Select Committee on Health Written Evidence

123. Evidence submitted by Gerald Gilbert (PPI 138)


  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.


  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.


  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.


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



  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.


  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.


as viewed from the top down as viewed from the bottom up
Accountable to the Dept of HealthAccountable 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


(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 Appointmentshealthcare 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 supportInformal 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

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