Select Committee on Health Written Evidence

1. Evidence submitted by the Department of Health (PPI 1)

  1.  This evidence addresses the terms of reference set out by the Committee. Additional information can be found in:

    —  Part 11 of the Local Government and Public Involvement in Health Bill published in December 2006; involvement_in_health.htm

    —  A Stronger Local Voice published by the Department of Health in July 2006; and

    —  The Government response to A Stronger Local Voice published by the Department of Health in December 2006.

What is the purpose of patient and public involvement?

  2.  We believe that the ultimate purpose of user and public involvement is the production of improved services, which better satisfy the needs and wants of users of services. Patients, carers and users of services are experts in the care they need and want their input is therefore essential if services are to be tailored to their needs, to create a patient led NHS. We also feel that it is essential to involve users, as well as the groups that represent them, in the commissioning decisions that are taken, to ensure they have input into what services are provided in any locality. This will create local ownership and support for services.

  3.  Patient and user involvement also assists in the scrutiny of services through representing people's views, and allowing users a route to assuring the quality of the services they use.

What form of patient and public involvement is desirable, practical and offers good value for money?

  4.  The system of user and public involvement should involve as many people as possible. During the consultation leading up to the publication of the White Paper Our health, our care, our say: a new direction for community services we heard that more people want to have a greater say about their local services. Our consultation also showed that people want to be involved in different ways—some having a large amount of time to dedicate, others wishing to dip in and out of involvement. The system of user and public involvement must accommodate different ways of getting involved, to give a large and diverse number of people a means of influencing the services commissioned and provided in their area.

  5.  The system of user involvement can also offer good value for money by ensuring that the greatest possible proportion of the funds available are spent on front line engagement work rather than on central structures to support user involvement. Currently approximately £9 million is spent annually on supporting CPPIH, which represents 32% of the total PPI budget. The costs of Local Authorities administering and monitoring contracts with host organisations will vary according to the nature of their area and each Local Authority's infrastructure. However, it is estimated that Local Authorities will need between £5,000 and £15,000 for this work. It is our expectation that the same amount of funding will go to the new system as is currently spent on PPI, therefore, even if each Local Authority is at the higher end of the scale, their expenditure represents roughly 8% of the total budget. We believe it is beneficial to redirect funds towards frontline engagement work.

Why are existing systems for patient and public involvement being reformed after only three years?

  The Department of Health's Arm's Length Bodies Review announced the abolition of the Commission for Patient and Public Involvement in Health in July 2004. The decision supported a wider agenda set by the review to reduce bureaucracy and free up more resources for the frontline.

  Following this announcement and the publication of Commissioning a Patient Led NHS and the proposed reconfiguration of PCTs, Ministers announced a strategic review of the PPI system as they recognised that the nature of health and social care delivery is changing radically, for example:

    —  PCTs' changing role to focus on the commissioning of services;

    —  the role of commissioning as the means through which services are managed, controlled and developed;

    —  the move towards greater choice of service providers and service delivery;

    —  the increased focus within social care on choice and control with more emphasis on personalisation of services, self-directed support, and the use of direct payments;

    —  the move towards the integration of health and social care, the delivery of more services within the community; and

    —  the emergence of NHS Foundation Trusts, as well as many other providers from the independent sector.

  6.  PCTs and other commissioners are the power base of the new NHS, with 80% of budgets being devolved to them. In the future there will be an increasing mix of providers, meaning that the old system of user involvement, that was focussed around individual NHS institutions is no longer appropriate.

  7.  We want to build on the excellent work of PPI Forums and other methods of service user and public involvement, to create a new system that is clear and accessible. It should provide more people, young and old, from a wide diversity of backgrounds and needs, with the opportunity to influence public services in ways that are relevant and meaningful to them.

How should LINks be designed, including:

Remit and level of independence

  8.  We believe that LINks should cover both health and social care. Currently the system of focusing user involvement around Forums established for each NHS Trust means that often services are considered in isolation. LINks will be able to cover all services in their area, looking at those jointly commissioned between health and social care, and gathering comments on all aspects of user experience.

