services provided by the two tiers. However, I know that districts are very worried about it. I think that certain aspects of that issue are very important, so much so that I wrote a paper on trying to resolve the famous problemI do not think that it exists, but it is often raisedof the question of public confusion.
I suggested that a way of resolving the problem was to do, if you like, a telephone test. If a person had a problemit could be with refuse, or it might be a potholethey would ring a local councillor or, in other circumstances, a local district councillor. I am sure that we can reach an excellent way in which to operate. Where problems are more strategic or technical, such as with education and social services, a person would ring their county councillor. That problem has caused difficulties in various areas, and I can understand why some authorities would want to go down the unitary track. I regret that, because I take Mr. Burts point that authorities are heading for very serious problems when they go through that process.
There is another issue. With some cases, there is a hope that by going unitary and hoping the bid will be accepted by the Government, all the cards will be thrown up in the air, and the new stack will be so new that all the authoritys financial problems will be resolved in a minute. Of course, they will not. However, the new regime will be able to blame it on the old one.
There are various reasons why councils may apply to become unitary. I do not believe that it is a good idea, because I find that the two-tier system works well, and I worry about representation for local people in a large authority.
Q46 Patrick Hall (Bedford) (Lab): Can I ask you whether your personal view on the subject is the same as the view held by the District Councils Group that you chair? Does the group have a policy on going unitary?
Gordon Keymer: May I make it clear that I chair the Conservative district councils grouping and I am its leader? It is the groups viewit has never argued against my haranguingthat my view is the correct one.
Q47 Patrick Hall: I am sorry, I have been misinformed that you are chairman of the whole groupthat was the information I was given. As chairman of the Conservative group, are you advising Conservative groups on district councils not to support or enter bids?
Gordon Keymer: No. I respond to their cries for help and advise accordingly. I believe in everybody having the right to do what they like. In an ideal world, I believe that there should be no laws. We would all be out of business, but it would be great. Working on that basis, therefore, it is up to people individually to decide what they want to do with their own authorities.
People come to me with particular problems. One interesting example was the concept that was developed of the three options: you had to go for unitary, under invitation, pathfinder, or enhanced status quo. That can be interpreted from the invitation, but it was readand encouragedby certain people who wanted to go for unitary as meaning that you had to put in an application for enhanced status quo. This was going on right up to the very last days, running up to 25 January. Thanks to a helpful presentation to the Local Government Association by somebody from the Department for Communities and Local Government who, having been pressed by somebody who wanted to go unitary, said, No, that is not the case, I was able to say, No, this is not correct. It is those sorts of inquiries that I try to deal with.
One of the difficulties under the executive system, as opposed to the committee system, is that large numbers of councillors are unaware of what is going on at any particular moment. Advice was given on how they could tell their back benchers or front benchers, or whatever they are called now, how they could best handle these particular questions and try to spread a certain realism. I was getting questions both from county membersnot just from Surrey, but from all over the countryand district members who were seeking clarification.
Q48 Tom Levitt (High Peak) (Lab): It has to be said, for the record, following the point made by my hon. Friend the Member for Bedford, that every member of this Committee thought that we were interviewing the chair of the district councils group of the LGA. There has clearly been a mix-up here. Do not blame it on the councillor at all. Obviously, there has been some misunderstanding along the way.
However, back to questions. I will endeavour to follow the high standard of forensic objectivity established by the hon. Member for North-East Bedfordshire. There is clearly a trend in the Bill for a movement towards all-out elections every four years. That supports the model of an elected mayor, which we will come on to in part 3. But at the moment a large number of the councils that have annual or third, third, third elections are district councils. Do you see district councils following that trend or maintaining a third, third, third scheme, which some would regard as preferable?
Gordon Keymer: First, the fact that the choice is in there is excellent. I fully support that. When we got control of our own council, the first thing we did was have a public referendum and then write to the Government, saying, We want to move to all-out elections; at the moment, we are in thirds. We were told that the Government wanted more elections, not fewer. I am very pleased about that. I think that it is very important. But I would not go further than that, because I think that it is a classic case of local choice. There are strong arguments in favour of both. I personally believe that four-yearly elections are strategically much better. If you get anything near to a hung council, annual elections are a nightmare: you never stop campaigning and if one side produces a good idea, the other side has to show that it is bad because they fear that it will be used in the next election. I support four-yearly elections. On the other hand, thirds is much better for running an efficient election operation. I think that it is very much open to local choice. In fact, I would have to go back to my own authority again and say, In 2000, you wanted to go for all-out elections. Do you still want to do that? I welcome the opportunity very much.
Q49 Tom Levitt: Some might say that the choice is restricted, because those that have all-out elections every four years are not being given the choice to move to third, third, third. Do you think that the choice should go both ways?
Gordon Keymer: I come from a council that has a modified committee system, which I am very pleased about and which I wholeheartedly support. I think that that is the best systemI sorry that that is going to cause terrible horror in local government. I have mentioned the problems of executives. I regard the committee system as open and transparent. It involves back benchers fully in the work and allows scrutiny before the action takes place, rather than afterwards. So if you are talking about choice offered under the Bill, I do not think that there should be a prescription on choice. I think that it should be up to the local authority and the local people to choose whichever method they believe is the best one for them.
Gordon Keymer: I think that there may be a move that way, but it is not as clear-cut as it appears. Weneed to think about it again, because people can seethe counter-arguments. Peter Ainsworths august predecessor was Geoffrey Howe. I used to discuss with him the idea of having all-out elections. He was very much opposed to that and gave good reasons at the time. I really must think again about whether things have changed that much since his own very clear views on the matter.
Q51 Andrew Stunell (Hazel Grove) (LD): You gave an excellent answer a few minutes ago to what was probably my question, so maybe we could rehearse it again. You have a modified committee system. It is
Gordon Keymer: Yes. I really do believe in it. In fact, I am so convinced that I am rather sad and sometimes go down in the evenings to watch my committees at work, thinking, Here are people who, from the very beginning, can involve themselves in local government, learn to speak and debate with officers and graduate to the council chamber and the full council meeting.
What is happening too much at the moment in the executive system is that council meetings are dominated by two or three people and the rest are spectators. The figures speak for themselvesnote the turnover of people who stay for only one term and leave because they are frustrated. The trouble is that we are trying to produce a whole lot of mechanisms to keep them happy by extending scrutiny and so on. If you look at it quite cold-bloodedly, all those things could be covered by active membership in the committee system. It is a great shame. People are not easily fooled.
How do we involve councillors? I have said that we need more councillors, so obviously I want to ensure that those who do come stay. I know how many of mine have come up through the committee system and are now proving very good chairmen and vice-chairmen of committees. I am thinking in particular of one excellent young person who is actively involved in debating for council, whereas when he started he was very taciturn and did not really contribute. He has changed enormously, and I believe that that is due to the committee system. I do not think that he would have changed if we had an executive system.
Also, an executive system unfortunately appeals in some waysI shall put this carefullyto the baser elements of human nature. Humans tend toward secrecy. They want to keep things to themselves and keep other people out. If we want an example of how that happens, the recent exercise on the bids for unitary and the way that I have been approached on it shows how devastating the executive system can be. People were able to get an incredibly long way down the track toward the finishing line in preparing a unitary bid before the members finally realised what was going onrunning a group with a committee system, I cannot understand thatand put the brakes on. It is quite extraordinary. Perhaps Government money could be well spent in comparing the two in a case study of authorities where bids were and were not put in, what the mechanics were to get there and why the bid looked in some cases as though it were going in but did not.
Q52 Andrew Stunell: So you would say that the decision making was more thorough and produced better results under the enhanced committee system?
Gordon Keymer: I believe that it is. I believe that it is also better with a relationship between members and officers. At a committee meeting, you have a chance for open debate and questioning. One can argue, as my former chief executive argued, that there is no point
The Chairman: We move to part 5, which deals with the co-operation of English authorities with local partners.
