123. Evidence submitted by Gerald Gilbert
(PPI 138)
SUMMARY
1. This submission to the Health Select
Committee is based on many years' working voluntarily on healthcare
issues. Two outstanding experiences during this time are being
asked by hospital staff to draw management attention to a significant
issue that they themselves could not, as they were either not
receptive to, or available for, a frank discussion; and raising
issues unprompted at meetings that staff felt unable to raise
themselves, but were greeted with nods or wry smiles around the
table. From this wide and varied background, a number of observations
and comments can be made. These have been used in developing answers
to the specific questions that the Select Committee has raised.
2. A basic problem appears to have been
a failure, either to comprehend the complexity of PPIH, or to
address it effectively. This seems to have been recognised rather
belatedly, with talk of several hundred people becoming involved
in a large LINks area. The first need for tackling complexity
is for a single and clear objective to be understood, agreed,
and committed to by all parties. Even then the message has to
be kept as a continually reminder to all. A number of options
for action may be considered and evaluated, and the most advantageous
adopted. However careful this preparatory work has been carried
out, some problems will inevitably arise. When this happens, it
is essential to analyse the reasons and to correct them if possible.
If correction is not possible, then one has to stop digging a
bigger hole. This entails going back and reviewing the case for
the next best option. It is not sensible to rush out and buy the
latest model (which may be even worse than the current one). Good
planning is also required. From a broad overview, it is necessary
to drill down into detail, and then re-surface to check against
the initial assumptions. It must not be assumed that the details
can be made to fit without checking. Overall, the person in charge
has to exhibit and encourage a determination to succeed, with
difficulties and risks being also assessed as opportunities. This
level of detail is the key to PPI. Local Implementation Teams
(LITs), already in situ in most areas and covering many aspects
of healthcare, are the venue of analysing problems and finding
solutions. But they do need the right germination conditions and
input from patients, carers or their support groups.
3. Arising from the above failing, many
other mistakes have been made. The role of the Forums was promoted
as go-it-alone, without recognition of important contribution
to be made by so many other individuals and local organisations,
with the need for facilitation, coordination and encouragement.
Members were selected on a different basis, and the key role (and
time and effort required) of the Chairman not defined or recognised.
The responsibility of Forums has been only seen from the top down,
which should only apply direct to the Department of Health for
financial accountability and good governance, not to any other
body or Commission; whereas Forums should be principally accountable
to patients and public. The task requires local professional staff,
selected by the NHS Appointments Board, for the top-down responsibility,
with experienced support staff also based locally (an aspect that
the Select Committee expects and acknowledges from its own staff).
With Forums in such disarray it should not have been surprising
that many Trusts have largely overlooked the potential benefits
that they should have derived from well-informed constructive
dialogue with them.
4. Although the Select Committee has not
asked directly for comments on the Local Government Bill, its
imminent passage through the House of Commons does make this most
relevant. It is quite bizarre that a healthcare matter, affecting
the NHS even more than Social Services, should be included towards
the end of a large Bill on local government. The only valid reason
for this is the need to regularise the position of the PPI Commission,
that the Government announced was to be abolished, back in 2004.
There may be another agenda, but it should not be on grounds such
as economy of scale, or forcing forward the move to play down
the burden and responsibility for healthcare from the NHS as the
major player, onto the Social Services and the voluntary sector.
How LINks might work in practice has yet to be seen. From discussions,
it has become apparent that the "early adaptors" and
pilot LINk groups are going to have to feel their way, without
much in the way of guidance from CPPIH or any other body. It would
be premature, fool-hardy and bad management practice to introduce
legislation to remove Forums until their successors have been
seen to work. I have attempted another definition of "health
economy area". There are signs that the larger PCTs are already
setting up sub-structures with similar boundaries. (So much for
the economy of scale).
5. The problems and challenges would have
been a major obstacle in any event, but the situation has aggravated
by two other significant factors; financial pressures and the
pace of change. The task would have been demanding even in a relatively
stable environment. Many concerns of patients and carers would
have existed, since most problems arise at the interfaces between
two systems. Healthcare examples include discharge from hospital,
need assessment and care packages, which overlap the boundary
between the NHS and Social Services, as already considered by
the LITs. Continual change has meant that attention was directed
almost exclusively towards consultations and the consequences
of re-configurations rather than ongoing problem areas.
