11. Evidence submitted by Bristol PCT
PPI Forum, United Bristol Hospitals NHS Trust PPI Forum and North
Bristol NHS Trust PPI Forum (PPI 63)
1. INTRODUCTION
TO THE
SUBMITTERS
The Submitters are the elected Chairs of statutory
Public and Patient Involvement Forums for NHS Trusts and Primary
Care Trusts in the Bristol area. In this area (formerly covered
by the old Avon Health Authority and Avon County Council), separate
health economies centred on the Unitary Authorities created in
1996 are still closely interconnected by geography, history and
health services configurations which have evolved over many decades.
This interconnection and the mutual dependencies are currently
recognised by the involvement of local NHS bodies, and their corresponding
PPI Forums, in the Bristol Health Services Plan—a
sweeping plan to rationalise and modernise NHS services for the
population of the whole area.
2. COMMENTS ON
THE THEMES
OF THE
SELECT COMMITTEE'S
TERMS OF
REFERENCE
What is the purpose of patient and public involvement?
We believe that this is to ensure that the views
and experience of patients and the public are taken into account
alongside those of NHS professionals when important decisions
about NHS services are being made.
3. What form of patient and public involvement
is desirable, practical, and offers good value for money?
3.1 It is critical that PPI should operate
not just on a passive consultational level, but that it should
be at the heart of policy formulation and decision making. Too
often, it has taken the form of seeking opinions on a small number
of pre-established options for change. Representatives of the
public should have real influence in the whole process, from the
recognition and formulation of the need for change through to
the practical decisions for implementation and monitoring. Finding
the logistics and structural arrangements to allow this are the
greatest challenge faced, and the governance arrangements and
the membership structure of LINks are problems that we do not
feel have been given any productive thought in the documentation
we have so far seen. When these central issues were raised with
representatives of the DoH at a recent conference for stakeholders
in the future LINks, it was openly admitted by them that no clear
solutions were in sight.
3.2 It also seems very clear that the current
arrangements for PPI through Forums have been grossly under-funded,
and thus under-resourced. This seems to be a universal perception
amongst all involved in PPI Forums. Much of the criticism levelled
at CPPIH flows from its inability to direct adequate resources
to support Forums, and one small example of this has been the
blanket ban on paid advertisements in the local press to publicise
Forum meetings, and facilitate public presence and input to Members'
consideration of local health issues. The criticism from government
that Forums have not been good at involving local people seems
highly disingenuous given this basic government-imposed handicap.
We fear, listening to the well-sourced rumours that funding will
not be increased, and considering the refusal to ring-fence funding
going to Local Authorities for LINks, that the severe under-resourcing
of PPI structures will continue when LINks take over these responsibilities.
4. Why are existing systems for patient and
public involvement being reformed after only three years?
4.1 Why indeed? It was apparently not the
legislation, but the political will and commitment that was lacking.
Barely six months after PPI Forums were created, the Government
announced the abolition (less than 18 months after its own creation)
of their parent body the Commission for Public and Patient Involvement
in Health. Despite the uncertainty since then over the exact future
shape of Forums, until comparatively recently, the messages coming
from government insisted that Forums remained the future vehicle
for PPI. The proposals for LINks did not appear until July 2006,
and there had been no prior indication of the drastic changes
now being implemented. It is true that NHS policy initiatives
such as Foundation Trusts, Payment by Results and Patient
Choice are changing the stakeholder landscape, but none of these
has appeared without warning in the last year. Any arguments that
"PPI Forums are just not working" must have been apparent
to policy-makers at the very time they were giving assurances
that the future for PPI lay with Forums. There is a strong impression
that PPI has been used as a "political football" since
January 2003. The response given by CPPIH to the consultation
on A Stronger Local Voice tells the story of funding promises
broken and deadlines advanced to an impossible extent during its
struggle to get the PPI Forums established and working effectively.
Once again, Members of Forums smart with injustice under DoH criticisms
that the new arrangements have not lived up to expectations: how
could they, when those expectations were not matched by the essential
political and resource commitments?
4.2 We feel strongly that PPI Forums have
not been allowed to develop to their full potential. Even so,
one of our largest local acute Trusts so values its Forum's work
that it has asked it to continue this work when its statutory
existence is ended, with equivalent powers granted by the Trust
to replace those lost when the legislation is changed. This Trust
has developed an excellent working relationship with the Forum,
and the Board routinely considers reports by the Forum on its
services and formulates action plans to implement appropriate
measures in response to their findings.
4.3 Another example of the success of local
PPI Forums is the excellent working relationship that they have
developed with the Local Authority Overview and Scrutiny Committees
covering the Bristol area. Forums have co-opted membership or
other representation arrangements at all these OSCs, and they
have been described by one as the OSC's "eyes and ears".
