120. Evidence submitted by Barry Fineberg
(PPI 15)
1. What is the
purpose of patient and public involvement?
1.1 The Health and Social Care Act 2001
required all local bodies responsible for health services to be
subject to local consultation, directly or through representatives,
notably in their planning, but also in their development and operation.
A subsequent White Paper (2006) "Our Health,
Our Care, Our Say" brought social care into focus with health,
both part of a more comprehensive system closer to peoples' homes.
This later requirement throws into relief a greater reliance on
public consultation in order better to define and to incorporate
the detail and the diversity of local needs.
2. What form of patient and public involvement
is desirable, practical, and value for money?
2.1 The Department of Healths' call for
the reconfiguration of primary care looks to more local community
services as a counterweight to existing hospitals in complementary
functional patterns. The smaller organisational scale is implicit
in its formative language referring to supports "closer to
home", "putting the patient at the centre", or
a "patient lead NHS"—the human scale.
2.2 The vision is splendid. The challenge,
however, has a self-defeating complexity that needs greatly more
manageable local frameworks and processes. The Department of Health
makes clear the desirability of its vision. Its practicability
however requires a much smaller focus, a more intimate public
arena than is realisable through current government forms. The
necessity both to define and to enable local frames of reference
at appropriate levels of need below that of existing authorities
must be manifest if the confidence and the engagement of local
communities in consultative dialogue is to be comfortably established.
There are also implicit economies both of effort and of expenditure
in local enterprise and organisation given, as far as possible,
appropriate self-managing discretion.
3. Why are existing systems for patient and
public involvement being reformed after only three years?
3.1 The energy and dedication of Forum members
in the exercise of their monitoring duties is exemplary. It is
clear to me however, as a Forum member, that successful outcomes
have been elusive, exhausting, and greatly incommensurate with
time and effort.
3.2 There is a sense that whilst the health
management system within which the Forum has been embedded is
commendably organised in its sundry parts, it is deficient in
the connections between many of those parts beyond their own separate
influence and control. Efforts to navigate such intricacy through
supplementary liaison functions only compound that very complexity.
3.3 Government effort for reconfiguration
must therefore be a step in the right direction, providing that
simpler mechanisms are now put in place to enable gradual, evolutionary
change in timely and cost-effective ways. Such directives will
encounter these functional resistances within current systems
which must be addressed. More bite-sized units of organisation
and management will instead greatly enhance the efficacy of new
patterns of initiative and service at grass-root levels.
3.4 The scope, range and effectiveness of
public effort in PPIH Forums has been limited by the foregoing
complexities. Participation as a consequence has been mainly reactive,
to forces and factors of which there is often little foreknowledge
or understanding. Efforts of Forum members to grapple with this
challenge have been noble and worthy but, in my observation, barely
sustainable. Though wider networking might attract greater numbers
of Forum members to share this burden of responsibility, the difficulties
will in my view remain intractable. The way forward must be to
adopt a more proactive stance, through closer public command of
the processes of planning and commissioning, as the Department
urges.
4. How should Local Involvement Networks
(LINks) be designed?
4.1 The proposed organising principle and
framework that follows gives structure, form, energy and direction
to social forces. It has a scope for graduated, measurable and
systematic processes of change, bringing wider economic and political
forces into balance with social need. It is this local balance
which government seeks to engineer and to engage, the enablement
of local markets in health and welfare and their accountability
to local communities. The aspiration for enhanced local democracy
must be very important and carries with it a marker for change,
bringing interdependent remaining services more coherently together
with each other and with their political controls.
4.2 Many citizens would identify with smaller
communities more readily than with the boroughs and cities in
which communities are embedded. The strategic and political purposes
of the wider whole can however be better realised by acknowledging
the city as the sum total of its boroughs, and the boroughs as
the sum total of its local and diverse communities. The planning
and delivery of public services through township networks would
be found to be more responsive and more focused than to widely
dispersed undifferentiated populations.
4.3 Sets of local community may be mapped
at corresponding levels of need from street and neighbourhood
upwards through town centres to clustered groups at higher service
and regional levels. Social mapping and its ensuing service hierarchy
together frame a more ordered urban structure which must be the
spur for civil engagement and its mobilisation through an enhanced
sense of local attachment and mutual responsibility.