CREDENTIALS
6. I have been actively involved in healthcare
matters for the past twenty years or so, from working with the
then Member of Parliament to get a local community hospital rebuilt,
then leading a public campaign to discourage the Authority from
closing one of its two wards shortly afterwards, and organising
major fund-raising events over many years during which time these
raised some £100,000. I served as a Regional Officer of the
National Association of Hospital Friends, and was invited to join
a Community Health Committee. I was a member of a PPI Forum for
a time, and am a member of the Community Hospitals Association.
I am not a member of any political party, and this submission
is made solely on a personal basis.
BACKGROUND TO
SUBMISSION
7. With my personal interest and experience,
I have been able attend and participated in numerous local, regional
and national conferences and other meetings on this subject. Examples
include the London National Launch of the Commission for PPIH,
a meeting of Forum members convened by the Surrey & Sussex
strategic Health Authority, and the Opinion Leader Research conferences
on the options arising from the Government decision to dismantle
CPPIH. For these I have often submitted a contribution for discussion,
and afterwards prepared notes and circulated them amongst a network
of other enthusiasts and contacts.
8. Recently I have summarised much of my
thinking into three documents: The NHS Challenge—The Case
for a Fresh Approach, Making the Mission Possible, and LINks and
the Department of Health. These have been used as the basis for
answering in Section 4 the questions posed by the Select Committee.
Only the last of these three documents has been included with
my submission as a reference document. It is little changed from
the original dated 27 January 2005, which was sent shortly afterwards
to Mr Meredith Vivian, Head of PPI at the DoH. His reply dated
February 16 was rather interesting. "Thanks for your comments
and attachments. I do find your comments most helpful and thought-provoking.
Re the transition board. What we have in place is a programme
board comprising those organisations which have specific responsibilities
around the delivery of PPI arrangements. It is a board to oversee
the strategic direction of how we implement the ALB Review—it
is not there to provide insight into the operational aspects or
to oversee the transition from A to B. We do have plans to ensure
that on all the work streams to deliver the ALB Review we have
forum member input and I am sure you will hear more about these
in due course. Re the timescale issue. Without primary legislation
there is very little we can do to speed matters up. The CPPIH
remains in place to deliver its statutory functions and until
another body has those functions they cannot be handed over. What
we can do in the meantime is make sure that we develop as effective
a set of new arrangements as is possible—also making sure
there is enough time to put them in place prior to CPPIH abolition.
I know this will mean that in the short term we may have to make
the best of less than ideal arrangements but I am sure we are
wise to take our time and get the best long-term system in place.
Thanks again for your comments, kind regards, Meredith Vivian,
Head, Patient and Public Involvement".
This provides an interesting backdrop to the
lack of progress in the past two years.
9. In addition to the document referred
to above, I have attached "Post-Forum Teams and the Chairman
Role". This was prepared in response to a request for suggestions
on how to appoint a chairman for a PCT Forum, recently enlarged
to match the PCT mergers. This outlines one way of involving many
more people in the PPI experience, as the DoH itself is now suggesting.
The LIT approach has been used when setting up teams to discuss
and then make plans and recommendations for each of the Government
standards of the National Service Framework for Older People.
A similar approach would be helpful in addressing the National
Programme Budget Project, which considers the treatment of 21
major diseases as the realistic targets to be met.
10. I know that the Surrey 50+ Group (formerly
Better Government for Older People) has some 450 members who would
like to play some part; and the former West Surrey Health Authority
had a database of 600 local organisations (mainly voluntary) with
a similar interest. This illustrates both the complexity of the
challenge, and the source of willing helpers.
11. I am also aware of the DoH's July 2006
publication Health Reform in England—PP Engagement in Commissioning,
and the Conservative Party's proposal Health Watch. Both use a
new expression "engagement". I refer to verbal transformation
later, but for the present will use the Government proposed expression
LINks, which also appears in the Select Committee's terms of reference,
although this is not yet on the statute book.