Q53 Lynda Waltho (Stourbridge) (Lab): Some have expressed concern that the proposed community call for action could become a nimbys charter or a vehicle for extremist individuals or organisations, or that it could be used in a frivolous, vexatious, malicious or politically motivated way. Do you agree and what safeguards would be needed to prevent that?
Gordon Keymer: I am sorry to raise the subject again, but I repeat that the committee system allows the community call for action to be made more effectively than the executive system. In fact, in many ways, the community call for actionand I understand the drive behind it and welcome thatis, in many ways, a bolt-on in an attempt to deal with the problems of the executive system. As you have asked for the problems, one huge one is that of raising expectations. I imagine that Committee members find that with their own electorates. People hear about the community call for action, and one of the difficulties that we have in local government is the difference between those with a universal franchise as a mandate and those who have formed a pressure group.
That problem is going to increase as cynicism with politics as a whole increases. One has to look very carefully at whether we are going to encourage that by suggesting that, in some way or other, you can by-pass your council processes to have your particular case brought forward. Let us leave aside the question of costs. However, a protection could be built into the Bill to ensure that councillors were not under great pressureit could be a question of choice and whether they wished to take up the issue.
There is also the question, of which you are probably aware, of certain areas of crime and disorder whichI think I am right in saying and the Minister will be able to tell me whether I am correcthave been excluded from this particular area and are not directly under the community call for action. That is, in practical terms, a problem because trying to explain to people whether it falls under the call is something that might be worth looking at a bit more carefully in drafting the Bill.
Mr. Woolas: Thanks very much to Councillor Keymer for highlighting that. We will be discussing that when we move on to the Bill, but it might be helpful to point out here that the community call for action process, as far as crime and policing are concerned, is covered by the Police and Justice Act 2006, which has yet to come into effect. The
Q54 Tom Levitt: With the move from taking responsibility for standards away from the national body and putting more emphasis on local councils to run the show themselves, is there a risk of national standards being lost and of having different standards applied in different places? If so, how do we account to members?
Gordon Keymer: I know that questions have been asked about whether districts can handle standards. From my own experience, I think that they have coped very well indeed in difficult circumstances. I laugh when I think back to an early meeting of the Standards Board at which it was worried that it would not receive any complaints. That struck me as being a bit like Robespierre worrying about whether anyone would be denounced in the French revolution. My viewand I think that of my partyis that we should abolish the Standards Board. However, taking your particular point about local standards, yes, I think that it can set local standards. However, there is one particular issue which I have been looking for in the Billand again I hope that the Minister can help me on this because I have not been able to find itand which was in the White Paper. That is the very important issue of allowing members to be more directly involved with areas that directly affect themthe old problem of the planning application for the house down the road.
In the White Paper, the wording was unless their interests in the matter are greater than those of most other people in the ward. I have looked through the Bill and I cannot find that reference. However, if it does come up in discussion, I would just say that I am worried that we will have another problem because, from my point of view, a members interest will always be greater because of their need to get elected. That is a very serious issue.
I believed that we were heading towards a situation in which no member could speak about a planning application in his or her ward, let alone down the road, because they were under pressure and worried about getting votes. If you have 100 residents complaining about something, you think very carefully about how you make your representation. I support the idea, although I think that it needs greater clarity, but I worry that the wording might make things worse than they are at the moment.
Q55 Tom Levitt: I am sure that there will be codes and guidelines covering the operation. Do you think that there would be a problem if a tight interpretation of the guidelines were applied in one council ward and in the ward next door, in a different council, a different standard were applied? Do you think that that might happen?
Gordon Keymer: I was talking about districts working together on service provision. That is an area that has been accelerated and boosted, and I hope that the Government will try to find further ways of doing
I was directly involved in defending a rather tragic case of a new councillor who very quickly became caught up in the machinery of council in a way that any innocent could easily have done. He found himself the subject of a complaint to the Standards Board as a result. It took two years to be adjudicated, which came back to his own council. In the end, he was told that he had to have further training. That councillor is very good, but I would be very surprised if he stands again. If I were he, I would not. Whatever we do, we must get round this erratic and damning way. Worry is a terrible thing, and it is hard for a councillor to have this hanging over him for two years. It may seem strange, but people do worry about that sort of thing.
Q56 Alistair Burt: We are all worried about how standards are handled. We all understand that it is no longer possible to have a complete free-for-all and self-regulation to protect the public; finding a common base is therefore important, yet you highlight the individual problems that have bedevilled the Standards Board since it was introduced. From your experience and that of your colleagues, do you see any way that we could amend the Bill to get to the heart of those worrisome concerns? It is a matter held in common with us all: we want to encourage people to stand as councillors and we want the public to know that there are good standards on the council. But the impression has been gained somehow that because of the existence of the board, there is more trouble at local councils than ever before. Has your group of district councils been able to think of a way to amend the Bill so that it achieves more of what we are all genuinely searching for?
Gordon Keymer: I think that at the moment, you have proposals for having an independent chairman of the Standards Board. In the end, I am laissez-faire. Although I accept your concerns, and in any situation there are going to be problems, there is already the law. The most serious cases have usually involved the law directly, and the Standards Board has not made a difference. We therefore have the problem of how to deal with standards that are not directly to do with the law, but are just expected to be high standards. I think that you are on the right track in that the local standards committee is the way to go. Each council having its own set standards with guidelines is by far the best course.
Let us be quite clear: we are all politicians and we all have problems of public perception, as I mentioned earlier, and we all have a responsibility to deal with that. However, it will be extremely difficult. It is not just a UK problem; it is a European problem and probably a worldwide problem, I suspect. Within that, we have to produce guidelines in which people operate. We will have to see how that works. At the moment, we seem to have drawbacks that are far greater than the benefits. I do not have a feeling that people have been coming up to me and saying, Councillor Keymer, I have much greater confidence in my council now because we have the Standards Board. I would like to see guidelines. The guidelines are there, so let us give it
I look back at Donnygate. What was Donnygate but a cabinet system by another name? We should work out what the problems are first and then try to deal with them. However, I think that the standards that we have set within our own councils and standards committees are working well at the moment. Although I have welcomed cases being submitted to the Standards Board, I have not encountered any casesat least locallythat have gone to the Standards Board and that have been the subject of a good decision. In most cases, the relevant people have been damaged, which has been neither to their benefit nor to the benefit of people at large.
Q57 Mr. Woolas: I want to follow up on your point about an independent chair. Is it your view that it would be better for local committees to be constituted by a majority of councillors, or by a majority of independent people? Do you have a view on that?
Gordon Keymer: Yes: I believe that they should be made up of councillors. In a perfect world I could understand where you may be coming from in relation to the advantages of having independent members. Unfortunately there is a practical problem with what I mentioned about pressure groups. I do not necessarily know what other councils have found, but finding independent members is difficult. I think of a case in which I defended one particular chap. People do their best but they find it difficult to grasp the difficulties under which a councillor works. The argument is probably one of the oldest that there is: does the professional body exercise discipline or does one get outsiders to do the task? Normally there is an element of outside people, but I should like a majority of councillors on the committee.
Q58 Alistair Burt: You might be able to obtain a majority of councillors and yet have sufficient independent people on the board to ensure that there would not be a group majorityto ensure that there would not be any political councillors majority. That might be a way to balance the interests.
Gordon Keymer: That is a good suggestion, although, to be fair, it is hard to say that because someone is in the same party they will necessarily be much more lenient. The assumption might be an obvious one, but it is not necessarily true. There should be independent members, because if they are carefully selected they can be helpful. Ultimately, however, I am keen that, as in Parliament, we should do our best to police ourselves. It would be a sorry day when we had to introduce total independence to look after us.
Q59 Alistair Burt: I take your point, but one could think of cases in which it would be difficult to persuade the outside world that a case had been fairly handled if an unfortunate decision were made and if people could point to a majority of councillors who were of the same party as the individual concerned. The appearance of fairness is important as well.