4.4 Town centre networks offer the most
critical level of intervention in the hierarchies of space that
make up the city. The model is organic and holistic in its scope,
corresponding with natural principles of distribution and organisation
in which neighbourhoods are the cellular parts of an organic whole,
the township. Its nucleus, the town centre or High Street is a
fixed point in a sea of infinite statistical variables, with optimal
purchase in any local urban calculation, social, political or
economic. Its catchment population is its community, an identifiable
and measurable entity. Given public voice, the emergent community
would be enabled once more to seek leverage in the local arena
which is the natural market of its central place. Neighbourhoods
as a modus operandi fit within such embracing frames of reference,
giving them focus, direction and purpose.
4.5 This formative critique corresponds
with market principles, describing a social market system. It
carries a scope for market forces to be called to social account
at ascending levels in the spatial hierarchy. Its theoretical
justification lies in the empirical development of Central Place
Theory, a founding geographic principle.
4.6 Town Centre Forums would be in a position
to better encourage and support local service providers in formal
or informal partnership with public, private, voluntary and informal
sectors, perhaps in the form of a local trust. Local townships
and their High Streets remain historically the natural arena for
local citizens. This contrasts with ailing High Streets, hollowed
of former functions and purposes, continuing to command from their
innate focal position continuing spheres of attraction and identity.
The pending death of the High Street with its detriment for local
trade and social enterprise is seen with regret and resignation
in the face of its seeming irreversibility.
4.7 The Department of Health's directive
for Practice Based Commissioning could be a lever for change.
Ensuing patterns of natural community will enable a systematic
service reconfiguration at all levels of need. Primary clusters
for health, welfare, social and other supports may then be focused
jointly with local GPs, pharmacists, dentists and opticians around
their High Streets. This common organisational format offers a
whole, the sum of which is greater than its parts. There is scope
here for fine-tuning to bring normally disparate local provision
into a convergent whole, breathing new life into local community.
4.8 This impulse for local engagement may
however be no more than a passing phase, a merely transient set
of aspirations, unless Government statements of intention to power
such ambition with local budgets is made tangible and real, giving
local people influence, leverage, and ultimately greater control.
For forty years, government intervention in deprived city areas
has mostly failed through poor targeting and lack of congruence
between agencies but, most critically, because of their limited
nature and inevitable transience. There is a scope in pending
reconfiguration to reinsert the local dimension, to endorse its
former significance more comprehensively in all mainstream programmes,
so that locally targeted expenditures may then have more focussed
and lasting impact. This potential will, I am confident, attract
once again a public engagement in political life. Perhaps three
quarters of health and welfare expenditure is intended for local
communities. Local budgets will however engage local publics greatly
more than customary participatory and consultative processes if
they promise "real money", in place of what many have
felt were but token exercises.
4.9 In acknowledging the natural clustering
of GPs and allied health and welfare services around all our town
centres, there is real leverage for radical change in the adoption
of that reality as the natural focus and the natural model, a
catalyst for a revived local economy. Current imperatives for
change are a window of opportunity which, in the added context
of the pending Local Government White Paper must be seized.
4.10 There is here a scope and a context
making it possible to better engage all aspects of local governance
and management through a more coherent and common organisational
format and process, and through mutual compatibility. Recent announcements
on numbers, costs and programming of new community hospitals,
clinics and complementary support facilities do not appear to
indicate what consultative process, if any, has informed these
choices. To what extent does a demonstrable local need shape these
decisions? Do they reflect prior understandings with local health
authorities, or do they accord instead with a one size fits all
formula which cannot be locally scrutinised? There is a concern
that terms of reference and criteria which might inform such decisions
should have the greatest regard for the contextual framework of
these provisions, closely reflecting different levels of need
and natural geographic catchments.
4.11 There might be no generally agreed
set of organisational principles to better enable this process.
In the interests of better governance, efficiency, equity and
coherence however, action-research might therefore be urgently
needed into the factors and methods by which such rationales may
be established in the field.
4.12 The foregoing describes social and
spatial criteria for the design of local networks reflecting the
professional background of the author. Its spatial critique, its
clusters and hierarchies, is rooted in organic concepts of ordered
distributions and controls, and its perception of natural community
through catchment populations. The Committee's terms of reference
however look also to factors such as remit, membership, appointment,
funding, powers, and relations with Primary Care Trusts. The proffered
network design principle is offered however as a sine qua non
for organisational coherence and a precondition for manageable
change of such magnitude and complexity. It is not in itself a
policy, but rather a framework for policy.