12. The Committee's terms of reference also
refer to the NHS only. I accept the Government's latest view that
the subject is wider than that, covering as it does healthcare
provided by the Social Services, another clear responsibility
of the DoH. The LINks proposal actually goes much further. It
considers the "locality" as the geographical area covered
by a local authority with social service responsibilities. This
may be one way of resolving the "co-terminosity" dilemma,
but also illustrates how a concept such as Bringing the NHS closer
to Home develops, first into Care in the Community, and then an
attrition of the role of acute and community hospitals, by removing
PPIH from the NHS agenda, and placing the burden and responsibility
for healthcare on the Social Services and the voluntary sector.
My objection to such gradual easing in new meanings does not imply
any opposition to progress, such as the concept of super A &
E departments, but I do consider that changes made for scarcely-concealed
financial reasons may not by in the public interest, which is
at the heart of PPI.
13. The Select Committee's report on
NHS Finances included numerous references in the evidence to "local
area", but I can find no definition of the expression. I
believe that an essential component in the overall healthcare
system still is secondary hospital care, in what used to be referred
to as district or general hospitals (and intermediate care provided
by PCTs in community hospitals). From this, I would define a local
health economy as being centred on a NHS Hospital Trust, with
one or more hospitals, or a Foundation Trust hospital, serving
the same purpose; funded by one or more PCTs; working in conjunction
with Social Services covering the same geographical area; and
supported by some part of a Mental Health Partnership and Ambulance
Service Trust. This has proved to be a practical and manageable
concept in the past, and I see no reason for changing it on the
grounds such as economy of scale. It has been used in considered
detailed responses to the Select Committee's questions, in Section
4.
RESPONSE TO
THE COMMITTEE'S
QUESTIONS
Purpose of PPI
14. The single underlying concept of PPI
is that Healthcare clients; patients, carers and voluntary healthcare
organisations representing them; must have their views taken into
account at all times. It calls for a sound working relationship
between the "system" and clients, with the emphasis
on outcomes rather than processes.
The desirable outcomes are:
(a) Meeting the needs (not wants) of clients.
(b) Providing a service with value-for-money.
(c) Making more effective the care pathways
already in place, as well as gradually introducing innovations.
(d) Ensuring that disturbances do not cause
self-destruction, but are continually reduced and smoothed out.
15. These outcomes are an embodiment of
democracy, and also, arising from the Bristol Infirmary investigation
and the Kennedy report, were an essential part (Section 11) of
the 2001 Health and Social Care Act, which itself related to the
Overview and Scrutiny duties required by Section 38 of the 2000
Local Government Act.
What form of PPI is desirable, practical and offers
good value for money?
16. A number of words and expressions have
been used to define PPI; involvement, consultation, and engagement,
significant (coupled with "changes"). The fundamental
requirement is for the client representative(s) to have a seat
at the LIT (Local Implementation Team) table as an active and
constructive participant with the opportunity to contribute, whenever
problems encountered with existing procedures need to be resolved,
and when new plans and procedures are being considered.
Why are existing systems being reformed after
only three years?
17(a) The reason is that clearly they are
not working well. The Government recognised this early on, with
the decision to abolish the Commission for PPIH. To discus how
this situation came about, it is necessary to look deeper. It
is suggested that the complexity of the task was not appreciated,
that planning was superficial, and the corrective action adopted
was wrong.
(b) When dealing with complexity, it is
essential for a careful path to be trod. The first need is for
a clear objective to be understood, agreed, and committed to by
all parties, who must sign up for it. Even then the message has
to be kept as a continually reminder. This means keeping an eye
on the ball, and avoiding distractions (such as blind alleys,
red herrings, and other agendas creeping in).
(c) Good planning is also required. From
a broad overview, it is necessary to drill down into detail, and
then re-surface to check against the initial assumptions. It must
not be assume that the details can be made to fit without checking.
(d) A number of options for action may be
considered and evaluated, and the most advantageous adopted. However
carefully this preparatory work has been carried out, some problems
will inevitably arise. When this happens, it is essential to analyse
the reasons and correct them if possible. If correction is not
possible, then one has to stop digging a bigger hole. This entails
going back to the drawing board, and reviewing the case for the
next best option. It is not a good idea to rush out and buy the
latest model, which may be even worse than the current one.