Gordon Keymer: That is a very good point. The case that I was referring to was that of a large London council that was Labour-controlled, and the person concerned was a Conservative. There is no doubt in my
The Chairman: I think that that brings us to the end of our questions. For the record, in relation to the confusion on the precise title of Councillor Keymer, I point out to the Committee that the wording in the motion agreed to by the Committee was unchanged from that tabled by the Government in the Programming Sub-Committee. I thank you for attending, Councillor Keymer.
Gordon Keymer: May I clarify? By far the biggest group in the Local Government Association is the Conservative group of councillors, which I lead. Technically, however, I am not the leader of the whole set-up. The independent group leader is a district councillor and he or she acts, effectively, as the head of the whole set-up in the form of chairing its meetings. But we are by far the largest grouping.
Mr. Turner: On a point of order, Mr. Benton. I do not say that we have wasted our time, but a lot of our time could have better spent if we had had somebody from the Association of District Councils who spoke for the whole association, rather than just the Conservative party. I am not blaming the witness that we have just heard. In fact, I am not blaming anybody, but we need to bear that in mind for the future, because we are learning as we make our way through. There are district councils that are in favour of unitary authorities, but we have not heard their point of view and I think that we should have had that.
The Chairman: That is not a point of order, of course, but it is, perhaps, something for future Programming Sub-Committees to bear in mind.
Alistair Burt: Further to that, can we hold our hands up? It is perhaps part of the process of being very quick. My impression certainly was that the councillor was the chairman of the Association of District Councils. We advanced our arguments in good faith. Clearly, there was no system of checking, given the speed with which it was done, and we all worked on that basis. But there we are; we learn a bit from that. He was still jolly good though, wasnt he? [Hon. Members: Hear, hear.]
The Chairman: We move on to the next group of witnesses. Perhaps the witnesses would like to identify themselves.
Merrick Cockell: Good afternoon, I am Merrick Cockell. I am chairman of London Councils, which used to be called the Association of London Government. Martin Pilgrim, our long-time chief executive, is known to many of you. The Association of London Governmentnow London Councilsrepresents all 33 London local authorities. I happen also to be the leader of Kensington and Chelsea borough council.
The Chairman: Thank you very much for coming. We shall start with part 4 of the Bill, which deals with parishes.
Q60 Robert Neill (Bromley and Chislehurst) (Con): I am grateful for the seamless transition which I hope will not come as a complete shock to our two witnesses. Actually, it may, because they have never seen me move so fast.
Do we really need urban parishes in London?
Merrick Cockell: I think back, Mr. Neill, to discussions in a different place when we were both on the Commission on London Governance. We looked at the various options for Londons government, including urban parishes. After an exhaustive afternoon spent with various representatives from, I think, Milton Keynes, we reached the conclusion that this really was not necessary for London. I am not going to oppose the concept of subsidiarity, because all London authorities are committed to that in its various forms and all of us operate those according to our needs. In our memorandum, there is evidence from Croydon and one council from each of the political parties giving examples of their current mechanisms, which work well.
We found that parish is a term that covers everything from 71,000 in Weston-super-Mare, down to tiddly little groupings where no one ever bothers to stand for elections. Of course, our London wards have populations of about 10,000 or 11,000, which seems to be the average for parishes. Our view was that, as a principle, we have already got that direct connection between directly elected representatives and their communities.
Martin Pilgrim: If I could add to that. We were here for the last evidence session and I was taken by the references to the role of back-bench councillors in authorities with an executive-scrutiny split. It seems to us that the danger of having parishes in London is that it would detract from the representative and local action role of ward councillors. We should be seeking to build upon that, rather than creating a new set of arrangements on top of what we have already.
Q61 Robert Neill: A significant part of the report from the Commission on London Governance talked about enhancing the role of the councillor as local champion and it cites various ways in which that might be done. Perhaps we might have an opportunity to have a look at that.
As we know, political parties are in operation in some parts of London with elected members, even under our current system, whom we might not be happy to see dominating a parish council if it were based in a particular local government area. I know that London government is concerned that there should be pretty rigorous controls to prevent a council that decides that it would not be in the interests of community cohesion to have a parish that might be dominated by an extremist element from being taken to judicial review if it refuses the petition. Is that covered sufficiently in the Bill or we do we need further safeguards? If so, what?
Merrick Cockell: No, our view is that it is not sufficiently detailed in the Bill and we hope that you can address it. Clearly, we are grateful that the
Your example of political extremism is the most obvious concern of us all. We have only to look back to the May elections to see where an extremist political party could easily have gained control of one London borough, which would not have been good for the whole process. The opportunities could easily be seen in London parishing. That is one side of it.
The other side, which has its dangers as well, is of a particular, probably geographically based, grouping, perhaps of people who objected to their local authority trying to apply a policyit could be a variety of things from finishing off a parking zone system to include the whole boroughseeing it as a means to oppose that and to protect or even advantage. Most London boroughs have areas that are particularly wealthy and they may wish to separate themselves from the problems and the wider community by setting up themselves as a parish council, with the ability to precept, inevitably requiring a bureaucracy and those other incumbencies that might go with it. There are at least a couple of risks around community cohesion in the wider sense.
Q62 Robert Neill: Have you done any work on the possible costs of setting up an establishment in London? You have talked about bureaucracy and setting up costs.
Martin Pilgrim: We have not, but we have cited evidence that we produced in a publication that we plan to let members of the Committee have after the meeting.
Martin Pilgrim: It is evidence of the scale of parishes in the rest of the country. As Councillor Cockell said, they can vary and be quite large. In some parts of the country, the expenditure by the parish council is greater than the expenditure by the district council in the same area. That must carry with it a bureaucratic overhead.
Q63 Robert Neill: I say that specifically because I remember in a different life defending the clerk of a large parish council who ran off with the funds. I was surprised that there were a lot of funds to run off with. It was quite a problem. Perhaps you would also supply members of the Committee with the report of the Commission on London Governance on that point.
Martin Pilgrim: Yes, with pleasure.
Q64 Tom Brake (Carshalton and Wallington) (LD): May we return briefly to your concerns about parish councils being established by extremist parties? Have you put specific proposals to the Government that would provide the necessary safeguards? Have the Government have rejected them? What is happening with the proposals that you have put to the Government?
Martin Pilgrim: We are in a continuing dialogue with the Government. As was said earlier, the proposal for parishes was first mooted two years ago. We raised our concerns then. We were pleased to see in the White Paper that the Government recognised our concern in two waysfirst by devolving the power to create parishes to, in our case, London borough councils, and secondly by making it clear that community cohesion would be reasonable grounds for rejecting a parish. We are still in discussion with Government at ministerial and official levels about whether the Bills present provisions will give us enough strength to resist parishes on grounds of community cohesion. We are discussing whether we need probing amendments, and we are talking to officials and Ministers about it all the time.
Q65 Tom Brake: Do you yourselves have a form of words that you feel confident would address all your concerns if it were in the Bill?
Martin Pilgrim: With our legal advisers, we are working on that form of words. Our concern is that we would really like our decisions on such things to be completely judge-proof, and clearly that is unattainable in law. We are looking to see how we might strengthen it. Subject to our continuing discussions with Government at official and ministerial level, we will return to the Committee with ideas as your thoughts develop, or at later stages.
Q66 Mr. David Burrowes (Enfield, Southgate) (Con): In terms of the grounds to refuse the creation of a parish, would you not want more discretion and freedom to refuse, rather than being pigeonholed into refusing on grounds of an adverse effect on community cohesion? What about taxpayers concerns about the cost, or the borough taxpayers overall right to choose?
Merrick Cockell: Having urban parishes as one of the choices before a local authority is right. There might be circumstances in which that will fit. To give too many opportunities to oppose things might not be to our benefit. Our concerns revolve around the threat to our communities ability to operate together within the whole authority and indeed beyond a single authorityto take that wider viewpointrather than having, as I said at the very beginning, a natural opposition to the concept of passing powers down.
