Select Committee on Health Written Evidence

17. Evidence submitted by the Commission for Patient and Public Involvement in Health (PPI 109)


  Patient and Public Involvement is essential for the achievement of key strategic objectives in health policy. A system of patient and public involvement should provide patients and the public with an effective voice alongside other decision makers in health and social care, locally, regionally and nationally. The PPI agenda has been characterised by uncertainty and indecision over the past four years and CPPIH has managed to progress the PPI agenda in difficult circumstances. Despite this considerable capacity for engagement has now been built, which should be nurtured under any new arrangements. The Commission welcomes the proposals to widen patient and public involvement. LINks as currently proposed are unlikely to deliver the objectives stated for PPI. Resourcing issues must also be examined to ensure that the aspirations laid down for LINks are attainable within the finances available to them, if the Government's ambitions for LINks are to be delivered.

  1.  The Commission for Patient and Public Involvement in Health (CPPIH) was established by the NHS Reform and Healthcare Professions Act 2002 and became operational in December 2003. It is an independent, non-departmental public body, sponsored by the Department of Health.

  2.  CPPIH now oversees and supports 402 statutory Patient and Public Involvement (PPI) Forums, made up of local volunteers, one for each Primary Care Trust, NHS hospitals trust, mental health trust and ambulance trust in England. It also provides advice to the Secretary of State on patient and public involvement (PPI).

  3.  Since December 2003 there have been a variety of proposals and changes of direction affecting PPI Forums and the CPPIH. In June 2004, as part of the Arm's Length Body Review, it was announced that the CPPIH would be abolished in 2006. This was subsequently postponed until summer 2007 and then to the end of 2007. This long period of uncertainty and unclear direction has significantly impacted on the development and achievements of PPI Forums and the CPPIH

  4.  CPPIH welcomes the Health Select Committee's inquiry and hope the Committee's deliberations will contribute clarity and leadership in developing PPI policy. CPPIH is pleased to submit evidence for the Committee's consideration and is willing to expand in oral evidence, if so invited.


  5.  Public involvement aims at securing the accountability of decision-makers to the public, whether local or otherwise. The case for it derives from the right of citizens, whether or not they are current users of NHS services, to actively contribute to discussions about the use of public funds and the difficult and complex choices involved in applying finite resources to health and social care. Public involvement should be incorporated into decision-making on the development and planning of services including: service planning (what services should be provided), strategic planning (what should be achieved by delivering those services) and commissioning (who delivers services). It is particularly important to securing improved public or population health.

  6.  Patient involvement takes place at the interface between the patient and the actual operation and delivery of care. It aims to improve the effectiveness of services, and should contribute to securing equality in service delivery. Information gained from this process may also be used to inform higher level decisions about commissioning and operational delivery (how services are delivered and where).

  7.  Whilst there is a large amount of academic literature on patient and public involvement, there is a lack of agreement and clarity about what PPI is, what it is for and what national policy on PPI should be.

  8.  In CPPIH's view, the objectives of PPI are to:

    —  improve outcomes in health and social care;

    —  facilitate citizens sense of "ownership" of health policy and services;

    —  secure equality of opportunity in receipt of health and social care; and

    —  address inequalities in the health of the population.

  9.  To further these objectives the role of a PPI system is to provide the public with an effective voice alongside health and social care professionals, service managers and planners, and national policy makers in all health related decisions-making.

  10.  In our view real progress has been made in recent years in joint decision making between individual patients and practioners, and through initiatives such as the expert patient programme. However, there is still much to be done to deliver real patient and public involvement in decisions that affect health for groups, communities and indeed nationally.

  11.  There is evidence from many sectors (especially outside health) that involvement of stakeholders (especially those most affected by its outcomes) in decision making at all levels, including policy making, results in better decisions and ones which are understood and accepted by service recipients and taxpayers. However, this does require a change of culture within the NHS and social care and also amongst the public.

