Select Committee on Health Written Evidence

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.


  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.

previous page contents next page

House of Commons home page Parliament home page House of Lords home page search page enquiries index

© Parliamentary copyright 2007
Prepared 6 February 2007