Q67 Mr. Burrowes: I am not suggesting that, but are the only grounds for refusal community cohesion? Do you not think that that is one ground, not an exclusive ground for refusing?
Merrick Cockell: Those are the only grounds that we as London Councils
Q68 Mr. Burrowes: I appreciate that, but in terms of looking to advise on the Bill, would you want ideally to have other grounds than community cohesion?
Martin Pilgrim: One philosophical difference between grounds of community cohesion and of cost is that the people themselves in the parish area would vote for and incur that extra cost, whereas our consideration is the effect on the wider community. To go back to Councillor Cockells point, we cannot be against subsidiarity. If people want to vote for more expenditure, that is up to them. Our concern is the effect on the rest of the borough.
Q69 Alison Seabeck (Plymouth, Devonport) (Lab): Forgive me, because I am probably not as expert in such matters as you, but is there not scope with the community governance reviews for applications to set up parishes to ping-pong? There could be a petition asking to set one up and then a petition saying, No, we dont want it. Do you have a feeling about whether the Bill as it is drafted sets any time limit on that between, for example, a parish being established and another petition saying, We dont want it? For example, if the BNP or some other extreme group took control but the wider population thought, This is not good; well get up a petition to disestablish it. what would the situation be in relation to the legislation?
Merrick Cockell: I have not really thought through a massive petitioning to establish and then to disestablish, but I can certainly see circumstances in which a political extremist organisation campaigned to set up a parish and other groups would literally go on the streets to oppose it. That in itself would be extremely damaging, if we imagine it being fought out at local level. I had not considered it, but that ability would be troubling. It would not be prevented by current proposals, because one would have to have gone through the process before the local authority could take a view whether it would support or agree to a parish being set up.
Q70 Alison Seabeck: I am advised that there are two years before a petition can come in after one has been established. The scenario we have been discussing is two petitions running in an area at the same time, and what that might do for community cohesion.
Merrick Cockell: Yesand then, of course, the wider community being drawn in, not only those who are being petitioned. That is at the very root of our concerns about community cohesion. Our concern is that a wider area of London could be thrown into disarray.
Q71 Tom Levitt: I think everyone will agree that the enhanced roles of the community and voluntary sectors both in influencing policy and in helping deliver services as partners with local government have been healthy. How can we make those partnerships work even better on structures such as local area agreements and local strategic partnerships, which bring the voluntary and community sectors in to work with local authorities?
Merrick Cockell: I will speak from my own experience of my borough. I chair the local strategic partnership, and I think that it is a good principle that the leader of a council does so. It is an essential partnership that needs a stamp of recognition and approval from the democratically accountable leadership.
The relationship with the voluntary sector has taken time to evolve, in my experience, but we have got there. I think that that applies to other strategic partnerships as well.
However much local authorities try to involve the voluntary sector and othersbusiness sector, tenants, and so onin the creation of local area agreements,
One of the concerns about the proposals is that the local targets the local organisations, be they the council or voluntary sector, set seem to have less importance within LAAs, and are viewed in a different way from the nationally imposed targets. I think that that is regrettable. If a community accepts that the Government have a legitimate right to their targets, but adds to those, the local targets should be as important as national targets.
Q72 Tom Levitt: Do you think then that the voluntary and community sectors have played a positive role in the LSPs and LAAs in your area?
Merrick Cockell: It is a mixed picture overall. If there is one common thing about local strategic partnerships, it is that we are all looking to see who is doing it well. I do not think that any of us feel that we have really got it sorted out. There are different varieties, but I think that the direction of travel has been positive. A lot of the tension and perhaps distrust that was there at the beginning is being worked through. It requires constant application and willingness to be involved, and it can be tricky, because the voluntary sector and other sectors inevitably feel themselves to be second-quality partners to the statutory authorities, which control the money, officers, mechanisms and those sorts of things. Some of them have a right to do that through the democratic process, but others can dominate the process. Therefore, you have to take particularly positive steps to draw in other groupings that do not have the power of budgets, or any power.
Q73 Tom Levitt: As far as controlling the money is concerned, I believe that London Councils quite significantly cut the amount of money that is given to voluntary organisations. Has that helped or hindered the process of trust building?
Merrick Cockell: I am grateful to be here to put right that misconception. The budget for the next financial year as exactly the same as that for the last financial yearit is a frozen budget. We have started commissioning and to refocus our priorities. From your earlier conversation, I am sure that you will be glad to know that we have done that across the partiesthe three political groupingsand indeed the City of London in its independence, and we have worked out those new priorities for London. It is still about £26 million, which is a lot of money. The publicity around an initial proposal to cut the budget by a third was no more than that.
Q74 Andrew Gwynne (Denton and Reddish) (Lab): I am interested to hear what you have to say about how London Councils works jointly with its partners and about the co-operation across London boroughs. Do you think that the provisions in the Bill go far enough to require partners to co-operate with local authorities or should the proposals go further?
Merrick Cockell: Certainly, we are co-operating with an amendment, because I think the list is incomplete.
Martin Pilgrim: One of the issues for us is whether the Bill, as it is drafted, picks up all the London agencies, particularly around the Greater London Authority and its functional bodies, with whom we need to do business. There is a downside to that as well, inasmuch as in our dealings with the GLA, we tend to want to sup with a long spoon most of the time. So it is a matter of how we implicate the GLA and get the appropriate partners. Getting the right relationship with the GLA is important for us. That is one of the issues that we will be lobbying the Committee about as the Bill progresses.
Merrick Cockell: We are having dinner with the Mayor this evening, so I will tell him what you just said, Martin.
Q75 Mr. Woolas: May I follow up my hon. Friends question? It was about a regional level, but what about at a local level within the local authority? Would you like further powers to coerce co-operation, as it were?
Merrick Cockell: I cannot think that any more powers are required. Certainly, from my experienceI have done comprehensive performance assessment reviews on other authorities, so I have seen the way that they operatethere is a commitment from other organisations and groupings within London boroughs to be part of that strategic partnership. I do not think that anybody is insisting. They vary, so in one you might have the local fire commander being on the body and in other areas that, for a different set of reasons, just does not make sense. In Kensington and Chelsea. we have an arms length management organisation that has a seat as well as the residents association representing other residents. That might be unusual. Others may not do that. Some have a very small group of under 10 people who actually lead the strategic partnership and that seems to work for them. I think the structure in itself, within the community, has to just feel right for that community. Being hamstrung by Government or legislation does not help. I would say that it has to be able to evolve naturally. Anything that requires certain structures that no longer fit in with experience and local requirements would be a hindrance.
The Chairman: Finally, we move to part 11 of the Bill on Patient and public involvement in health and social care.
Q76 Robert Neill: Have you made any assessment of the likely impact on your member authorities that might arise from the changes that the Bill makes in relation to public involvement in public health issues?
Martin Pilgrim: For most of this Bill, we have left our thoughts to our national colleagues in the LGA. My concern with this part of the Bill would be the extent to which our relationship with the health service generally is dominated by the immediate issues around primary care trust budget cuts and how that is being handled within the health service. To some extent, looking at structures and so on is very much secondary to the crises that boroughs have to deal with when coping with rearrangements in the health service.
Merrick Cockell: We have a lot of worries at the moment.
Merrick Cockell: Cost shunting in boroughs such as Brent and Hillingdon, in particular, involves large amounts. Local councils are having to put in considerable amounts, which is inevitably being reflected in the council tax. It is just being announced at the moment. Overall in London there is a deficit of £135 million in Londons health service. It is so strongly felt that we have the chairman and chief executive of NHS London attending our next leaders committee next week, having put through a motion at the last leaders committee. The issue is of real importance and we have asked for an emergency meeting with the Secretary of State. We hope that she will agree to it very soon.
