Select Committee on Health Written Evidence

11. Evidence submitted by Bristol PCT PPI Forum, United Bristol Hospitals NHS Trust PPI Forum and North Bristol NHS Trust PPI Forum (PPI 63)


  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.


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.


  —  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


Bristol PCT PPI Forum

Penny Robinson


United Bristol Hospitals NHS Trust PPI Forum

Chris Windows


North Bristol NHS Trust PPI Forum

9 January 2007

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