  12.  The role of PPI in securing longer term strategic objectives in health policy was underlined in the Wanless Report. It warned that failure to achieve a "fully engaged scenario" would have serious implications for the nation's ability to resource health care in the future.

What form of patient and public involvement is desirable, practical and offers value for money?

  13.  The Kennedy Report, which emphasised the value of patient and public involvement (PPI) stated:

    "There are, perhaps, four principal areas in which the involvement of the public is most pressing, arising from a commitment to a patient-centred NHS. They are: the development and planning of services; the operation and delivery of services; the competence of healthcare professionals; and the protection of vulnerable groups. In each case the public must be involved at all levels from the national to the local."[9]

    "The problem...concerns how, in a modern democracy, a public service such as the NHS can have embedded within it not only the principle that it exists to serve the public, but also mechanisms to ensure that this aspiration is translated into reality." [10]

  14.  Writing on deliberative democracy, the Stanford University academic James S Fishkin concluded that "getting the informed and representative views of the public requires a means to facilitate discussion and grant access to good information and differing experts, and a public space where people feel free to express themselves." [11]

  15.  Health professionals and health service managers have a well-established role in decision-making, as have institutional stakeholders such as local government in social care; historically neither patients nor the public have been included.

  16.  Fully involving patient and publics in decision-making requires the following to be in place:

    —  A clear policy direction.

    —  Supporting legislation, setting out rights, duties and governance.

    —  Appropriate resources.

    —  Sufficient capacity.

    —  A means of knowledge sharing.

    —  A process for escalation.

  17.  CPPIH believes there must be publicly funded mechanisms to facillitate patient and public involvement, not least because of the current pace of profound reform in health and social care. These mechanisms should be governed within overall legislative frameworks which provide:

    —  a remit to secure the full involvement of local communities;

    —  a statutory right for patients and the public to be involved in decision-making locally, regionally and nationally;

    —  a focus to address deficiences in equality of access especially for those that are less often heard;

    —  a clear opportunity for escalation;

    —  processes to ensure value for money; and

    —  the ability to review and learn from experience in the rapidly changing environment of health and social care.

  18.  Involvement should occur at every level of decision making but should be appropriately focussed in order to be practical and provide value for money.

  19.  In commissioning and planning a priority should be to secure a role for representatives of the public in decision-making and policy making locally, regionally and nationally. A useful model might be that of trade union representatives involved in collective bargaining, where a representative has the authority to negotiate with management on behalf of the work force derived from the fact that he or she represents the views and interests of other people.

  20.  This type of involvement would also be effective in improving public "ownership" of the challenge and complexity of decision making in health and social care involving finite resources in the service of ongoing and growing demand. There is strong evidence that understanding and commitment are much improved if people feel they have been actively involved, or properly represented, in decision-making.

  21.  Public involvement is key to addressing deficiencies in equality of access to health and care services by ensuring the needs of disadvantaged sections of the population, and of people with certain conditions, are properly met.

  22.  At a service improvement level, patient involvement should ensure that a wide range of experience is transmitted to and taken seriously by decision-makers particularly that of the less often heard. It should be a means to ensure that vocal and powerful patient interest groups do not dominate debate.

  23.  Patients can help secure efficient services, for instance by commenting on management processes that do not fit in with people's needs. An example of this is the perverse practices used to achieve government's target that all patients should be able to see a GP within 48 hours (itself the result of public demand) which in some instances, prevented patients from making advance appointments. Considerable inconvenience could have been avoided had the patient perspective been sought (and indeed GPs) and acted on at an earlier stage. As it was the issue was only taken seriously when it was raised with the Prime Minister on live television.

  24.  Patients can further contribute to effective service delivery by commenting on the human elements of treatment, for example on whether health professionals treat them with dignity and honesty, convey useful information about their treatment and make them feel confident they are getting the best care.

Why are existing systems for patient and public involvement being reformed after only three years?

  25.  Health and social care is undergoing substantial reform and it is to be expected that changes will be needed in the infrastructures for, and focus of, PPI especially as they themselves are still growing and developing.