Overall, anything in respect of the proposal that connects the local council better to primary care trusts, in particular, is very important. In fact, my authority is considering being one of the pilots should the proposal go through in its current form. One of the difficulties that we are trying to assist with at London Councils is how the local health service in the boroughs is scrutinised. At the moment, there is a gulf between the local PCT, which the local authority has a statutory responsibility to scrutinise, and the London-wide health authority. We support a single health authority for London, but there is a gulf between the two so London Councils is seeing whether it can provide a scrutiny role, either sub-regionally or for London as a whole. It is impossible for both sides to deal with PCT-level scrutiny and the next level of chairman and chief executive London-wide. Somehow we must help to deal with that. If it ends up with a great connection, we would be broadly supportive of the principle.
Q79 Robert Neill: From what you say, you sound supportive of the LGAs national view that the Bill ought to require the involvement of the health authorities and so on.
Merrick Cockell: Yes.
Q80 Robert Neill: I have just one further point. The Commission on London Governance has done some work on the relationship that you hinted at between the boroughsthe primary care trusts in particularand how commissioning might go forward to see whether there were greater scope for collaboration. Is there anything that you want to add about that?
Merrick Cockell: The state we are in at the borough tier of London government has a lot of coterminosity between the services. That applies to the police and to primary care trusts. There are real opportunities to take that to the next stage. Perhaps not all London councils are at the same level of being equipped to deal with that, but there are a considerable number. We have such a high proportion of good and excellent performing councils in London that we can look at working with greater responsibilities being with locally elected politicians for all the public services in their area. We are working at London Councils with a sister
The Chairman: Thank you. That concludes our questions. Thank you, Councillor Cockell. Mr. Pilgrim, thank you for your attendance and your testimony.
We now come to the next group of witnesses. We can see your nameplates, but would you like to introduce yourselves to the Committee?
Elizabeth Manero: I am Elizabeth Manero, the director of Health Link.
Sally Brearley: I am Sally Brearley, the chair of Health Link. Would you like to hear what Health Link is?
Elizabeth Manero: Health Link is a social enterprise engaged in patient and public involvement. We grew out of London Health Link, which was the regional association of London community health councils. When CHCs existed, we operated across London in the way that was mentioned a moment ago.
Health Link was formed in January 2004. We draw views into policy making and policy implementation, particularly from hard-to-reach groups. We have a network of 125 lay patient representatives, all of whom used to be CHC members in London. They have great expertise in monitoring health services and are also well connected to their local health services. That is our core of informed people, and from it we have drawn a number of the patient reference groups that we have been commissioned to provide. For example, we run the patient reference group for NHS Connecting for Health in London, on the London choose and book programme, and we ran another group for the London patients charter project board. Sally and I are also involved in a patient reference group for specialised commissioning in London, which likewise operates at a pan-London level.
Our model is to draw in the people with whom we are familiar and who are well informed and well skilled in patient involvement, and encourage them to influence policy, but also to incorporate the views of others, who suffer health inequalities and whose views need to be heard.
Sally Brearley: May I also say that I am a member of a patient-public involvement forum for Sutton and Merton primary care trust? I also do some work for the Centre for Public Scrutiny on supporting health scrutiny in London and the south-east.
The Chairman: Thank you. We shall begin with part 11 of the Bill on Patient and public involvement in health and social care.
Q81 Alistair Burt: Good afternoon and thank you for coming. The Government have praised the excellent work of forums, and the energy and expertise of those involved. Are the Government right to abolish them?
Elizabeth Manero: The other day, I met someone from my local patient and public involvement forum who was involved in mental health and who talked about the despair and disillusionment of the forum members, many of whom are mental health service users. They had found, yet again, that they were told, You are really great; you are doing a great job, but we are going to get rid of you. The message that comes across from that is, We are going to get rid of you, not You are an excellent resource. Actions are judged more than words, and all the other reassurances about the quality of the forums, which I thoroughly endorse, are undermined entirely by abolition.
I do not agree with abolition, although I agree completely with the objectives that appear to us to underpin the proposalsbroadening patient involvement and trying to ensure that it goes beyond a committee-based approach. We endorse that entirely, but removal of the existing structures, and with them all the people involved, is a mistake.
Sally Brearley: I totally agree with that. It is unfortunate that we now face proposals to abolish forums, whereas the Government previously assured us that they did not intend abolition. The House of Commons Library research paper 2007/01 remindsus that, in July 2004, Melanie Johnson, then Parliamentary Under Secretary at the Department of Health, said that Forums were the cornerstone of patient and public involvement and that she said, They will not be abolished, nor will their independence be undermined. In the arms length review, which told us that the Commission for Patient and Public Involvement would be involved, we were also told that, Patients forums will remain the cornerstone of the arrangements we have put in place to create opportunities for patients and the public to influence health services.
As you are aware, it was only in July this year, in A stronger local voice, that we heard that patients forums were indeed to be abolished. I do not think that abolition is necessary. Perhaps we cannot return to CHCs, although in some ways I think that that would not be a bad idea, but there is no need to move to LINKs. We can achieve the stated aims, which we said we commend in terms of widening involvement and extending the remit to cover social care as well as health. We can go forward by modifying, improving and strengthening patients forums. I do not think that there is any need for us to look at LINKs.
Q82 Alistair Burt: I appreciate the comprehensive nature of the answer, which you are perfectly entitled to give. What is it that worries you most? Is it the fact that it is another reorganisation or is it the loss of independence, because plainly it is not the Governments intention to remove the patient voice? Why do you think that the way in which they want to set it up will not be as effective as what is currently there? Will you tell us what you think is missing given that the Committee might try to do its best to reintroduce what you think is missing if that would actually give effect to what the Government are looking for?
Elizabeth Manero: I referred earlier to the model that we have tried to operate in Health Link, namely a core group of people who are informed, trained, supported and able to sit in a forum like this in the health service and actually engage and make a difference. That core is not there in the LINKs proposals.
Elizabeth Manero: Why should they? If they have already been told that they are so excellent that they are going to be got rid of, it is a bit of a risk that they will not engage again. That was difficult enough when I was chair of London Health Link and encouraging the members of London CHCs to move forward. Many of them did not. Therefore, if those moved forward again are going to be told that they are so good that they are being disposed of, it is difficult to anticipate that they will remain. If there was a provision in the Bill which secured that continuance, that might be a different matter, but there is not.
Sally Brearley: The proposals are so vague that it is difficult to see LINKs as a body. It might be a body but not as we know it. They talk about putting in place a means for delivery and activities, but it is not at all clear that we will have the effective body of informed people that we have with patients forums. Therefore, I think part of the problem is that we cannot see from the details given in the Bill that we are going to have anything as effective as patients forums. If we could be assured to some extent that there will be room, as you said, for existing members of patients forums to transfer to LINKs, at least that would be something. However, there are other reservations about LINKs which I will not go into now unless you want me to.
Q84 Andrew Stunell: You have already dealt with the question whether the Government were right to get rid of community health councils, but we have also seen at the national level that the Commission for Patient and Public Involvement in Health is being got rid of. Will you comment on how we might get that national oversight in future?
Elizabeth Manero: That is one of the other very significant gaps in this Bill because there will be no national voice. Prior to the establishment of the CPPIH, there was the Association of Community Health Councils for England and Walesthe Committee must forgive me for using its acronym, ACHCEW for the rest of the afternoon. ACHCEW was a bottom-up national organisation, whereas the CPPIH is a top-down organisation, so its role is to manage performance, which needs to be done. However, we are now losing the CPPIH and we have nothing in this Bill. Therefore, there will be LINKs consisting of no particular entity but a group of organisations. It is not dissimilar from, and actually it really seems to be a community empowerment network for health. You will know that better than I. However, we have already got a community empowerment network in the area, so I am not sure that we need a LINK as well. What is the difference between the two?
What is more, forums are capable, because they are statutory entities in their own right, of setting up their own national organisation. If they wished, if they had
The reason that we have a four-hour target in NHS accident and emergency units is because of the work that ACHCEW and community health councils did on waiting times in A and E. Sally and myself used to go every month and observe the number of patients lying on trolleys in A and E and how long they were there. We did that because we knew it was an issue. Hence, we now have an improvement in service as a result.