(e) How the above might have been applied
to PPIH? It is clear that the purpose and objective was not clearly
defined and understood, and that attention was concentrated on
organisation not desired outcomes, and on changes in facilities
and systems. It is not surprising that a number of serious obstacles
were encountered. Obstacles can be seen in a certain amount of
open or hidden resistance by some NHS managers and clinicians
in response to a perceived challenge to their authority (and probably
within the DoH itself). Of the two, hidden resistance is the more
difficult to counter, often dressed up with spin. Over recent
years, the pressures on managers have been great, with new targets,
organisation changes, advancing technology and clinical protocols,
workload and time. A major problem for many has been Finance.
Finance in the NHS has been discussed elsewhere, and at length.
It should have been approached on a better basis (as the Select
Committee itself has recognised), kept in proportion, and never
have been allowed to take centre-stage during PPI discussions.
(f) The Commission itself produced detailed
but not very helpful procedures. It did not attempt to define
the Forum members' role. Suitability of new members was assessed
from criminal records and looking at an individual's areas of
interest and concern, instead of their ability to contribute and
work in a team to a common agenda. The emphasis has been on doing
the work themselves, rather than as proactive facilitators.
(g) With Forums themselves, in such disarray,
it is no wonder that many Trusts (and Overview & Scrutiny
Committees) have found little time to take them seriously.
How should LINks be designed in relation to
Remit and level of independence
18. The remit of a LINk should be to fulfil
the single purpose of PPI, ensuring that healthcare professionals
have the benefit of a wide-ranging input from both patients and
the public into discussions on problems encountered, and solutions
to be considered. LINks should be enabled to carry out this role
without direction or guidance from any Government department or
Commission. They should be accountable only to the Department
of Health for good governance and financial control, through a
national and regional management structure and (non-executive)
professional staff, the latter appointed by the NHS Appointments
Board.
Membership and appointments
19. LINks members should be appointed by
local voluntary healthcare support organisations, solely on the
criteria of their ability and willingness to work as a team towards
a common objective, calling for an appreciation of the need to
involve, encourage, and co-ordinate, the activities of the many
other individuals on numerous working teams (LITs) within their
locality; and to facilitate this work, by dialogue with healthcare
providers and commissioners. A LINks team should consist of a
small number of members, say 20 maximum for the largest, with
an Executive Committee, a Chairman and Vice-Chairman, selected
by the members from amongst themselves.
Funding and support
20. Funding should be received from the
DoH, as indicated under 18 above. Professional and experienced
administrative support is required at a local level, with administrative
staff being recruited and managed by the professionals appointed
as 18, with appointments being subject to review by the members.
Area of focus
21. The geographical area should correspond
to the local health economy area, rather than be set by any other
boundaries. The role of LINks and its members is very large, and
concentration on key aspects is essential. Important local issues
such as public health, healthy living and preventative measures
must not be allowed to divert attention from the provision of
healthcare. Other valid concerns are fringe matters that are adequately
covered by other existing arrangements and management procedures.
These include complaints procedures, and routine inspection rights.
Statutory powers
22. LINks require little in the way of statutory
powers. Relations with local health Trusts is discussed below,
and right of appeal on disputes should only be available to Overview
and Scrutiny Committees and the LINk Regional and National executive
bodies.
Relations with local health Trusts
23. The LINks Chairman or his nominated
delegate should have open-door access rights to all Trust non-executive
board members and to the Chief Executive. This applies to Primary
Care Trusts, NHS Trusts and NHS Foundation Trusts, but not to
any independent providers. He should also have a speaking (non-voting)
seat at all public meetings of the Trust. LINks should hold (say)
quarterly meetings in public, to give an account of its own work
and plans, and at which all Trusts should be required to send
an authorised representative to provide give any necessary explanation
of written answers to previously notified questions, and to give
a brief report on matters judged to be of interest to LINks and
the public.
National coordination
24. Links will need a national and regional
management structure to simplify and make more manageable the
responsibilities outlined above to the Department of Health for
good governance and financial control. They will also need higher-level
support for taking to the Secretary of State any matters that
they are unable to resolve with the Overview & Scrutiny Committee,
and to lobby national voluntary sector organisations . Election
to these bodies, and the case for all having an executive committee
have been discussed elsewhere, and are not important at this stage.