  There is a therefore an ongoing need for formal review and assessment of how PPI is developing alongside this changing landscape of health and social care in order to provide evidence for any further changes to be made.

  26.  CPPIH agreed with the Department of Health's decision to take a fresh look at patient and public involvement in the light of very significant NHS reform and changes in social care. We had already told the Department that the current arrangements are inflexible, including the statutory requirement of one forum per trust, and placed far too much responsibility on too few people to deliver effective public engagement, let alone on the scale required in the reformed NHS. The regulatory framework stemming from PPI Forums" inspection role brought with it a bureaucracy that many potential forum members found off-putting.

  27.  However, the reform process has unfolded against a background of constant change in policy and an unclear direction. Its origins lie in the Department of Health announcement in December 2003 that a review of Arm's Length Bodies (ALBs) would take place in the first half of 2004, as it wanted to reduce the number of its sponsored ALBs, reduce the staff headcount and achieve a significant saving in expenditure. The Commission for Patient and Public Involvement in Health was included in the Review of ALBs only two weeks after it became operational.

  28.  At first it was expected that the DH would merge CPPIH with another ALB (probably the Healthcare Commission), however, on 22 July 2004 the Department announced it would be abolished.

  29.  On the day of the announcement of its abolition, the then Minister for Health, Melanie Johnson MP, said of the CPPIH:

    "I emphasise that our decision to abolish the commission was not borne out of concerns about its performance... The commission's performance, particularly its achievement in setting up the forums and recruiting about 5,000 members within a tight time scale, is highly commendable."

  30.  It appears, therefore, that the ALB review was the initial driver of of PPI reform, rather than a change in PPI policy in Whitehall or concerns about CPPIH's performance. Whereas CHCs had been in existence for about 28 years, CPPIH had hardly been operational for sufficient time to draw any conclusions about its effectiveness in carrying out its organisational and wider public responsibilities. However, the consequence of this decision was to leave the Depatment of Health with the task of finding an alternative body to oversee PPI Forums and appoint Forum Members.

  31.  At that stage PPI Forums were seen as continuing to play a vital role. The Health Minister Rt Hon Rosie Winterton MP had written to Forum Members on 28 May 2004:

    "I want to reassure you that the future of PPI Forums is safe. PPI Forums whilst still in their early days are beginning to carry out valuable work and I am pleased with the progress that is being made. We do not want to waste the opportunity we have got with forums to make a difference to the NHS and people's experience of it".

  32.  This message was reinforced to Forum members in a letter from the CPPIH Chair and Chief Executive on 23 July 2004:

    "Ministers have made clear that PPI Forums themselves will continue to exist, referring to them as the `cornerstone of the new arrangements'."

  33.  It was also proposed on 22 July, 2004 that the NHS Appointments Commission would take over forum member recruitment and performance management and Forums would develop links with the Healthcare Commission. Meanwhile the numbers of Forums would be reduced, with the abolition of NHS Trust Forums, Ambulance Trust Forums and Mental Health Trust Forums. Instead, there would be one PPI Forum for each Primary Care Trust.

  34.  The Department of Health embarked on a limited consultation exercise which concluded in March 2005 that the remit of PPI Forums was too broad, and that forums should concentrate on monitoring and reviewing NHS delivery, seeking the views of the public and making recommendations to the NHS.

  35.  In August 2005, however, following a decision to postpone the abolition of CPPIH (scheduled for August 2006), to the summer of 2007, the Department of Health embarked on a Strategic Review of PPI and abandoned the proposals referred to in paragraph 33.

  36.  This coincided with other Department of Health policy streams: the national consultation exercise in autumn 2005 leading to the Our Health Our Care Our Say White Paper on healthcare outside hospitals and the publication in July 2005 of "Commissioning a Patient-Led NHS" which proposed to that Primary Care Trusts' primary role would be commissioning, heralding a push towards a greater plurality of service providers, greater use of the private and voluntary sectors to provide services to NHS patients and the marketisation of the NHS.