If we do not have a bottom-up national organisation, that sort of activity cannot take place. However, in addition we do not have, at local level, an entity that can say, We have had five complaints this month about waiting times in accident and emergency. We need to do something about that. What shall we do? Lets go and investigate, lets find out what best practice is, lets see whats happening locally. If we do not have the governance, the scale and the resources to undertake that kind activity, we are in danger of having a lot of talk between an awful lot of people, but I am not quite clear what the result will be.
I have yet to see evidence that more people saying the same thing is of value, when you have not managed to address what a smaller number of people are saying already. How many people does it take to say that the hospitals need to be cleaner or that hospital infection rates need to go down? How many people do we need to say that? I do not understand what the objective is in that regard.
Sally Brearley: I am sure that you need no reminding that in the original proposals for replacing community health councils there was not a national body. Indeed, patients forums were not in those proposals. Patients forums, the national body and the independent complaints advocacy service were hard won during the passage of the legislation to abolish community health councils. We seem to have gone back to square one, in throwing away what was so hard won the first time around, when CHCs were abolished.
Elizabeth Manero: They would include a small entity, of the right size to represent the relevant geographical area, of people who were trained and supported, who were accountable and who had a code of conduct that they had signed and had to keep to. There would be a complaints process, so that any deviations from the code could be dealt with. We need proper governancestuff that does not need to be invented because it has been going on for so long, such as elected chairs, and rules and regulations. It is dull, but you do need that to have a core activity that works.
That would be the core of a new system, but beyond that would be links out to a wider network of organisations. We do a lot of work with organisations such as Thames Reach Bondway and Groundswell, which work with homeless people. Those organisations do not know anything about health, but we can go to them because we do know about the health service. We can engage with them and find out what the health issues for their client group are. That means that those
To translate that model to what we are talking about, if you have a local organisation with clear powersone that can go out and engage with perhaps even organisations in the community empowerment networks or otherswhich represents people who suffer health inequality in the local area, the views of those people can be brought in to influence the way that services are provided.
Just to give one example of that from our work with homeless people, we involved homeless people as advisers on patients forums statutory visits to A and E, so that we could hear what the issues were for homeless people using it. One thing that came up was the fact that if a homeless person with drug or alcohol dependency goes into A and E with a broken leg or whatever, they get their treatment, but they cannot be referred for detoxification, even if they decide that they want it. They are told to go and speak to their GP about it, but they probably do not have a GP. There is no means of referring someone who has come voluntarily into the health serviceno way of exploiting that opportunity and providing them with a service that they have decided they want, so they go off. There is a waiting time, but what are they doing during the waiting time? That is the end of that.
That issue came out of our visits with homeless people. We were able to go to the hospital concerned and say, Right, we need to set up a system for this. We have got funding and we are now developing a system like that, to ensure that when homeless people get into the health service, all their needs are dealt with. That cannot happen unless you have us knowing about the way A and E workshaving context in the health service, governance and all the rest of itand those organisations that can support people who are totally on the edge, so that you can bring the two together and add some value.
Sally Brearley: The Government say that their intentions are to involve more people and to extend the remit to social care, and also relate to the changing area, so that it can follow the patient pathway, rather than just having forums attached to individual NHS bodies. The elements of what we need to deliver that are absolutely in place. They are patients forums, and PCT patients forums in particular. In the existing primary and secondary legislation, there is a duty on PCT patients forums to work together where they share interests. There are also additional powers that PCT patients forums have, which could enable them to be the key bodies in extending involvement and in changing the remit to health and social care, as well as consultation. We have got the elements in place to do what the Government say their intentions are, and it would be much more economical to deliver it in that way.
Q86 Andrew Stunell: To follow up, if I may, would you be able to submit a note to us that sets out what you see those steps as being? For me, certainly, it is a little bit hazy as to what the outcomes ought to be.
Sally Brearley: Yes, we could do that. The work of the early adopter LINKs would be key to that, where existing patients forums are acting as the key bodies in drawing the relevant partners together.
Q87 Patrick Hall: I have been listening carefully and it struck me how much common ground there is between what we have just heard from Health Link and what Ministers are saying about what is needed for patient and public involvement. But again, there are clearly some strong disagreements about the mechanism and the process, which is obviously what we need to understand in this Committee.
The Government make the observation, as I understand it, that PPI goes well beyond patients forums. Possibly you would agree with that because there are many voluntary organisations out there and beyond them there tens of thousands, millions even, of individual human beingsmembers of the public who sometimes access health care or social care.
The Government have an ambition, which I think you might share, but not necessarily through LINKs. The ambition is to reach out, past people who volunteer to serve on community health councils and forumsI am not denigrating that at allto those hard-to-reach groups of the more needy, vulnerable and alienated people. The Bill proposes that the way to do that is not through patients forums but through LINKs. I am interested in how you think that can be achieved, either through patient forums or through LINKs. It is clear that Health Link supports that ambition. We have before us a proposal that LINKs can and should do the job. How do you think LINKs could do that job? What powers and what resources would be necessary?
Elizabeth Manero: There is reference in the Bill to authorised representatives for the purposes of entering, viewing and observing NHS premises. I am not clear how many of those authorised representatives there will be and in what way they would differ from the rest of the members of the LINKs, but possibly there is a route there to developing the core that I have been describing of people who are supported and trained and have governance and so on.
I would like to add one point. We talk a lot about involving people. Well, there is not much point in involving them if there is no result. In my experience, which is now about 15 years of patient and public involvement in the health service, the relationship that you have with the health service, which takes a long time to build, is a sort of balance. You have to have enough powers to make it listen to you, because otherwise it will not, but not so much power that it is disproportionate to the fact that you are not elected, and therefore should not have that amount of power.
In my experience in Barnet, where we had many stormy times, you started off and had to really demonstrate that you were prepared to exercise considerable amounts of power and make quite a lot of difficulty for a health service trust before it would listen to you, but once you had done that, you then found that you had a very good relationship with it. People used to ring me at home and say, Were thinking of doing thiswhat do you think? How can you get some people in so we can discuss it?
That kind of relationship takes a very long time to build. It is not seen, and the work that we did to inform our response to the Governments proposals was to survey members of patients forums and CHCs on their experience of visiting the health service. What came through was very interesting, and I can send this to the
That relationship between any public service, but particularly the health service, and the local community is what all these networks and so on are trying to forge, but you cannot see that relationship. I think that the people who have been working on developing that relationship up until nowthe patients forum membersneed to remain. That would be one criterion for this working. There has to be an identifiable successor core to the patients forum in the LINKs set-up. Just having arrangements, means and so on in the Bill will not do it. They are the edges, they are the frame, but there is no picture in the middle.
Unless we can have that core, I do not think that there will be anything to get hold of, anything to work or, indeed, anything to attract people. Again, I do not know as much as perhaps I should about community empowerment networks, but how easy is it to get organisations actively to participate in them? However easy it is or is not, the fact that at one end of the local authority corridor someone is doing that and that at the other end someone is procuring another organisation to do precisely that with another load of organisations through the health involvement team does not make any sense to me, I am afraid. It is bureaucratic and expensive.
In order to achieve the objective that we all share of wider patient involvement, that must be part of a grown-up and effective relationship. You cannot have that relationship without powers and without knowledgeable, well-supported people. You cannot have appropriate involvement without the wider input that we are talking about from the groups that support harder-to-reach groups.
Q88 Patrick Hall: May I go back to the point about resources? You obviously have direct experience in that you deal with health. I do not know how you are resourced, but you are and therefore you have a view about what is needed. If we were to embrace social care, too, which is a good thing and very ambitious, what sort of resources do you think would be needed in the area covered for a LINK, or whatever you want to call it, to deal adequately with the challenge?