How should LINks relate to, and avoid overlap
with
Local Authorities and Overview & Scrutiny Committees
25. LINks relationship to both Local Authorities
and Overview & Scrutiny Committees (OSCs) should be limited
to being a comprehensive source of detailed experience and knowledge
on all PPI matters. OSCs should be able to call upon LINks for
reports needed to undertake both elements of their responsibilities.
It seems that at present, Councillors are hard-pressed to undertake
this work, in addition to their other duties to electorates. They
then have to rely on evidence submitted by the Trusts, and on
Health Advisers, who may have an extensive experience within the
NHS (which gives a certain amount of bias to their judgement).
Some OSCs have been unable to do more than scrutinise Trust's
proposals, and not any longer-term overview activities. LINks
should make available information to local authorities based on
work already undertaken, but should not be required to undertake
any additional tasks.
Foundation Trust Boards and Members Council
26. Relationships to Foundation Trusts and
their boards should be the same as stated above for all other
NHS providers. These Trusts receive revenue funding from the NHS
via PCTs, and should be as accountable for PPI as all other NHS
bodies.
Inspectorates including Healthcare Commission
27. LINks must be allowed to carry out their
own tasks and responsibilities without being expected to undertake
extra work for other organisations. Their own work has to be put
in the public domain, and so be available for all.
Formal and informal complaints procedures
28. Individual problems that arise in hospitals
or elsewhere within NHS bodies should be taken up directly between
the parties involved. Existing arrangements (PALS, and for matters
that cannot be resolved at that level, ICAS) should be satisfactory,
and outside PPI activities. One desirable feature is that both
PALs and ICAS should submit periodic summary statistical reports
to LINks, so that any significant trends can be picked up.
Circumstances calling for, and form of, any wider
public consultation
29. If PPI were set up as outlined in this
submission, there would be little need for consultations on reconfigurations.
At present these are very expensive and time-consuming for Trust
staff and management, and stakeholders alike. Trusts would still
have to make public announcement of all proposed changes to service
provision. OSCs would invite LINks and the Trust(s) to comment,
and then, also taking into account any public representations
made directly to it, decide if a public enquiry was warranted.
If so, the OSC would conduct this along established lines. The
LINks could refer matters with which it was not satisfied to its
Regional management, who would attempt to resolve with the OSC,
and if not successful, refer it to the Secretary of State.
Gerald Gilbert
January 2007
Annex
POST-FORUM PPI TEAMS AND THE CHAIRMAN ROLE
Different names are now being given or proposed
by different parties for PPI Forums, but the underlying principle
was clearly embodied in the Health & Social Care Act, 2001,
and as explained very fully in subsequent Department of Health
publications, such as "Patient and Public Involvement in
Health", April 2004. The Act introduced a feature that was
claimed would "make Forums more powerful than Community Health
Councils", since patients and the public were to be INVOLVED
in the decision-making process, with a seat at the table and a
voice to be listened to when the pros and cons of options were
being discussed. This would be enhanced by Forums having a non-executive
member on the Trust Board, as distinct from the CHC right to have
a speaking, but non-voting, role at the Board's public meetings.
The right to refer disputes that could not be resolved locally
was withdrawn by the Act and replaced on the understanding that
Overview and Scrutiny Committees would draw heavily on the Forum's
detailed work (and so be able to judge the merits of the case
presented to them alongside the submissions of the Trust). Forums
would also be supported administratively by not-for-profit organisations
instead of having their own professional staff. Although the Chief
Officers of these were appointed by the Department of Health and
all the staff were employed by the local Health Authority, they
did have a degree of independence strengthened by their close
working arrangements with CHC members. The Chief Officers networked
with others in the area, and had the general and legal support
of a National Association, but the latter was abolished with the
CHCs. The staff, often part-time, usually had extensive healthcare
backgrounds. Without trying to re-invent CHCs, it is worth noting
that they related to the "local healthcare area" and
not just one Primary Care Group, as the PC Trusts were then known.