  37.  CPPIH put forward proposals in November 2005 for supported local health networks, with a much larger individual membership, and local voluntary and community sector involvement, to the Minister of State for Health. We envisaged health networks being funded, supported, performance managed and championed by a new national body and developing from existing PPI Forums at their core.

  38.  CPPIH was inexplicably excluded from membership of the subsequent Expert Panel which sat between March and May 2006, chaired by Harry Cayton, Director of Patient Experience and Public Involvement at the Department of Health and Ed Mayo, Chief Executive of the National Consumer Council. However, we believe our proposals influenced the recommendations contained in "A Stronger Local Voice".

  39.  CPPIH supports the department's aim of introducing more local flexibility and ensuring more people are able to become involved.


  40.  Decisions about health and social care are made at a variety of levels. While some are made locally in individual trusts, others are made in PCTs, local government, SHAs and nationally. To be effective, PPI and particularly public involvement needs to be in place at all of these levels.

  41.  In this context Local Involvement Networks (LINks) as set out in A Stronger Local Voice will achieve only some of the objectives set out in paragraph 4. LINks are likely to be most effective in delivering patient involvement in local decisions about operational delivery and providing patient and some public involvement in local commissioning decisions.

  42.  CPPIH has serious concerns about the LINk related clauses in the Local Government and Public Involvement Bill (clauses 153-164). Far too much is left to local discretion with little of the detail in the primary legislation, relying heavily on secondary legislation.

  43.  This is likely to result in a lack of uniformity and lead to significant service quality variations in LINKs (creating another postcode lottery in PPI). (Ironically, these were criticisms of the old Community Health Councils. (CHCs system, which led to the establishment of CPPIH.)

  44.  Morover, being purely local organisations with a local remit LINKs as currently described will have no mechanism or remit for influencing for example regional decisions on major service redesign or reconfiguration, or on national policy.

  45.  The CPPIH view is that further attention should be given to national co-ordination and oversight as described in the following sections.


  46.  Clause 153(2) of the Local Government and Public Involvement Bill sets out the remit of LINks. It states that the activities to be carried out are:

    —  promoting and supporting the involvement of people in the commissioning, provision and scrutiny of local care services (services provided as part of the health service in England; or services provided as part of the social services functions of a local authority);

    —  obtaining the views of people about their needs and experiences of local care and making those views known; and

    —  making reports and recommendations about how local care services might be improved to persons responsible for commissioning, providing, managing or scrutinising local care services.

  47.  CPPIH welcomes the inclusion of social services as well as health services within the remit of LINks. In addition we recommend that LINKs have additional responsibilities to:

    —  tackle the barriers to engagement, ensuring that powerful interests do not dominate debate or indeed their own proceedings; and

    —  address deficiencies in equality of access to services especially for those that are less often heard.

  48.  We are concerned that the legislation only refers to local care services. Additional mechanisms and approaches are required which can influence decisions at all levels including high level strategic and commissioning decisions. These mechanisms should involve LINks working together in a co-ordinated manner to provide involvement in these other decision-making processes.

  49.  Independence is important for the LINks to be credible and to avoid undue influence by health professionals, managers and local government, especially where local government itself is responsible for the provision of services. In the CPPIH experience the very fact that PPI Forums are independent organisations has been crucial to attracting volunteer members, yet the Bill is silent on this matter.

  50.  LINks should be accountable to local communities for the substance of their work, and to an outside authority, for performance management purposes—to ensure each LINk performs to national standards, offers effective leadership, works in line with best practice and has appropriate governance in place. To avoid conflicts of interest or politicisation the outside authority should not be an NHS body or the local authority. No such body is planned as a successor to CPPIH.

  51.  CPPIH regrets that the Local Government and Public Involvement Bill makes no provision to hold individual LINks to account beyond the requirement to produce an annual report according to the direction of the Secretary of State.