Elizabeth Manero: You would need an officepeople do not relate unless there are premises and unless they can go somewherebecause that is where they have the informal meetings and informal network. You have to have a competent staff that can provide the right kind of support to the secretariat and to meetings and so on, and that knows about the health service. You have to have member expenses and member training. Member training has never had the attention it should have had throughout the 34-year history of this saga. People need to be adequately trained to understand not only the health service but the needs of people who are not there. That is important. Those are the elements that you would need, but I cannot put a figure on it without notice.
Sally Brearley: I can perhaps give you a comparable figure, but it dates back to 2000. A previous chief officer of a community health council in north-west London told me that the CHC budget, which would have covered a London borough, was approximately £130,000. That included the office, three staff and member expenses. Those are the figures for 2000. We are now talking about extending the provision to social care and for 2007 or 2008, so my feeling is that it would have to be significantly more. One of the worrying things about the proposals is that we are not told what the budget will be to support LINKs. We understand that it depends on the comprehensive spending review, and perhaps we cannot know the exact figure, but it would be useful to have an indicative figure.
We must not forget section 11, which I believe is now section 242 under the National Health Service Act 2006 and places an obligation on the NHS to consult patients and the public. We do not want LINKs to duplicate that. The PCT patients forum has a duty to monitor the NHSs performance of section 11. That is another way in which patients forums ensure that the NHS actively involves its users. It is quite right, of course, that they do.
Q89 Tom Levitt: Sally drew our attention to page 91 of the Library research paper when she quoted Melanie Johnsons 2004 statement on protection from abolition. I want to quote page 97, which cites the Government response that there are several fundamental differences between PPI forums and LINKs, for example LINKs will cover social care services as well as health, they will be established for a geographical area rather than a specific organization, and they will also decide locally how members will be appointed and how others will be able to contribute to their work priorities.
Apart from the addition of social care services, bearing in mind that we have already moved to PCTs that are much more aligned with local authority boundaries and the fact that the link with the local authority will give democratic scrutiny through the conventional democratic channels, I cannot honestly see how any of the good things that you have talked about tonight that forums do cannot be done by LINKs and in spades, and how the forums cannot merge into LINKs in future. Why are LINKs a step backwards in your view?
Sally Brearley: I would say rather that they are an unnecessary step forward. I agree with what you are saying, but, to change it around, what is being proposed can be done adequately by slightly modifying the present structures. I would like evolution rather than revolution, yet again, in the NHS.
Q90 Tom Levitt: That is probably down to a legal technicality, in that we have to abolish something before we can replace it. For instance, we abolished the pound note but we did not abolish the pound. There is continuity: the function and purpose will remain even if the name changes.
Sally Brearley: But the people may not. If I may go back, there were more than 10,000 community health council members. There are about 4,400 patients forum members. How many of them will transfer to LINKs
Q91 Mr. Burrowes: To pick up on the point about transition, one of the concerns is that those hard-working forum membersI know some in Enfield who have done a very good jobwill see the new LINKs as lacking the teeth of the present forums, particularly in respect of the statutory duty to inspect, which is being downgraded. We are not talking about a change of structure. In fact, there is a reduction in power on the fundamental issue of inspection.
Elizabeth Manero: We have done a lot of thinking about that. We are so used to the idea of an inspection right that we were horrified when the proposal came up to remove it. We lobbied extremely hard to get what is now in the Bill. To me, inspection means the Healthcare Commission, the social care inspection provision and national regulatory bodies such as the Audit Commission, which is mentioned in the Bill, but I referred earlier to the relationship between the health service and its local community. It is that interface where inspectionif we cannot find another wordcomes into play for forums. Those people speak on behalf of local communities of taxpayers who fund the health service and are totally dependent on it when they are at their most vulnerable. It is therefore appropriate for them, on behalf of patients, to see inside the health service and talk about the things that matter.
I gave the example earlier of homeless people. If you are lying on a trolley in A and E, you cannot climb off it and go to another A and E where you think you will get quicker service. Someone else has to perform a role for you, so entry and dialogue with NHS management and practitioners about the way that services are provided are essential.
There is no right in the Bill to go in, as there was under the two previous reforms, because there is nothing to have a rightthere is no entity, which is one of the key weaknesses. LINKs are merely objects of the duty of NHS organisations and so on to let them in. They are weak because there is no entity. If I were in a LINK, I would not be able to write to my NHS organisation and say that I was concerned because I had had complaints about its chiropody service, or whatever service, and that I would like to go in and talk to the staff. That is invaluable when you are doing visitsyou get all sorts of intelligence from the staff that you would not otherwise get. You find out whether they are short of money, resources or staff. It involves a relationship, and entering and observing is to do with furthering the relationship and making it more robust, and procuring dialogue about changes and improvements. It is not inspection in the way that the Healthcare Commission might inspect. It will go in with a list and ask, Have you got this and this? It is not the same as that.
Although it is regrettable that there is not a powerthere cannot be a power because there is no entity, which is another reason why I would like an entityI do not have a desperate problem with the lack of the word inspection.
Sally Brearley: The Department of Health has tried to reassure us that it intends that LINKs will be able to enter and view premises where NHS services are
Q92 Alistair Burt: Our last question involved asking about your confidence that the new arrangements would increase public participation and involvement. My sense is that your comments have indicated that you feel that there is a gap in what is being provided and that that confidence may not be there among the public. Would you like to reprise what you think might assist in closing the gap between intention and your perception of what is actually there and what you want to see tightened?
In the consultation process, did you have any explanation from the Government why they were doing what they are doing? We have had plenty of discussion about the what, and for the purposes of what we are doing in the Committee, your answers have been highly illuminating in illustrating a gap in perception between what the Government are genuinely seeking to achieve and what you feel is out there. That will provide a terrific opportunity for us to probe and discuss that when we reach the appropriate part of the Bill. However, that is all about the what. What is your perception of the why? Why should the Government want to do what they are doing and upset what you think appears to be working perfectly well?
Elizabeth Manero: Just to pick up on that last point, I would not say that it is working perfectly well. It has been going for three years and it is travelling a journey that CHCs took 30 years to get to the end of. It is going in the right direction but it has a considerable way to go.
As to why, I do not know why. In our own response to A Stronger Local Voice, we said that we could not see the point. It seems to me very expensive. We are sitting here this afternoon having this discussion, but I do not think that that is appropriate because we should not be doing this at all. We should be leaving the system in place and reforming and amending it. I cannot answer the question why, I am afraid.
On confidence, there must be much greater knowledge locallylocal authorities could certainly help with thisabout patients forums and what they do. They do a lot of very good work, and it is not known about or understood. At national level, it is absolutely essential to have a national body speaking for patients clearly, with authority and independently. Otherwise, this will be seen as just a little local activity with no real credibility.
Sally Brearley: It would be interesting and illuminating to know how many of the responses to A Stronger Local Voice said that they supported the establishment of LINKs. I know that a lot of people responded to that document, and that situation reminds me of the discussion that we had about who had said they wanted CHCs to be abolished. It was very difficult to locate a significant number of people who had said that in the discussion leading up to the publication of the NHS plan. We have the Governments stated intentions which, as we have said, we feel are laudable, but I am struck by the similarity to a quotation from Bertolt Brecht, which I am sure many of you are familiar with, that the people have lost the
We are very awkward customers, us patients forums people, and us CHC members were very awkward as well. But hey, that is the nature of democracy. You might not like what we say, but we are going to go on saying it.
Q93 Alistair Burt: You will be delighted to hear that, on the Conservative Benches, la lutte continue. We will certainly be putting forward some of the things that you said. On the consultation on A Stronger Local Voice, do you think it would be helpful if the submissions to the exercise were made public? I believe that they have not yet been.
Sally Brearley: Yes, absolutely.
Elizabeth Manero: Yes. I cannot see why they would not be. I was not aware of that. It is very odd.
Q94 Tom Brake: You may have been intending to supply us, in response to Andrew Stunells request, with a document setting out what would make LINKs work. It would be useful if you could include in that the key steps that you would take if you wanted to convert your present structure of forums into LINKs and what three or four steps you would have to take to achieve that.