A number of joint training and working sessions have been held,
and a joint data-base of workplans has been set up to coordinate
activity. Forums regularly present their service review reports
to the OSCs, and these are always well received, with officers
of the relevant NHS organisations being called by the OSC to address
concerns raised in the reports. In addition, officers of the Forums,
of OSCs and of local NHS organisations meet regularly to discuss
work and developments.
4.4 We have heard the Department's argument
that PPI through Forums is not working, but these examples (and
there will be many others across the country) proves that the
present system can and will work. The establishment and "testing"
of these local relationships has taken time, and it is ironic
that their statutory basis is being removed just when their value
is becoming clear.
5. How should Local Involvement Networks
be designed?
5.1 Our feeling is that the development
of thinking on LINks is being driven by conceptual ideals, with
insufficient attention to the practicalities of how they will
work. Given the stage of development of the move towards LINks,
and the commitment given to legislation in the Local Government
and Public Involvement in Health Bill, we find this lack of
practical detail very worrying.
5.2 We know from experience that Forums'
success depends on effective organisation and administrative support.
Although we know little in detail about LINks at present, we have
been told that they will have very large numbers of participants—estimates
have swung between "hundreds" and "thousands"
per LINk. Communication and coordination alone will be huge undertakings,
and the wider administrative needs will make support of these
bodies a massive task. The Government response to consultation
suggests the governance model of a "Stewardship Board",
and the suggested responsibilities of such a Board (page 20 of
the Response) include the accountability for and management of
a budget, work planning, membership and governance issues, direction
of Host staff, commissioning of external work, performance management,
coordination with a wider membership—all this on top of
the work of involvement that will be the LINks true task.
5.3 A major gap in the detail we have seen
so far, is the manner in which LINks will be held accountable
and by whom. This question has been raised by delegates at a recent
DoH conference on LINks, where it was met with a shrug of official
shoulders, and a request for any suggestions from the delegates.
Eventually, the answer was proposed that LINks will be accountable
to the populations of the PCT areas that they represent. No explanation
could be given of any mechanism by which this might work, and
the DoH representatives seemed completely wrong-footed by this
very obvious and central question. We feel that this is a major
area of concern.
5.4 The Select Committee's Terms of Reference
pose a number of specific questions on the nature of LINks, and
we will address some of these:
(i) Remit and level of independence—we
would see the level of independence currently achieved through
an arms-length-body as being the minimum level of independence
needed from both government Departments and from local government.
(ii) Membership and appointments—we
welcome the fact that LINks would be able to determine their own
membership.
(iii) Funding and support—we
have already touched on this, and would stress that the resources
provided to local authorities for the resourcing of LINks should
be ring-fenced to that purpose, and should be adequate for the
wide range of activity envisaged and for the essential publicity
and communication of LINks with their "constituencies".
(iv) Area of Focus—We welcome
the ability that LINks will have to operate on both sides of the
boundary between health and social services, and recognise the
strength of the government's arguments for this.
(v) Statutory powers—we think
it is essential that LINks should inherit the powers to require
information and to visit NHS premises currently exercised by PPI
Forums.
(vi) National Coordination—It
is important that there should be some mechanism for communication
between LINks, and we think that the issue of "ownership"
of any such arrangements might become important. There will always
be the fear locally that any such national arrangement might become
a mechanism for "managing" LINks, and be subject to
influence from government departments.
(vii) Relationships and overlaps—We
wish to stress the importance of a public voice for PPI that is
independent of the political agendas of the NHS and local government.
On their visits, PPI Forum members have been struck by the comments
of patients that they value a non-intimidating ear for their comments.
Frequently, members have had the experience during their inspection
visits of being approached by patients a second time after NHS
staff have left, and hearing a different story to that originally
told in front of those staff. We do not blame the staff for this:
it is human nature that no one wishes to wish to offend those
who are caring for them. It does, however, illustrate how important
perceived independence is in gaining the views of patients and
the public. The Healthcare Commission has also recognised the
importance of PPI Forums' contributions to its NHS bodies self-assessment
process, and would no doubt find the participation of LINks equally
valuable. Far from worrying about any overlap, the Commission
has said that the Forums' comments as part of the self assessment
process has had a major impact on the process for validation of
the self assessments of some NHS bodies.
6. RECOMMENDATIONS
FOR ACTION
TO THE
GOVERNMENT
— Maintain Forums' independence and
statutory powers.
— Provide realistically adequate funding,
ring-fence the funds, and ensure that there is provision within
this funding for proper publicity and communication with the public.
— Clearly define the structures, responsibilities,
and governance arrangements of the new PPI organisations. Do not
pass the buck by expecting each LINks to devise its own.
— Don't rush it. If this system is
less successful than the last, you will lose the good will of
volunteers, and LINks will collapse.
Bob Maggs
Chair
Bristol PCT PPI Forum
Penny Robinson
Chair
United Bristol Hospitals NHS Trust PPI Forum
Chris Windows
Chair
North Bristol NHS Trust PPI Forum
9 January 2007
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