  52.  To ensure the LINk performs effectively, it should, by statute, have a governing body on which representatives of individual members and representatives of the local community may serve. This body would be responsible for making decisions about its work and the allocation of resources, communicating with the wider membership and representing the LINk to stakeholders, the media, elected representatives etc.

  53.  The governing body should be required to adhere to Independent Commission on Good Governance in Public Services standards to ensure the LINk is well directed and controlled, and has transparent rules for making decisions about objectives, priorities and its use of public money.


  54.  CPPIH regrets that the Local Government and Public Involvement Bill is silent on membership and governance of LINks and does not allow the Secretary of State the power to make regulations on such matters. We believe the LINk should have a formal membership and actively encourage and support new members and recommends the Bill be amended accordingly.

  55.  The CPPIH welcomes and strongly supports the move towards broadening and simplifying LINK membership. However, we continue to urge an evolutionary transition from PPI Forums to LINks. In the past three years, forum members have acquired considerable knowledge of their local NHS, and developed relationships with trusts, with local community organisations, with the public and with Overview and Scrutiny Committees. That experience and those relationships will be crucial to making the new system work.

  56.  For individuals, membership would confer benefits such as access to training, a right to submit proposals for the LINks work programme, and the right to take part in LINks internal decision-making. Members would also receive information and access opportunities for wider involvement in civic life.

  57.  Voluntary and Community sector organisations should also play a significant part in the LINks work. There could be a federal membership structure with separate sections for individual members and representatives of VCSOs.

  58.  There should be some national criteria and rules for membership to avoid the inconsistency in membership rules (and indeed governance arrangements) which were a feature of Community Health Councils and which the Department of Health itself used as a justification to abolish them .


  59.  The CPPIH experience of the the current Forum Support Organisation system demonstrates that support needs to be available locally, based on providing secretarial, administrative and organisational support, research and outreach

  60.  Capacity for effective involvement is currently limited and needs to be nurtured, to encourage and promote involvement and ensure that people have the level of knowledge and understanding of how health and care services are organised and delivered and of the decision-making processes to contribute effectively.

  61.  Effective PPI requires a substantial investment in capacity building, particularly within local authorities serving large or diverse populations, or large geographical areas with both urban and rural communities, or areas with high levels of deprivation.

  62.  To achieve this, training and support needs to be available to participants, particularly those who have not engaged with healthcare decision-makers before.

  63.  CPPIH (and other organisations) have begun to build capacity for involvement in service improvement and operational delivery, although this is a continuous process and needs to be sustained. We have begun capacity building in the areas of PPI in commissioning but this is still at an early stage. Capacity for PPI in the development and planning of services still needs to be developed.

  64.  LINks should also have access to research, policy and communications capacity to match that available to commissioners and providers of health services.

  65.  Policy and strategic decisions affecting local healthcare are also made regionally by SHAs or by national government, therefore local PPI organisations will benefit from a means to share information and good practice, comment on health and social care policies, work together in a co-ordinated way and have an effective escalation process to ensure involvment in regional and national decision making.

  66.  There should also be a national framework of support to carry out detailed research, procure legal and policy advice, share best practice and facilitate communication between LINks.


  67.  The Government response to a Stronger Local Voice set out a huge range of tasks for LINks including developing relationships with a wide range of individuals and organisations and maintaining regular communication in a wide variety of formats, collecting information from a wide range of sources and passing that on to commissioners and providers of services, regulators and inspectorates; developing specific relationships with local commissioners, service providers, OSCs and regulators of health and social care; acting as a hub for networks of service user groups and other organisations.

  68.  A considerable budget will be required to realise the Government's ambition of the public being involved in decision-making, particularly involvement with commissioning and the development and planning of services. CPPH recommends that decisions about proposals to reform PPI are made in full knowledge of the resources and funding that will be made available to deliver them.

  69.  The legislation that established PPI Forums and the CPPIH was decided in the absence of this information and consequently many of the intentions of that legislation were unachievable due to funding restrictions.