  9.  LINks should be independent of external control, so that they are able to make their own decisions about what issues to consider, and make recommendations based on the comments they hear. We are eager that LINks are described in a minimum of detail in legislation so that they are free to be flexible to local circumstances, rather than being centrally prescribed.

  10.  Local Authorities will be required to procure a host organisation which will support the LINk, however, they will not have control over the LINk's actions, or how the LINk spends its funds, this should ensure the LINk is free from political control.

Membership and appointments

  11.  We think that membership of LINks should be locally determined by each LINk structure. We do not wish to prescribe a central governance structure and form that the LINk should take. We will offer some models that the LINk could choose to follow, but its membership and structure will be free to follow whatever form is most appropriate locally.

  12.  It is important to note that the term "membership of a LINk" may be misleading. It will be possible, and indeed sometimes desirable, for people to feed their views and experiences into a LINk without seeing themselves as "members". By making a complaint, or filling in a comment card or talking to a PALS officer, an individual is contributing to the evidence-base collected by the LINk. Similarly, LINks may want to have their own web sites to which people will be invited to visit and log their thoughts, ideas and experiences. The key issue is that LINks are able to reach out to and hear from as wide a range of people as possible rather than relying on the views of a small group of heavily "involved" people.

Funding and support

  13.  Money will be given to every upper tier local authority which will be required to contract with a local organisation such as a voluntary and community group host LINk. The host organisation will hold the funds of the LINk, and will spend them as instructed by the LINk's governance structure. The host will provide administrative and organisational support to the LINk.

  14.  We believe that subject to normal budgetary pressures, the new system should receive the same level of funding as is currently available to the Commission for Patient and Public Involvement in Health (CPPIH) and patient forums. The Government is currently involved in a Comprehensive Spending Review which will set spending 2008-09 to 2010-11. We expect the results of this review to be published in the summer.

Areas of focus

  15.  We believe that LINks should have the power to determine what areas of work they focus on, within their statutory functions which will be:

    —  promoting and supporting the involvement of people in the commissioning, provision and scrutiny of local care services;

    —  obtaining the views of people about their needs and experiences of local services;

    —  making the views they gather known to commissioners and providers of services, and making reports and recommendations to those taking decisions about these services.

  16.  We believe that the LINk, directed by its governance structure, and the decision making process it has put in place, should have the power to focus on issues which it has heard are of concern to the local community.

Statutory powers

  17.  LINks will have similar powers to patients' forums, these include the power to:

    —  enter and assess health and social care facilities;

    —  make reports and recommendations and receive a response within a specified timescale;

    —  request information and receive a response within a specified timescale; and

    —  refer matters to an Overview and Scrutiny Committee and receive an appropriate response.

  18.  To enable LINks to gather information from all types of patients and users of services, there will be times when it is right to collect peoples' experiences whilst they are currently using services. We therefore plan to provide LINks with the power to enter health and social care premises (with some exceptions) and to observe and assess the nature and quality of services.

  19.  LINks will not have the right to enter all premises, for example they will not have the right to enter social care facilities which provide services for children. Not all members of LINks will undertake this role, indeed some members will not want to undertake this type of activity, and that will be acceptable. Those who are able to exercise the right need to:

    —  have appropriate skills;

    —  have received appropriate training;

    —  be cleared by the Criminal Records Bureau; and

    —  be able to demonstrate an understanding of patient confidentiality and an appropriate level of sensitivity towards the role.

Relations with local health Trusts

  20.  We intend LINks to be flexible, and able to be adapted to best fit local circumstances. Therefore, whilst we are not prescribing their structure or make up, we imagine that a LINk may well wish to set up specialist interest groups, for example, one that considers mental health services within its area, or relates to a particular hospital trust. LINks may wish to work together in considering services which span local authority boundaries.

