Select Committee on Health Written Evidence

137. Evidence submitted by Mike Tiernan (PPI 110)

1.  Focus of this Response

  This response deals with the three initial broad questions posed by the Committee, and touches only briefly on some of the more detailed questions. The original consultation on the "Stronger Local Voice" proposal has already produced a wide response to many of the detailed issues but this Inquiry has introduced these three fundamental and very pertinent questions which the original consultation largely overlooked.

2.  Source and Perspective of this Response

  The writer is a Mental Health Service User Involvement Coordinator employed by a PCT, with four years experience in this post and six years in a previous post as Service User Involvement Coordinator employed by a specialist Mental Health NHS Trust. The views are those of an individual, but are reflective of many people working in the field. The absence of any notification of this Inquiry through expected channels such as CSIP/NIMHE has precluded a collective response.

3.   What is the purpose of patient and public involvement? Also, to what extent is it being achieved?

  PPI has several key purposes, with varying degrees of value, feasibility and success. The DoH sentence, "service users should be centrally involved in the evaluation, monitoring, design and delivery of services" includes two of the most important (evaluation and monitoring) plus two of the most difficult (design and delivery). Evaluation and monitoring are the most successful functions, but following through on rectifying deficiencies is more problematical. Design of services in true partnership with service users is in reality quite rare. Its feasibility is restricted by; the limited capacity (in terms of numbers) of service users motivated to be involved, power structures which are inherently (though usually subconsciously) not really receptive to it, and power structures working in a top-down system in which transformative decisions are the exception rather than the norm. Delivery of services by service users, although still very rare, is usually very effective, eg service user run crisis houses.

  Accountability to patient and publics, in terms of participation and transparency, has been successful at changing the previously endemic reluctance of organisations to disclose the motivations behind their decisions.

4.   What form of PPI is desirable, practical and good value for money?

  In the context of mental health and some other specialities the soon-to-be dismantled system of independent PPI Forums covering a NHS Trust footprint fulfilled these criteria and should have been built on and extended, perhaps by linking the Forums to the relevant Overview and Scrutiny Committees. Setting up regional PPIFs with a statutory right/duty to report to the regional SHAs would have been an effective next step towards a national Forum.

  Many people working in the field regard this as a missed opportunity which will result in a "weaker local voice" and a continued absence of a regional or national voice for patients and public in mental health. The mental health perspective will be diluted by:

    (a)  being subsumed by a generic Links Forum and a generic Overview and Scrutiny Committee; and

    (b)  multiple smaller Links Forums which will have difficulty, and perhaps no incentive, in working together over a Trust footprint.

  Building on the existing system would have been more effective and more cost effective than the new system. If the government persists in the new system, quite intricate, costly and burdensome linkages would need to be in place to retain the benefits of the previous system, let alone to improve on them.

  Independent PPI Forums, working alongside other patient and carer groups, have had moderate success in spite of difficult circumstances. Mental health service user groups have long advocated for support in facilitating regional and national channels so that those many aspects of service design and quality which can only be influenced at a national level would have better, more regular and statutorily supported access to the real views and suggestions of service users. An opportunity to move closer towards that has been missed. Even acknowledging the one positive benefit of a statutory link to OSCs it is difficult to see how this proposal is even as good as "three steps forward and two steps backward".

5.   Why are existing systems for PPI being reformed after only three years?

  Why indeed? Only the government can answer this, but the rationale in the "Stronger Local Voice" document does not present a cogent argument. The government's continued emphasis on the local dimension, whilst perfectly legitimate, is often at the expense of the wider regional and national dimension, through which alone certain things can be changed.

  Certainly, for evaluation and monitoring the local dimension is paramount, but for effecting significant change in service design the sub-regional and national arenas are crucially important. Ever since its inception patient and public involvement has suffered from fragmentation, but Trust footprint based PPI Forums were an effective step in the right direction. That step is about to be reversed and it is difficult to see how that can benefit even the generic acute hospitals services, let alone the mental health sector.

  After a sustained period of increased investment in mental health it would have been wise to build on effective patient and public participation and scrutiny to ensure that money was achieving the desired improvements. The fait-accompli manner of consultation on this proposal (which asked basically how it should be done rather than asking whether or not it should be done) causes widespread perceptions of either ambivalence or poor judgement.

Mike Tiernan

Voices in Partnership Coordinator

10 January 2007

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