  70.  Historically, very limited resources have been devoted to PPI. In 2005-06 the Department of Health expenditure was £74.8 billion; the CPPIH budget was £31.7 million, (reduced to £28 Million in 2006-07). CPPIH and PPI Forum expenditure thus represented 0.04% of the total Department of Health spend in 2005-06.

  71.  An analysis by the Commission on the budget required to deliver even the local LINk proposals gives a budget requirement of £64 million—more than twice the CPPIH budget. It should be remembered that many LINks will be required to deliver PPI over large geographical areas.

  72.  In 2006-07 CPPIH had a budget of £28 million and if all of this money was divided equally between the 150 LINKs this would amount to circa 180k each. Our understanding is that a formula will be applied so LINks that cover a bigger population ie Manchester will receive more than LINKs that cover a much smaller area ie Isles of Scilly. Based on our experience of running Forum Support Organisations a typical LINK would need to receive a budget of over £424k. CPPIH can provide a breakdown on request.


  73.  LINks should focus on securing systematic local public involvement in improving health, social care and public health, from local service improvement through to commissioning and strategic decision-making. This is not just about gathering and presenting public views but helping people input directly to decision-makers and securing change based on that input.

  74.  They should also work together in a co-ordinated way and have an effective escalation and representation process to ensure involvment in regional and national decision-making.


  75.  These are important to ensure LINks avoid becoming mere talking shops and are able to make a real impact on decision-making.

  76.  CPPIH is pleased that the Local Government and Public Involvement Bill confers on the LINk the right to demand (and receive) information from service providers and make reports and recommendations. However, we are concerned that rights of referral to Overview and Scrutiny Committees seem to be restricted to referrals of social care matters.

  77.  PPI Forums have powers under the NHS Act 2006, to refer any matter they consider appropriate, for consideration by a relevant overview and scrutiny committee, or any other authority the Forum thinks fit.

  78.  Clause 156 of the Bill (Service Providers duties to allow entry to authorised representatives of the LINk) includes provision for conditions to be satisfied before a duty arises, including:

    —  provision limiting the extent of a duty;

    —  provision for imposition of conditions and restrictions;

    —  limitation of the duty to allow entry to certain types of authorised representative; and

    —  limiting the hours during which a duty applies.

  79.  Existing Forum members have been clear about the value they perceive in their existing powers of inspection. While the CPPIH welcomes the inclusion of these powers it fully supports the limiting of them to a restricted number of authorised representatives of each LINk. In our view this supports the need for some powers of inspection but also supports the objectives of wider involvement and simplification of the general membership processes.

  We are, however, concerned that the proposed rights of entry are more limited than those currently enjoyed by PPI Forums and urges conditions to be kept to a minimum.

  80.  Representative of LINks with powers to enter premises where services are provided, will have to be subject to inquiries into their suitablilty, including criminal records checks as PPI Forum members currently are. The government must make clear who is responsible for these inquiries and for training authorised representatives in the effective use of powers and how these activities wil be funded and resourced.

  81.  CPPIH recommends that LINks should also:

    —  Have powers to commission research and other work from outside organisations when necessary.

    —  Have the means to develop guidance and share best practice as well as to raise public concerns at regional and national level. It would be more cost effective to provide such support at a national level.

  82.  CPPIH recommends that there should also be statutory rights for the public to participate in decisions about strategic commissioning and service planning and the power to secure a review of decisions if it believes they were taken without meaningful consultation or effective patient and public involvement. These strategic decisions may often be made at regional or national levels and mechanisms must be provided for LINks to work together to provide involvement outside their local remit.


  83.  CPPIH agrees LINks should focus on the "whole patient's journey" rather than on institutions. Nevertheless, they will need effective relationships with trusts, which should draw on their ability to network. LINks should play the role of the trust's critical friend, making available advice and local knowledge. A relationship with the local LINk would be one of the means by Trusts could involve people. However, merely involving the LINk would not relieve the trust of its duty of wider consultation.