They considered matters in which the local hospitals, mental health,
Social Services and ambulance services were concerned, and representatives
of these were all invited and expected to attend and contribute
to CHC public meetings.
None of the fond hopes of 2001 have actually
come about successfully, for various reasons. The attitude of
the Department of Health has been ambivalent, and the role adopted
by CPPIH unhelpful (to put it mildly), including in not actively
following up the proposal for Forums for regional and national
representative and coordination bodies The Healthcare Commission
has not played an active role yet, apart from asking Forums to
participate in more visits to healthcare establishments. (In January
2005, it appointed a Patient and Public Engagement Lead, a Lorraine
Denoris, but I do not know what became of her). It seems likely
that the now-enlarged PCTs, whatever their merits, will have to
delegate much to local sub-committees in order to be at all in
touch with local issues.
The role and duties of the Chairman of a Locality
Team need to be thought through and widely discussed to try and
get a common approach. There is obviously a need to keep the job
manageable. This means lots of delegation, not getting personally
involved chairing sub-committees and special interest groups.
It will require networking with voluntary groups and Social Services,
as well as establishing good relationships with the Overview and
Scrutiny Committees as well as the PCT Board and its locality
sub-committees. On the last point, the DoH can re-organise the
PCTs as often and how it likes: there is no obligation on PPI
groups to follow these changes, and have their work organised
by the DoH for them.
So here some ideas on a Job Description are
offered below for consideration.
JOB DESCRIPTION
FOR TEAM
CHAIRMEN
1. Able to organise and hold meetings, getting
the agenda and papers to members and local Trusts well in advance,
giving team members and others invited to attend an opportunity
to contribute to discussions, yet keeping to the time allotted
to the meeting.
2. Considers that the team needs a local
office in or adjacent to the PCT's own, with some professional
assistance in legal and procedural aspects.
3. Understands the need to get a wider patient
and public involvement in healthcare than team members can provide
on their own, and be prepared to work with others, such as BGOP
(eg,50+) and local healthcare charities, to that end.
4. Actively supports the case for all teams
within the locality working together, not only those nominally
associated with the one PCT.
5. Appreciates the need to get involved
in the work of local sub-committees and Local Improvement Teams
set up by the PCT and other local Trusts; and with the Overview
& Scrutiny Committees set up by local government.
6. Believes that the Chairman should be
ex officio Non-executive Member of the Trust Board, or at least
have a speaking if non-voting rights at the Trust's public meetings.
7. Considers that its reports should carefully
considered by Overview & Scrutiny Committees, and if not,
they should have the right to appeal directly to the Secretary
of State.
8. Believes that the work of the team could
be enhanced with regional and national representatives and executive,
to relate with NHS Authorities and healthcare charities at the
appropriate level.
LINKS AND THE DEPARTMENT OF HEALTH
LINks—
| as viewed from the top down |
as viewed from the bottom up |
| Accountable to the Dept of Health | Accountable to Patients, Carers and the Public Volunteers
(—although an honorarium might be considered for national and regional delegates
|
| Professional employees
working together in:
| and management committee members) and working together in:
|
| A National and nine Regional organisations
|
| Each With a Management Committee—
|
| Chief Executive Officer
Other directors: Finance, Legal,
| Chairman appointed by and from the
other non-executive members
|
| The Knowledge/Communications/Events
Appointed by the NHS Appointments
Commission
(Other staff appointed by CEO)
| all appointed by Assembly
(NB More non-execs than execs!)
National Assembly (1)
18 delegates (max 2/ region), appointed by Regional Assemblies
|
| Regional Assemblies (9)
Chairman appointed by and from 20
Delegates (max 2/forum), appointed by
Health Economy teams
|
| LINk teams for each Health Economy Area—200?)
|
| Chief Officer (125?) | Circa 20 members, appointed by local
|
| Appointed by the NHS Appointments | healthcare PPI voluntary groups
|
| Commission. (Other staff— | Management Committee
|
| Office manager and admin support— |
Circa 6 members. Chairman appointed from |
| members appointed by CO) | and by other members
|
| Locality sub-committees |
| with admin support | Informal structure, setting own rules but reporting to Area team. Members appointed by local healthcare PPI voluntary groups,
but to include min of two Forum members
|
|
