Select Committee on Health Written Evidence

14. Evidence submitted by The Centre for Public Scrutiny (PPI 62)


  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.


  2.1  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.


  3.1  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.


  4.1  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.

    —  Monitor and Ombudsmen.

  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.


  5.1  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.


  6.1  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 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.


  7.1  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.


  8.1  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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