  84.  The current experience of PPI Forums associated with specialist Trusts has clearly demonstrated the value of these specific relationships. With the planned abolition of PPI Forums, mechanisms need to be in place to ensure that this value can continue to be delivered within the larger LINks. There is a need to ensure that specific relationships with specialist Trusts can be maintained for service users.


  85.  Given time, local LINks may themselves develop mechanisms for working together and gaining involvment in regional and national decsision-making provided that those opportunities are made available to them.

  86.  However, the experience of the CPPIH is that, in the same way in which capacity has needed to be built at a local level for local involvment, some driving and supporting mechanism is required to build capacity for regional and national involvement. This is especially so in strategic decision-making, planning and development of services if these are to occur in the timeframe required to support the significant changes and reform currently underway in health and social care.

  87.  Throughout this section we have identified the need for a framework outside the individual LINks to:

    —  Support patient and public involvement at regional and national levels.

    —  Provide co-ordination for local LINks to work together.

    —  Encourage communication between LINks and the sharing of best practice.

    —  Provide leadership for capacity building.

  88.  And a national framework for service quality and governance to ensure a degree of consistency in LINks local operations.

  89.  There is a therefore an ongoing need to review and assess how PPI is developing alongside the changing landscape of health and social care.

  90.  This framework should have access to the knowledge and expertise built up by CPPIH and could evolve from the existing organisation. An appropraiate body to deliver these functions should iteslf be independent of governemnt and accountable to Parliament.

  91.  Based on the CPPIH experience with PPI Forums and NHS trusts there is bound to be disagreement from time to time between independent PPI organisations and health and social care managers and professionals, and seek to ensure that public concerns can be built onto the policy making process at local regional and national level. A national organsiation would, for example, help a LINk raise issues which cannot be resolved locally or which have regional significance, with strategic health authorities. In cases where there is a national dimension, it could provide a powerful voice for LINks at national level.


  92.  There are many mechanisms for involvement, of which LINks will only be one. All public sector organisations should seek to involve the public in their work and it is inevitable the work of LINks will overlap with this. Given the current stage of development of PPI it is unavoidable that there will be multiple mechanisms, multiple opportunities for the public to be involved and some confusion and overlap. However it is important that LINks remain a clear independent voice to provide involvement even where other mechanisms are not in place or are not fully effective. However, more will be achieved through co-operation and LINks should be encouraged to develop productive relationships with other bodies.

  93.  The current structures for health and social care planning and delivery are only now beginning to move towards a "Patient led NHS". In addition to professional dominance within health and social care, there is a democratic deficit as neither the public nor their representatives can force local decision-makers in PCTs and trusts to reconsider proposals. One of the aims of PPI should be to help promote democracy and accountability, and this should be embedded in the relationships of LINks with other bodies.


  94.  A report published by the Centre for Public Scrutiny found that the Overview and Scrutiny Committee "holding to account" function is underdeveloped. [12]OSCs have no powers to overturn decisions, relying instead on persuasion and argument for influence. Productive relationships with LINks should help OSCs develop that role, with LINks acting as expert witnesses. They should be able to refer inform and advise the OSC, have the right to have their issues place on the OSC agenda and have speaking rights.

  95.  LINks and OSCs should be encouraged to carry out joint planning of work programmes, but without compulsion on LINks to adopt the OSC's priorities.

  96.  Overview and Scrutiny Committees may refer matters to the Secretary of State for Health, but it is she, not the OSC, who makes the final decision. PCT and NHS Trust Boards are accountable to the Secretary of State, not to representatives of local communities.


  97.  As with all Trusts, LINks should play the role of the trust's critical friend, making available advice and local knowledge. A relationship with the local LINk would be one of the means by Trusts could involve people. However, merely involving the LINk would not relieve the trust of its duty of wider consultation.

  98.  The primary roles of Foundation Trust boards and members councils are related to governance of institutions. They are not representative in nature, they do not guarantee accountability through patient and public involvement and the two roles should not be confused. The first responsibility of board members is to the board, not to the community.