Sally Brearley: Sorry, was that a question or would you like us to supply it?
Sally Brearley: Yes. I think that is exactly what the early adopters are doing at the moment, and they are learning from that.
Q95 Alison Seabeck: Two questions. You were very helpful at the beginning, setting out a little bit about your organisation. You did not say how you are funded, for example. Are you a membership organisation?
Elizabeth Manero: No, I did not say, I beg your pardon. We are commissioned by different bits of the NHS and the Department of Health and others to undertake projects, project work and patient involvement work.
Q96 Alison Seabeck: That is very helpful. The second thing that has been bothering me about your evidence is that you have repeatedly said that your members are being told that they are not valued and that we want to get rid of them. Who is saying that your members are not valued?
Elizabeth Manero: It is not my members.
Alison Seabeck: Well, members of the forum. Who is saying that they are not valued and therefore will not have a potentially important forward role?
Elizabeth Manero: As I explained earlier, actions speak louder than words, and because the organisations of which they are members are being removed and there is nothing in the Bill that guarantees their transference to the new organisation, I think that that is what counts.
Sally Brearley: In a sense, you have repeatedly said that the forums are going to be done away with, they are not going to be of use and they are not valued. I find that slightly of concern. I suspect that if the Minister of State for Health Services, the right hon. Member for Doncaster, Central (Ms Winterton) were here, she would say that that was simply not the case. She would say that they are valued and they will have a forward role, and because of the statutory requirement in the Bill to get rid of the current structure and replace it, that does not necessarily mean that those excellent people will not be encouraged to participate in the future.
Sally Brearley: I notice that the Minister is sitting behind me.
Sally Brearley: No, but I would like to acknowledge the fact that we have had, as forum members, letters saying that we are valued. What I would like, however, is an assuranceif the Minister or one of her colleagues can give it during the progress of the Billthat existing patient forum members can transfer automatically to LINKs. As Elizabeth said, actions speak louder than words. I would also like to mention that existing patient forum members have been checked by the Criminal Records Bureau, which is a costly and time-consuming process. To take on those members who have already been through that process so that they would be able straight away to deliver the inspection role would be great. Therefore, an assurance that patient forum members can transfer would do a lot to answer our worries.
Q98 Mr. Woolas: Do you see any benefit in enhancing the work that you do for local authorities, and particularly for elected councillors? How do you think that we could better join that up?
Elizabeth Manero: The role of overview, scrutiny and health is developing very well in many areas. Unfortunately, however, it sits at the town hall. If there were better practical linksthe links are there legislatively speakingbetween patients forums, the patients forums could be the eyes and ears of elected councils inside the health service. They could also help to bring in health issues that might be relevant to the well-being power and other functions of local government that are relevant to health. They could assist with bringing in the views and perspectives of people with health inequalities to that work. So, I think it is twofold really. They could be the eyes and ears of the scrutiny committee inside the health service. That would then act as a counterweight to the NHS. In the scrutiny committee, the NHS gives evidence and it is
Elizabeth Manero: I think so, yes, because there is the link between LINKs and scrutiny committees when it comes to making referrals. There is a plan to match the social care referral power in the Bill with the existing health power to make them the same. I think that that is very welcome. That opens up that channel of communication. On the health side, I am not so sure, because the LINKs relate exclusively to social and health care services, and their providers. Their role in health is less distinct than the current situation with patients forums, so I think that that is a weakness.
Sally Brearley: The majority of the local authority scrutiny committees to which I have spoken in the course of my work were worried about the proposals to abolish patients forums, because they regard them as their eyes and ears. The fact that patients forums have the power to enter and inspect, and that they are often aware of the issues concerning patients in their area, has been extremely valuable to scrutiny committees. Patients forums give the committees the information that they need to decide which services they are going to scrutinise, and the confidence that they are picking up the views of the population. Patients forums have been very welcome.
Scrutiny committees were slightly reassured when we were told that LINKs would have the power to enter and inspect, but they are worried about the potential gap between the abolition of patients forums and the setting up of LINKs. That seems to be the case from what we have been told about the transition process.
Q100 Andrew Stunell: Has the experience of PPIH members in London been the same as the experience of people in the north-west? In Greater Manchester, PPIH members have received two letters: the first telling them that their work was highly valued and that it would come to an end this month; the second, a week or two later, saying, Whoops. Actually, we would like you to keep going until October. Would you like to comment on the impact that that is likely to have on peoples willingness to continue?
Sally Brearley: Yes, these are confusing times. It is a testimony to patients forum members that so many of them have been prepared to go on, and are hanging on in there. The timetable of transition depends on the legislation, so it is inevitable that there is some uncertainty. As patients forum members, we may get subsequent letters that again alter the timetable. The Department of Health tells us that the plan is for forums to be abolished in December 2007 if the legislation goes through this Session, for CPPIH to continue until March 2008, and for LINKs to be set up sometime from January 2008 onwards. There seems to be a gap, so I am sure that we will get further letters about our membership.
Q101 Tom Brake: Notwithstanding the gap, would you cast your mind back to the abolition of the CHCs, and perhaps tell us what sort of gap or loss of effectiveness there was from the point of abolition through to you feeling confident that the present structure was working effectively?
Sally Brearley: I think that transition is not about one set of organisations ceasing on one day and another coming into existence the next. I think that we lacked a managed transition.
One of the great losses was the loss of CHC staff. The Minister at the time gave assurances to Parliament that there would be a role for CHC staff in the new structures. Unfortunately, it was not within his remit to deliver thatit was up to the CPPIH which, as we know, went with a different method of providing support, which was to contract it out to forum support organisations. There was a big gap, in which time any remaining CHC staff would have been few and far between, even if they had wanted to seek employment with the forum support organisations. There was a big gap in the support being offered. As Elizabeth said, there was also a big gap in terms of getting in place basic things such as governance arrangements and standing orders for how forums should operate. Many of the new recruits to patients forums, people who came in very keen to work in patients forums, left because it was such a shambles in the early months. We need a carefully managed transition. It was sad that in the transition from CHCs to patients forums we lost so much that was good about CHCs.
Elizabeth Manero: May I answer as well by giving an example? Your previous witnesses referred to the level of deficit in the health service in London and cuts in services. Without patients forums, how will any of us know the day-to-day effect of those cuts? How will a debate about whether or not those cuts were advisable be informed with a patients perspective? With the wholesale removal of patients forums in London which, as we speak, are monitoring the health service on our behalf and getting evidence on our behalf of the effects of those cuts, those services will be gone. The particular situation in the health service now with cuts happening is more serious than it was when CHCs went. That significant risk must be considered.
Elizabeth Manero: Yes, but they will be setting up. They will be recruiting and training people. They will be telling them where their local hospital is. That process can take six to nine months.
Elizabeth Manero: No, absolutely. I am saying that the timing of the transition, such as it is, is extremely unfortunate from the patients point of view. That is another reason to look extremely carefully at the transition arrangements.
Sally Brearley: Also in terms of that, who are we expecting to set up the LINKs, if indeed it will be a body? It is the people who the local authorities will contract with to provide the support. I think that it is termed Hthe hostin the Bill. The host will establish the LINKs. We do not know who the hosts will be. What will they know about establishing a LINK? Who will they choose to be the LINK? Will they do it by virtual means, as the provision outlines under the Bill? It states that it may be a person or persons or it may be done by any other means. So it will not necessarily be a body, even when it is established. I have worries about the host organisation setting up the LINK. How will it know what to do? What expertise will it have? How long will it take to go about it?
The Chairman: That concludes our questions. Thank you very much. On behalf of the Committee, I should like to thank you for your attendance today and for your witness.
Further consideration adjourned.[Jonathan Shaw.]
Adjourned accordingly at twenty-seven minutespast Six oclock till Thursday 1 February at half-pastNine oclock.
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