Select Committee on Health Written Evidence

15. Evidence submitted by the Cheshire and Wirral Partnership NHS Trust PPI Forum (PPI 33)

  At our last meeting on 2 January 2007, the Patient and Public Involvement (PPI) Forum for the Cheshire and Wirral Partnership NHS Trust (CWPNT) authorised me to send you the attached three notes.

  1.  The note "Proposed Local Involvement Networks to replace PPI Forums" dated 9 August 2006 summarises comments on DH document 27857 "A Stronger Local Voice" dated July 2006 under the three headings:

    (a)  what is good about the proposal;

    (b)  what is not good about the proposal; and

    (c)  suggested improvements.

  2.  The note "Feedback from Getting ready for LINks" dated 15 December 2006 summarises comments on DH document 7283 "Government response to A Stronger Local Voice" dated December 2006 and the "Getting ready for LINks" meeting in London on 13 December 2006 under the three headings:

    (a)  clarification of powers of LINks;

    (b)  next steps; and

    (c)  concerns still to be addressed.

  3.  The note "A three layer model for Local Involvement Networks" dated 2 January summarises proposals for structure arrangements for LINks and foundation trusts under the three headings:

    (a)  three layer structure arrangements;

    (b)  governance checks and balances; and

    (c)  specialist services crossing LINk boundaries.

    —  "a LINk may well wish to set up specialist interest groups" (DH 7283 para 2.20) would be inconsistent and ineffective;

    —  specialist LINks for specialist services would give rise to overlap and jurisdiction disputes; and

    —  hence the proposal for "Specialist Joint Committees with full delegated powers for that specialist service".

Murdo Kennedy

PPI Forum Chair

Cheshire and Wirral Partnership NHS Trust

8 January 2007


Final 6th Draft supported by the Mental Health PPI Forums NW Network and the West Cheshire PCT and Cheshire and Wirral Partnership NHS Trust PPI Forums


  The proposal to replace PPI Forums with Local Involvement Networks (LINks) is set out in DoH document 275857 "A stronger local voice: A framework for creating a stronger local voice in the development of health and social care services" dated July 2006. Good points of the proposal are as follows:

    (a)  it will combine involvement in commissioning, providing, monitoring and regulating for social care as well as health care (ie "joined-up involvement in joined-up systems");

    (b)  LINks will be linked to Local Authority Overview and Scrutiny Committees (OSCs) with strengthened powers to be consulted by commissioners, so decisions should be more locally accountable and transparent; and

    (c)  it will provide opportunities for broader membership, but LINk support must avoid repeating key mistakes made by CPPIH such as:

    —  wasteful and confusing delay in producing the key Handbook;

    —  over-emphasis on numbers rather than capability of members; and

    —  over-emphasis on unfocussed central computer system (KMS).


  Drawbacks to the proposal can be summarised as follows:

    (a)  lack of detail and guidance on models and governance for LINks, which will result in even greater delays and confusion than with the start-up of PPI Forums, hence exacerbating "post code lotteries";

    (b)  over-reliance on OSCs with conflicts of interest which compromise their ability to act as an "independent watchdog", since Local Authorities already both commission and provide social care and now they will also commission a host organisation to run their LINks; and

    (c)  LINks will have no power to require answers or entry, which will greatly impair their ability

    —  to hold autocrats to account;

    —  to penetrate cloaks of "commercial confidentiality"; and

    —  to act as real "independent watchdogs".


  In order to learn from previous mistakes, there is a need for:

    (a)  consistent national models and a governance handbook, with an ultimate right of appeal to a Regional Health Authority (following para 2b);

    (b)  a "LINk Overview Group" (LOG) of elected and trained volunteers for each LINk with powers to require answers and entry in order to able to act as a credible "independent watchdog"; and

    (c)  specialist (joint) LOGs for specialist trusts which cover large areas with multi-PCT (LA) funding, noting that many mental health trusts already have a three layer network with a high proportion of "expert" patients and carers in:

    —  a "grass roots layer" of user and carer groups and open forums with users, carers and statutory and non-statutory organisations;

    —  a "working layer" in working groups at all levels in the trust; and

    —  an "overview layer" consisting of the independent PPI Forum.

