Select Committee on Health Written Evidence

107. Evidence submitted by Worcestershire County Council Health Overview and Scrutiny Committee (PPI 115)

Executive Summary

  The following is a submission from the Health Overview and Scrutiny Committee of Worcestershire County Council.

  The key issues that are facing patient and public involvement (PPI) are identified as being the degree of commitment to PPI within all levels of the structure, from Government through to primary care providers and the impact of financial difficulties upon genuine PPI. A number of local experiences of these issues are outlined.

  Finally, the submission offers a number of suggestions for the improvement of patient and public involvement within the NHS.


  1.  Worcestershire County Council's Health Overview and Scrutiny Committee (HOSC) was formed in 2003 and comprises seven County Councillors and six District Councillors, one from each District in the County.

  2.  Since its formation, the HOSC has been involved in the planning of, and been respondent to, a number of consultation exercises conducted by local NHS bodies since the Health and Social Care Act 2001. This has afforded Councillors and Officers the opportunity to experience a variety of different approaches taken by NHS bodies to patient and public involvement in health.

  3.  This experience informs the following submission, which focuses on the Health Committee's questions regarding:

    —  The purpose of PPI—which we have interpreted to mean as including wider public consultation under Section 11 and Section 7 of the Health and Social Care Act 2001.

    —  When and how we feel PPI should be carried out.

    —  Why is it being reformed—to assist in this we have described some of our experiences on how PPI has been working in Worcestershire.

  4.  We conclude with our views on the process and some suggested recommendations for improvement.

Purpose of PPI

  5.  PPI is a necessary process to ensure patient-centred care, and the involvement of Health Overview and Scrutiny Committees helps to reduce the democratic deficit in the NHS. PPI must be seen to have clearly influenced the final decisions regarding service changes and reconfigurations. However, it is essential that such involvement has been an integral part of the development of proposals. Members recognise that it is naive to expect that all decisions taken will be supported by the patient and publics, but it is still important for patients to have a say - how else can the NHS understand patients' experiences?

When and How Should It be Carried Out?

  6.  We do not attempt to set out a blueprint for good practice in PPI. However, there are several points which we feel should be borne in mind when addressing this question.

  7.  Local NHS bodies should be framing all changes and reconfigurations, both expansions and cuts, within an ethos where PPI fundamentally underpins the organisation's decisions.

  8.  If the PPI strategy is to be trusted by the patient and publics it hopes to involve, then it must apply at all levels within the NHS from the Department of Health through to primary care providers.

  9.  There is a difficult balance to tread between how early to involve the patient and publics, and indeed Health OSCs. It is important that those consulted feel they have a genuine ability to influence decisions, but Members recognise that very early consultation could raise fears about the future of services, which may subsequently amount to nothing. It is suggested that this problem will inevitably remain, but that perseverance with PPI and the ongoing education of the public in the PPI strategy and the importance of a strategic perspective will go some way to addressing concerns.

Impact of NHS deficits on consultation

  10.  A significant concern that arose during 2006 was the impact that the need to make financial savings seemed to have on PPI. Our examples in the next section show that although the vast majority of the proposed service changes would have a direct impact on patients and the public, their rationale appeared to be based only on the need to make financial savings rather than having emerged through PPI. Members of the HOSC recognise that it is important for the NHS to address financial deficits. However, there appears to be no leeway for trusts to ensure proper PPI whilst considering how to reduce deficits. The result is a series of consultations where proposed changes are dictated purely by financial needs.

  11.  Although national and local rhetoric is that service changes and reconfigurations aim to improve services, it is noteworthy that more often than not, significant financial savings accrue from most proposals. Whilst there would be concern if proposed changes were not cost-effective, we consider that the effect of an ongoing emphasis on saving money within the NHS will have a negative impact on the public's perceptions of service changes and reconfigurations.

  12.  If the Government is truly committed to PPI, priority should be given to getting the basis for change right rather than simply remaining focused on the financial balance sheet, ie service changes and reconfigurations being led by local need and patient and public input rather than financial crises.

Why is it being Reformed: How has it been Working?

  13.  Worcestershire HOSC welcomes the efforts local NHS trusts have made to keep us informed and involved during what has been a particularly difficult year for them. Generally NHS staff have been willing to attend and provide information when requested. However the process has not been painless; at the risk of painting an unbalanced picture we believe the following examples will be of use to the Committee in its consideration of the PPI process.

  14.  In mid-2006 a series of proposed changes to services was put forward by the then three primary care trusts (a single PCT was formed 1 October 2006). It was made clear that the aim behind the proposals was principally to address financial deficits. A series of 60 service changes were proposed and were brought to the HOSC to discuss whether formal consultation under Section 7 was required. It was clear to us that although the vast majority of the changes would have a direct impact on patients and the public, they were based only on the need to make financial savings rather than having emerged through PPI.

  15.  In the acute setting, the Committee may be aware following some publicity, that changes were being proposed to chaplaincy services in the County's three hospitals. Again, it appeared that the proposals were driven by the need to make financial savings and members were particularly concerned about the absence of PPI in the development of the changes. The Trust's view was that chaplaincy services were not legally a health service and therefore did not require PPI. However this view does not help to reassure us that there is a commitment to PPI running throughout the organisation.

  16.  A further area of concern that has arisen in Worcestershire is the issue of PPI by regional commissioning bodies, such as specialised services agencies and cancer networks. In the case of the latter, three cancer networks cover different parts of Worcestershire. The result of this is that in any PPI, Worcestershire's voice risks being drowned out by the larger populations of the other areas within the network. For example, the three Counties Cancer Network covers both Gloucestershire and Herefordshire in totality, but only the southern part of Worcestershire.

  17.  Finally, we were very concerned that the recent consultations regarding the reconfiguration of strategic health authorities, ambulance services and primary care trusts, although legally not essential, offered no evidence that the proposed changes were strongly influenced by PPI. As we have said above, the credibility of PPI can only be ensured if commitment to PPI is embedded throughout the healthcare system, from the Department of Health down.


  18.  In our experience, although there is good PPI happening in some services, quite often proposed change within the NHS is put before the public at the stage where fundamental decisions on direction have already been taken and PPI is, in effect, only allowed to impact within pre-determined boundaries.

  19.  As we in Worcestershire are well aware, there may be political consequences of decisions taken by the NHS that are not in harmony with local feelings. On these occasions it should be possible to demonstrate PPI and offer an evidence-based case for the final outcome, which, although perhaps not welcomed, would offer justification of decisions taken. The alternative of simply bowing to public pressure for "political" reasons risks devaluing PPI.

  20.  Perhaps our key concern regarding patient and public involvement is whether there is genuine, ideological commitment to the strategy from the Department of Health through to primary care providers.

Recommendations for Action

  21.  In considering patient and public involvement in the NHS in Worcestershire over recent years, a number of areas for improvement/strengthening suggest themselves:

    —  Each NHS body should have a named officer responsible for co-ordinating PPI across the organisation. This post should be supported by representation at Board level to ensure PPI is taken into account at earliest possible stage of all work.

    —  Strategic Health Authorities could undertake a proactive role in ensuring robust PPI has been undertaken prior to formal consultation on service changes and reconfigurations.

    —  NHS bodies should promote specific, local examples where PPI has had a demonstrable impact upon the local NHS body's initial approach.

Worcestershire County Council Health Overview and Scrutiny Committee

10 January 2007

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