  99.  Foundation Trusts are not accountable to the Secretary of State, instead local residents registered as members of the foundation trust have the right to vote for members of the board of governors. It is unclear how foundation trust members can exercise real influence over the running and development of the trust. Moreover, membership of foundations trusts is self-selecting and not representative of many groups within local communities.

  100.  LINks should, however, be encouraged to develop relationships with Foundation Trust Boards and members councils without compromising their independence.


  101.  LINks will need to work closely with inspectorates, such as the Healthcare Commission and Commission for Social Care Inspection, to be an active stakeholder in annual performance reviews by Trusts and by regulators and in between those to alert them to serious concerns about service providers. CPPIH recommends LINks be given the power to refer matters of concern to an inspectorate as appropriate and that the Inspectorates have a duty to consult LINks.

  102.  It is vital that inspectorates also involve the public in decisions about their own activities. PPI has a key role to play in public accountability of the role of inspectorates themselves.


  103.  CPPIH does not envisage LINks playing a role in assisting or acting as advocates for individual complainants. However, information about services generating significant numbers of complaints would alert LINks to service issues in their local area and should be regularly provided in summary form.

  104.  In addition LINks should have a role in establishing patient and public views on the performance of the Independent Complaints Advocacy Services.


  105.  The value of consultation is that it brings the public together in making decisions about finite public resources. This should happens at all levels locally, from service delivery to commissioning and strategic planning, and nationally at the policy level. CPPIH welcomes the Committee's attention to Section 11 of the Health and Social Care Act, (now section 242 of the National Health Service Act 2006).

  106.  There should be an explicit duty on health and social care decisions-makers to consult LINks. At a minimum consultation should be carried out on decisions about the following:

    —  What services should be provided.

    —  Reconfiguration of services.

    —  Where services should be provided.

    —  The criteria for outsourcing services.

  107.  We are concerned that the proposed amendments in clause 163 of in the Local Government and Public Involvement Bill narrow the range of issues on which consultation is required to proposals which would have a substantial impact on the manner in which the services are delivered to users of those services, or the range of health services available to those users only.

  108.  The Committee will recall there was no requirement to consult under section 11 over the recent PCT reconfigurations as these were classed as managerial and administrative decisions by the Department of Health and considered to have no connection to service delivery. The consequence of this was that objections that such changes could adversely impact on service delivery were overridden.

  109.  CPPIH recommends that there should be a requirement to consult on major structural change such as large scale reconfigurations of organisations charged with securing the delivery of public services.

  110.  Similarly in the case of Pam Smith v North East Derbyshire PCT, established the principle that the public should be consulted on the outsourcing of local NHS health services.

  111.  CPPIH recommends PCTs have a duty to consult on outsourcing of NHS health services and build local concerns and wishes into tendering processes for commissioning services.

  112.  Finally, there is a widespread public perception that consultation occurs after decisions have already been made, and that taking part will not materially affect the outcome. CPPIH welcomes the new duty in clause 164 of the Bill for PCTs to report on consultation arrangements and the influence that the results have had on commissioning decisions. (Clause 164).

  113.  CPPIH recommends Clause 164 include a duty on PCTs to ensure that decisions on options for consultation are open to public influence and clearly reflect local wishes and concerns. This could be modelled on the Disability Equality Duty under the Disability Discrimination Act 2005 which creates a duty on public authorities to involve disabled people in developing their disability equality schemes. [13]

Commission for Patient and Public Involvement in Health

10 January 2007

9   Bristol Royal Infirmary Inquiry Final report Chapter 28, "Public Involvement Through Empowerment", July 2001 CM 5207. Back

10   ibid, "What is the Agenda for Public Involvement". Back

11   "The Nation in a Room-Turning public opinion into policy" Boston Review March/April 2006. Back

12   Process, Progress and Making it Work. Health Overview and Scrutiny in England Centre for Public Scrutiny 2005 page 7. Back

13   Disability Discrimination Act 2005 Section 49a. See also Guidance for public authorities on how to effectively involve local people Disability Rights Commission July 2006. Back

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