NOTE 2: FEEDBACK FROM "GETTING READY FOR LINks" (Comments from meeting in London on 13 December 2006)


  Progress since "A stronger local voice" (DH 275857, July 2006) is that the "Government response to a Stronger Local Voice" (DH 7283, December 2006) has addressed major concerns in that LINks will now have:

    (a)  powers to require answers within a specified timescale (paras 2.7, 2.25);

    (b)  powers of entry to health and social care premises (para 1.41), but restricted to LINk members who have received training to carry out visits in an appropriate and sensitive manner in line with a new "Visiting Code of Conduct" (para 1.42); and

    (c)  clearly defined independent funding for LINk support (paras 1.24, 1.25, 1.28).


  Unlike the unrealistic across the board introduction of PPI Forums without a Guidance Handbook in January 2004, DH 7283 sets out three key preparatory steps prior to rolling out LINks:

    (a)  an "early adopter programme" (para 1.7) will pilot the development of LINks over a spectrum of seven areas in order to work up models, mechanisms and relationships (para 4.1) and protocols and guidance (para 1.9);

    (b)  a contract specification for host organisations is being developed (para 1.20) and "local authorities will be strongly encouraged to involve local people and organisations in the process of awarding the first contract to provide support to the LINk" (para 1.22); and

    (c)  stakeholders are encouraged to begin to plan how to prepare and develop new roles and relationships (paras 4.3 to 4.6).


  The DH Patient and Public Involvement Team are to be particularly commended for the extent to which they have listened and addressed key concerns, far less their preparations for the enabling legislation. However, three further concerns which need to be addressed are that:

    (a)  commissioners need to be discouraged from using "The primary function of LINks is to gather the views and experiences of people using health and social care services in their area" (para 3.6) as a cheap way of evading strengthened Section 11 responsibilities (paras 1.51, 2.9);

    (b)  quality starts with consistency, so in order to optimise the balance between flexibility and rigidity, the statement that "a LINk may well wish to set up specialist interest groups" (paras 2.20, 2.21) needs to be firmed up to "LINks have a duty to demonstrate effective collaboration for specialist services which cross LINk boundaries; and

    (c)  partly from 3b, it is necessary in practice for the LINk to have an appeal loop from the "Stewardship Board" (para 1.39) to an appropriate regulator (eg HCC, SCI).

NOTE 3: A THREE LAYER MODEL FOR LOCAL INVOLVEMENT NETWORKS (LINks) (Authorised by the Cheshire and Wirral Partnership NHS Trust PPI Forum on 2 January 2007 for submission to the Health Select Committee Inquiry on PPI in the NHS)


  It is useful to consider a simple three layer structure for a LINk and see how it would compare and interact with a parallel structure for a NHS foundation trust.

    (a)  The overview level

    —  For a LINk, this would be the LINk Stewardship Board (LSB) where the LINk would elect volunteers to the LSB to be trained and accredited to hold and exercise the powers of LINks to require answers and entry;

    —  these volunteers should bring specialist knowledge and experience;

    —  however, for the LSB to function in an effective and objective manner, they must agree to consensus non-partisan working.

    For a foundation trust, this would be the Council of Governors.

    (b)  The working level

    —  For a LInk, this could consist of sub-groups led by LSB members to look into any part of the LINk's whole system watchdog responsibilities (ie commissioning, providing, monitoring for both health and social care).

    —  For a foundation trust, this could consist of members selected by the trust for involvement in internal working groups and members selected by the Council of Governors for involvement in wider reviews including LINks.

    (c)  The "grass roots" level

    —  For a LINk, this would consist of the various service user, carer and voluntary groups covering speciality interests.

    —  For a foundation trust, this would consist of the foundation trust members in the various geographical or other constituencies.


  A simple approach here is to consider how checks and balances can be built in by allocating different roles to different organisations as follows:

    (a)  LINk support organisation

    —  as well as administrative support, this would provide guidance in line with detailed national guidance in a handbook available prior to LINk start-up;

    (b)  County Council

    —  this would maintain the register of organisations comprising the LINk, as well as providing a strengthened and tiered OSC network;

    (c)  Health Care Commission/Social Care Inspectorate

    —  this could be seen to provide an independent appeal loop for the LINk LSB in the event of concerns or conflicts of interest with either 2a or 2b.


  For specialist services such as Mental Health, Oncology and Ambulance Services which are funded by more than one PCT and cover more than one LINk area, local flexibility has often resulted in "post code lotteries". It is thus proposed that:

    (a)  LINks should have a duty to demonstrate effective collaboration for specialist services which cross LINk boundaries;

    (b)  the most effective model to do this would be a Specialist Joint Committee to which adjacent LINk LSBs would have to delegate their powers for that specialist service; and

    (c)  the powers delegated to the Specialist Joint Committee would need to include the appeal loop to the Health Care Commission/Social Care Commission.

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