14. Evidence submitted by The Centre for
Public Scrutiny (PPI 62)
1. EXECUTIVE
SUMMARY
1.1 People should have a range of ways to
influence their well-being, health and care and outcomes from
local activity should be shared locally, regionally and nationally
in order to impact local, regional and national well-being, health
and care policy.
1.2 Local councils should play a key role
in ensuring that involvement frameworks are "fit for purpose"
and are able to help "shape the place". Frontline councillors
(through overview and scrutiny or the Community Call for Action)
should use their democratic mandate to ensure that decisions made
by local councils, the NHS and other partners are influenced by
local people.
1.3 The term "patient and public involvement"
does not adequately capture the desired outcome of accountable
well-being, health and care and should be changed to better reflect
the need for people to be able to influence decision makers.
1.4 The ability for people to influence
should be a strong "third pillar" of performance assessment
in health and social care alongside safety and value for money.
1.5 SMART targets to measure a "joined
up" approach in the public sector to well-being, health and
care should be introduced into Local Area Agreements.
1.6 There is too little networking between
non-executives (Councillors, NHS Non-Executive Directors and FT
Public Governors). Such networks can help to promote a dialogue
between communities, commissioners and providers about the balance
between accountability and professional judgement.
1.7 An "institutional/organisational"
structure is not best placed to deliver the range of opportunities
that people need to be able to influence their well-being, health
and care. A well resourced "community facing" structure
that crosses organisational boundaries and reflects patient journeys
will be better placed to deliver benefits for both patients and
communities.
1.8 The distinct but complementary roles
of all bodies seeking to influence well-being, health and care
need to be understood, accessible and carefully co-ordinated to
avoid duplication and to ensure that they work together for the
benefit of local people.
1.9 The current 12 week "consultation
window" is not an effective or efficient way to influence
decisions and the public sector should work towards a system where
patients, carers, communities and their representatives are able
to influence change to the extent that "formal" consultation
is not required.
2. INTRODUCTION
2.1 The Centre for Public Scrutiny promotes
the value and potential of scrutiny in modern and effective government—to
hold executives to account and to create a constructive dialogue
between the public and its elected representatives—to improve
the quality of public services. We believe that "better scrutiny
means better government". In the context of the Committee's
inquiry this principle should be applied to ensure that councillors
as "community leaders" can be satisfied that local arrangements
for patient and public involvement are able to facilitate reasonable,
informed judgements between public opinion and professional judgement
in ways that are understood and accessible to the public.
2.2 We promote four principles of good scrutiny
that are mutually reinforcing and lead to improved public services
through community leadership. These principles are outlined in
further detail in "The Good Scrutiny Guide" (attached).
Good public scrutiny ...
1. provides "critical friend"
challenge to executive policy-makers and decision-makers;
2. enables the voice and concerns of the
public;
3. is carried out by "independent minded
governors" who lead and own the scrutiny role; and
4. drives improvement in public services.
2.3 Since June 2004, CfPS has been running
a Department of Health sponsored support programme for health
overview and scrutiny committees. The support programme will end
in June 2007. As part of the support programme CfPS has published
a guide for OSCs and Patient Forums about how to work effectively
together (copy attached) and the Government response to A Stronger
Local Voice indicates that CfPS will work with OSCs to develop
relationships with LINks.
3. PURPOSE OF
PUBLIC AND
PATIENT INVOLVEMENT
3.1 We believe that the purpose of patient
and public involvement is to help decision makers reach decisions
that demonstrably take account of the needs and aspirations of
communities and individuals. In the context of well-being, health
and social care, patients, carers and the public need to be involved
at three levels:
— Strategic—improving
health and well-being by prevention, treatment and care.
— Local—planning and delivering
prevention, treatment and care services.
— Individual—decisions
about lifestyle, treatment and care.
3.2 We believe that there is a distinction
between "involvement" and "accountability"
and that where involvement and accountability are operating effectively,
the result will be "influence". The term "patient
and public influence" better expresses the desired outcome
of demonstrable involvement and accountability. Furthermore, we
believe the distinction between "patients and the public"
is unhelpful and that a better expression should be found to capture
the concept "can people influence?". We believe that
people should have several ways to influence, reflecting their
multiple interests as patients, carers, citizens and representatives.
4. DESIRABLE,
PRACTICAL AND
AFFORDABLE FORM
OF PUBLIC
AND PATIENT
INVOLVEMENT
4.1 The NHS Plan set out an aspiration to
put people at the heart of everything that the NHS does. The ability
for people to influence needs to be established alongside safety
and value for money as three pillars of performance assessment
across health and social care.
4.2 Organisational and system reforms have
been put in place to help people get faster access to better quality
treatment services but more work needs to be done across the public
sector to better understand:
— how people live their lives;
— how to develop their capacity to
experience a better quality of life; and
— how to help them when things "go
wrong".