  21.  We hope that LINks will create strong working relationships with the Trusts in their area, and build on the partnerships that have already been created by patients forums and local voluntary and community sector organisations. LINks will have powers to request information from trusts, as well as enter and assess their premises, these should help them in close scrutiny, and close working with these trusts.

National coordination

  22.  Whilst LINks are independent and will have the power to develop their own priorities and agendas, they will need to develop relationships with a number of stakeholders to fulfil their statutory role effectively. In certain circumstances LINks may want to work in partnership to scrutinise services across local authority boundaries. LINks may also wish to work together in regional groups, or even nationally to share experience and findings. We believe there is nothing to prevent LINks establishing a national body to share and co-ordinate their work if they so wish.

How should LINks relate to and avoid overlap with:

Local Authority structures including Overview and Scrutiny Committees

  23.  We envisage that LINks will have a close and mutually beneficial relationship with OSCs. LINks will have the power to refer matters of concern to the OSC and the right to receive a response. OSCs may well find LINks' recommendations useful in raising issues, with a large evidence base behind them, which many people have found to be of concern. This close relationship should not prejudice the independence of either party, as they remain separate organisations with their own decision making capability.

Foundation Trust boards and Members Councils

  24.  It may well be that many of the members of a LINk are also members of Foundation Trusts. It will be up to the LINk's governance structure and organisational rules to ensure that there are no conflicts of interest, and to manage any such problems. Foundation Trusts also have duties to seek the views of the whole community, therefore they may be very interested in the research and recommendations of the LINk. In addition, the Foundation Trust may share its findings with the LINk, and it is possible that they would do joint pieces of work together.

Inspectorates including the Healthcare Commission

  25.  It is our intention to set out in secondary legislation the requirements for LINks to co-operate with the regulators in relations to the LINks' functions of entering and assessing premises. This will ensure that LINks will co-ordinate their work to ensure that this does not conflict with, or duplicate the work of the inspectors.

  26.  We are clear that LINks are not an "inspectorate"—they have the power to enter and view premises, and observe services. This should be undertaken when there is an evidence base of comments they have received to indicate that there is cause for concern with a certain service. This power will also assist LINks in gathering the views of people whilst they are actually receiving services.

  27.  LINks will also have a role in contributing to the annual assessment process of the regulators.

Formal and informal complaints procedures

  28.  LINks will not have a role to deal with advocacy or complaints. This is the role of the Independent Complaints and Advocacy Service (ICAS) and Patients Advice and Liaison Services (PALS), who will continue to successfully deal with formal and informal complaints procedures.

  29.  However, LINks will often wish to use the data collected by these organisations to help them gather and access people's views of services. LINks' powers to request information will assist them in gathering this type of information, for example, in asking an NHS Trust how many complaints it has had on a certain issue.

In what circumstances should wider public consultation (including under Section 11 of the Health and Social Care Act 2001) be carried out and what form should this take?

  30.  Section 11 places a duty on the NHS to involve and consult patients and the public:

    —  not just when a major change is proposed, but in the ongoing planning of services;

    —  not just when considering a proposal but in developing that proposal; and

    —  in decisions that may affect the operation of services.

  31.  "Involving and consulting" has a particular meaning in the context of Section 11. It means discussing with patients and the public their ideas, their experiences, the plans being proposed, why services need to change, what they want from services, how to make the best use of resources and so on. It is more about changing attitudes within the NHS and the way the NHS works than laying down rules for procedures. We will simplify, clarify and strengthen the current legislation on health service consultation.

  32.  We intend to give PCTs a new statutory duty to respond to local people, explaining the activities they are undertaking as a result of what people have said throughout the year. There will be a structured process whereby commissioners will publish regular reports of what they have done differently as a result of what they have heard and say why they might not have taken forward some suggestions. The process will be open and there will be transparent communication to develop trust and confidence and increase accountability to local people.

  33.  A LINk or an OSC may decide to review how local commissioners are communicating with the public and make recommendations for improvement.

Department of Health

5 January 2007

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