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.
Introduction
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.
Conclusion
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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