4.13 Existing forums have sought to be absorbed
within new networks in order to retain their experience and skills,
for which a necessary evolutionary transformation should be possible.
Forum membership and capacity can be greatly expanded through
possibly informal sets of elected complementary forums at township
levels and above; underpinning and consolidating the role of councillors
and representatives with health, local and other authorities in
policy formulation and programming.
4.14 Economies of smaller scale must flow
from such reductions in complexity, enabling more responsive and
mutually coordinated local services. Given appropriate advice,
guidelines and seed funding, a newly reinforced public interest
can be encouraged and harnessed through self- defining and self-managing
processes. Transitional arrangements might be speedily effective
through enabling and encouraging the initial formation of networks
by voluntary action in the interim. Subsequent legislative endorsement
may then be shaped by the evidence and example of working sets
of local forums put in place informally "in the field".
4.15 Citizen mobilisation of such magnitude
and ambition may only be realised however on the promise by Government
to allocate specific funding packages to local communities, albeit
held on trust initially at higher levels. Management of existing
authorities may perhaps be modified correspondingly through matching
small-area information systems. Such fine tuning will rest in
turn on social audits derived from census and other information,
annually updated, on a per-capita basis for local budgets, and
as a more tangible subject for local interest, scrutiny and deliberation—the
essential catalyst for public engagement.
4.16 This outline genesis must however rest
on a greater degree of mutual trust enabled and encouraged through
flexible, informal and discretionary mechanisms, free of the more
prescriptive regulation that encumbers the better performance
of existing local authorities. A reducing complexity may also
be gained by those authorities through disaggregating existing
data and information for local populations. The total of their
more detailed needs may then be brought more clearly into balance
with higher level services and functions, a budgeting framework.
4.17 Local arenas will bring together social
and welfare agencies whose cross disciplinary coordination is
often difficult, and sometimes tragically elusive, having to cross
multiple boundaries of concern and responsibility. These agencies
would be enabled more closely to consult, to share and compare
information, and to act in more timely ways successfully together
through more locally common focus and boundaries.
4.18 This scenario is neither definitive
nor exhaustive. It gives only a token indication and a flavour
of more mutually trusting and engaging cultures of local politics
and local service which should be possible, and more greatly effective.
It seeks to develop the detail set down in the Double Devolution
and Neighbourhoods Agenda of David Milliband, former Minister
in the ODPM, presented to the expert panel meeting on 6 April
2006 by Mark Rickard of the former ODPM and now of the Department
of Community and Local Government. That panel, in its recommendations
to the Department of Health for the creation of local networks
has prompted this evidence for their configuration and establishment.
Conclusion
The foregoing seeks to address many of the questions
in the Committee's terms of reference from a particular point
of view, that of the redesign of existing structures in Health
and Social Service management systems and their political and
administrative frameworks. There is however an underlying imperative
here for reducing the size and scale of administrative units to
enhance their transparency, manageability and accountability.
Among considerations which must flow from this
premise will be objections to yet further layers of government
on the grounds of inevitably greater cost. Cogent argument is
however to be made and there is evidence in favour of significant
economies of smaller scale in the more ordered provision of public
and personal services through reductions of perhaps 90% or more
in their organisational complexity.
It is also my further observation that reductions
in organisational complexity through smaller scale are likely
to make possible material improvements in the control of cross-infection
and of epidemics. More widely dispersed patterns of lesser community
health provision will help curtail excessive movement now generated
within and between greater hospital or clinical concentrations,
both pedestrian and vehicular.
These and other matters beyond the reach of
this initial submission will require further consideration and
should also be seen in the context of health and welfare matters
to be incorporated in the pending White Paper on Local Government
reform. I trust the Committee finds much that is useful here and
much food for thought. I hope it will wish to follow up this reasoning,
with its implications, and shall be happy to answer its queries
at open session if the Committee so wishes.
Barry Fineberg
15 January 2007
The author is a member of Barnet Primary Care Trust
PPIH Forum. Members of the forum view the foregoing issues to
be largely outside their remit and have given no opinion other
than to draw the attention of the PCT to them.
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