4.3 People's ability to influence their
well-being, health and care needs to be a strong focus for:
— Commissioners in local government
and the NHS.
— Providers in the public, independent
and private sectors.
— Inspection Concordat partners.
4.4 Commissioners need to show how they
have incorporated people's views in to decisions they have made.
We welcome the indication that PCTs should do this through the
Patient Prospectus, although more clarity is needed about how
practice based commissioners will need to express their accountability
to communities. GP practices should consult relevant ward councillors
throughout the commissioning cycle.
4.5 The requirement to demonstrate accountability
should be extended to well-being and social care, perhaps through
council annual reports. We also welcome the indication that councils
and PCTs should publish a response to Director of Public Health
reports (an example of good practice can be found in Newcastle,
where the health OSC provides a commentary on the DPH report).
4.6 Providers need to show how they have
improved services (for example through patient/clinician dialogue,
PALS and ICAS data). NHS Trusts need to explain why they cannot
work with communities in similar ways to Foundation Trusts.
4.7 Inspectors, Monitor and Ombudsmen should
show how their assessments and recommendations are informed and
guided by people's experiences. Monitor (and the Foundation Trust
Network) particularly needs to identify how the Foundation Trust
model has added value in the area of public influence over service
design.
4.8 Local Area Agreements, building on the
duty to co-operate in the Local Government and Public Involvement
in Health Bill, should be strengthened by requiring SMART targets
for public sector organisations to demonstrate a "joined
up" approach to well-being, health and care.
4.9 We believe that someone has to balance
professional judgement (the views of clinicians and managers about
the best forms of service delivery) and accountability (people's
opinions and experiences). There should be a strong role for frontline
councillors as community leaders to determine whether well-being,
health and care have been and are being shaped around the needs
and aspirations of patients and citizens. There is scope to create
networks that bring together non-executives in order to make the
most of their distinct but complementary roles. We are committing
money from our OSC support programme in 2007 to support regional
networks that can create opportunities for this to happen but
this funding stream will not last beyond June 2007 and we believe
that there is a gap to be filled into the future.
4.10 In terms of affordability we believe
that each part of the framework needs to "do what only it
can do" and that overview and scrutiny committees should
be the guardian of the system locally, ensuring that it is "fit
for purpose" in the local context. NHS bodies should be funded
to provide opportunities for influence in proportion to their
populations and there are opportunities for public bodies to co-operate,
making use of existing engagement mechanisms developed by local
councils for reaching their communities. These mechanisms may
be strengthened through comprehensive community engagement strategies.
5. CURRENT REFORMS
5.1 A CfPS roundtable discussion on 30 November
2006 concluded that the current "anatomy of accountability"
in health could be construed as a "crowded goldfish bowl"
that lacks clarity about how the various parts can work together
to achieve the best outcomes for patients, carers and citizens
(transcript attached).
5.2 We believe that the current "institutional
and organisational" structure for involvement (through 570+
Patient and Public Involvement Forums) is not best placed to deliver
a range of opportunities for people to influence decisions about
their well-being, health and care in ways that suit them. We believe
that the best Patient Forums have delivered benefits for patients
but it seems less clear whether overall they have added value
for the public. We believe that the proposals for "community
facing" Local Involvement Networks (LINks) will add value
by providing opportunities for everyone to influence decision-makers
in local government and health, across the patient journey regardless
of organisational and administrative boundaries.
5.3 Given this community focus across health
and social care, we believe it is right for councils providing
social care to take the lead in procuring support arrangements
for LINks. We will work with overview and scrutiny committees
to help them hold council executives to account for the value
they achieve from the targeted grant for establishing LINks, particularly
in two tier areas where county councils will need to ensure that
LINks are not remote from local communities.
6. DESIGN OF
LINKS
6.1 People's opportunities to influence
well-being, health and care will be "protected" through
the legal requirement for commissioners and providers to reach
out to communities when designing and running services (under
the NHS Act 2006 and Part 11 of the Local Government and Public
Involvement in Health Bill). This could be seen to be reactive
influence, but good accountability also requires opportunities
for proactive influence.
Proactive influence is currently expressed at
a number of levels:
— Individual—patient/clinical
dialogue, PALS, ICAS and Ombudsmen.
— Collective—patient forums,
patient groups or advocacy bodies.
— Representative—scrutiny
committees, public governors and non-executive directors.
6.2 These means to influence are valid but
there is still a place in the framework for a mechanism to engage
people who do not have single interests or the time to serve on
formal bodies (including people whose views are generally not
heard). We believe that the best LINks will make the most of their
community focus to engage people in different ways. We believe
that the proposed remit for LINks across health and social care
is appropriate so that they can follow the "patient journey".
LINk visiting rights should extend right across primary and secondary
care as the opportunity to gather information and experiences
from patients in surgeries, clinics and wards is very important.
These rights should also extend right across the public, independent
and private sectors. We agree that these rights cannot reasonably
be given to all LINk members but only to a few in each locality.
6.3 In terms of membership, it may be that
LINks develop "constituencies" (for example people interested
in particular services or types of provider) in a similar way
to Foundation Trusts. Maintaining contact with a wide membership
will be important for LINks but this could be expensive and there
are lessons to learn from Foundation Trusts about how to manage
member participation. LINks must not become dominated by "factional
interests" and local authorities can have a role in overseeing
the genuine representativeness of LINks and guarding against undue
influence of any particular group.
6.4 LINKs will need significant resources
and support, particularly if they are to maintain a membership
base, conduct research and reach out in creative, innovative and
inclusive ways. Support for LINks must go beyond simply administering
meetings. Experience from our health scrutiny support programme
shows that to be most effective, OSCs need specialist policy support
and that direct funding stimulates new ways of working (see Sharing
the Learning attached). We note that targeted funding will be
given to social care councils to procure LINK hosts and this may
provide opportunities to secure additional funding for LINks beyond
central government grant.
6.5 Our experience from supporting scrutiny
committees is that a tremendous amount of good work takes place
that has an impact at local level (2,000 entries in our Review
Library on our website at www.cfps.org.uk) but there is no mechanism
for gathering "collective wisdom" in order to drive
changes in national policy. CfPS is seeking to develop the capacity
of its Practitioner Forum to perform this role in relation to
health and social care. The point being that opportunities to
share local work more widely is very valuable. This is distinct
from national "co-ordination" that would not sit well
with the flexibility that is suggested for the way LINks are established
and run.
6.6 Since funding and performance management
of LINks is to be directed through local government and the LINk
role appears to come within our definition of "public scrutiny",
there may be a role for CfPS to play (perhaps with partners such
as the LGA) to provide mechanisms for sharing best practice through
technology, events and publications building on our current model.
In particular, our health scrutiny support programme provides
a model of how best practice can be promoted through academic
research, direct funding for action learning and expert advice
and published guidance.
7. RELATIONSHIPS
7.1 As LINks will have a remit for social
care that is different from Forums, they will need to understand
how social care works and how it fits in to the overall picture
of local government. Organisations such as CfPS, LGA and IDeA
could provide awareness raising sessions for LINks and CfPS would
be happy for our regional health scrutiny networks to involve
LINks as appropriate.
7.2 LINks will have to develop close working
relationships with overview and scrutiny committees. CfPS published
a guide last year about how Patient and Public Involvement Forums
and OSCs can work effectively together (attached) and we could
provide similar guidance about LINk/OSC relationships. The key
to effective and efficient working will be for LINks and OSCs
to talk to each other about their programmes of work and to establish
how to make the best of their distinct but complementary roles.
7.3 LINks should provide valuable intelligence
for OSCs and OSCs should use outcomes from LINk activity to plan
their own work and develop their recommendations. This will need
careful co-ordination so that LINks and OSCs make the most of
opportunities in the new framework. Given that there will be one
LINk for each OSC area this co-ordination should be easier to
achieve than the existing Forum structure.
8. PUBLIC CONSULTATION
8.1 CfPS is aware that the Commons Public
Administration Committee has announced an inquiry about customer
and user involvement in public services. In relation to health,
it is vital that the NHS and local authorities engage people in
decisions about well-being, health and care. Our guide about tackling
substantial variations (attached) provides a range of practical
examples of local agreements about what constitutes "substantial"
in the local context. The LGPiH Bill talks about "significant"
changes to services and it should be a requirement for OSCs and
the NHS to have a local agreement about local triggers for consultation.
CfPS and the Independent Reconfiguration Panel could play a role
to ensure there are common standards.
8.2 By tackling engagement together through
local strategies, and by using LINks constructively, public sector
bodies can demonstrate to their communities that there is "joined
up thinking", helping to restore trust in public services.
Our recent roundtable suggested using patient lists could be a
good basis for engaging patients for example. Local councils should
ensure that Hosts make LINks aware of the range of opportunities
to use local engagement activities to avoid "consultation
fatigue".
8.3 We believe that a positive step towards
openness in decision making would be for the NHS to publish a
forward plan of decisions (similar to a local authority executive
forward plan of key decisions) to be made about service reconfigurations.
This would enable some pre-decision scrutiny by OSCs and would
provide a timetable for OSCs to form joint committees to respond
to cross-boundary issues. The current 12 week "consultation
window" is not an efficient or effective way to scrutinise
major changes to health services. By involving local people, LINks
and OSCs at an earlier stage it should be possible for the NHS
to move to a position where formal "public consultation"
in its current form is not required.
8.4 We would be happy to expand on our submission
in oral evidence if the Committee would find that helpful.
Jessica Crowe
Executive Director
The Centre for Public Scrutiny
9 January 2007
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