Select Committee on Health Written Evidence

34. Evidence submitted by Gateshead Hospitals PPI Forum (PPI 2)

1.   What is the purpose of Patient and Public Involvement?

  To ensure that delivery of health services meets local needs & desires and is not solely subject to national targets and directives.

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

  A system which allows local people to be involved in:

    —    Determining local priorities.

    —    Mapping existing provision and identifying gaps.

      Designing the service specification—including methods & locations for service delivery, as well as quality levels and monitoring.

    —    Includes significant lay involvement in the actual monitoring of the services.

  This obviously requires a fairly small group of people with knowledge of the local health economy, supported by paid staff, who can interact with a wide range of people and bodies.

  Value for money is a relative judgement. If the government believes—as it claims—that local people are best placed to determine what health and social care needs exist, then it has to pay a reasonable sum to ensure involvement is effective. This is surely better value than the amounts which are spent on external consultants whose reports rarely fit into local needs.

  Expenditure on supporting the Commission for Patient & Public Involvement and PPI Forums has been significantly reduced in the last year and is further reducing in 2007. This is significantly weakening the resolve and capability of PPI Forum members.

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

  No idea!!

  There is considerable evidence that PPI Forums were beginning to make an impact locally, regionally and nationally. If there are parts of the country where PPI is not as effective as it is elsewhere the effort should have been put into improving these areas—not destroying the rest of the system.

  In addition to the actual impact on health service provision PPI Forums are also increasing their contacts with local groups, effectively creating the networks that LINks are designed for.

  CPPIH and Forums were destabilised from the beginning with the Dept. of Health announcing a Review of Arms Length Bodies just after Forums were formed. Almost as soon as this announcement was made there were rumours that CPPIH would be abolished and Forums were facing an uncertain future.

  PPI should have been given at least five years to mature and make the desired impact. The NHS is a very complex structure and the vast majority of people have no idea of the difference between primary and secondary care. They are not even concerned about this distinction and, as far as they are concerned, they deal with the NHS as a single body. If significant changes about the way the NHS works are being introduced—as is the case—and more emphasis is being put on "local" services, it becomes obvious that patient and public input needs to come from people with a reasonable understanding of the implications. In many cases this means PPI Forum members who have spent 3 years building up knowledge.

4.   How should LINks be designed?

Remit and level of independence:

    —    To identify local priorities and concerns;

    —    To be totally independent of both the NHS and local authorities, so that the public perception is that LINks are there to represent them and not the vested interests of public bodies or politicians;

    —    The remit and responsibilities should be made clear from the outset because they will in part determine the structure and organisation of LINks and affect how membership is determined .

Membership and appointments:

    —    Membership should be open to anyone who has knowledge of, or an interest in, local health service delivery;

    —    However, members should have a wide perspective on health issues and not be allowed to promote a single group or individual condition;

    —    Decision making should be by consensus and anyone with a potential conflict of interest should declare it (eg someone who represents a group who are or will be applying for contracts to supply services to the NHS or local authority OR represents a group which campaigns for a particular condition);

    —    People falling into this category should bring information and expertise to the discussion but not take part in the actual decision making;

    —    Each LINk should decide how it wants to operate and this will inform how members are appointed;

    —    The exception to this is, as is currently the case with PPI, senior officials and managers of NHS Trusts and local authorities, as well as local politicians involved in Health and Social services scrutiny.

Funding and support:

    —    Funding should be guaranteed and available for a minimum of five years (subject to performance);

    —    Funding should be at "full cost recovery" and include increases for inflation and salary progression;

    —    It should include sums for publicity and, as necessary, employing specialist consultants;

    —    It should include a reasonable sum for training LINks members and reflect the fact that there will be considerable turnover—so training will be ongoing;

    —    Support should reflect the fact that LINks members will be volunteers with limited time and the support cannot be purely administrative. It has to include research and an understanding of policy and strategy.

Areas of focus:

    —    Geographically, primarily within a local authority area but, because the NHS makes many decisions at a sub-regional, regional and national level LINks must be able to interact and do the same;

    —    Specialist NHS Trusts such as mental health, ambulance and rare conditions need to be responsive to all of the associated LINks—possibly through the Commissioning process.

    —    The focus in terms of services should reflect the priorities and concerns of local people.


    —    It is crucial that LINks have the ability to require information and monitor/inspect as part of the assessment of the actual delivery of services;

    —  There is no point in spending months—even years—involving people in the design of a service and then stopping them seeing how well it is being delivered;

    —  This becomes even more important when dealing with services commissioned from the independent sector. The public is paying for these services and expects to be able to make the same demands on the private sector as it does the public sector.

    —    "Commercial confidentiality" has nothing to do with the quality of service delivery and independent/private sector providers should be subject to the same accountability as the NHS or local authority;

    —    Nor should LINks only be allowed to exercise these powers under the direction of another body (eg the Healthcare Commission). LINks need to be able exercise these powers as they deem fit to carry out their own duties, not someone else's.


    —    It makes perfect sense for LINks to work constructively with the NHS (and local authorities). LINks need to understand the pressures placed on these bodies by central government and this can only be achieved by open and honest discussion;

    —    However, where LINks identify a problem, they should be free to highlight it and seek corrective action from the NHS or local authority. In the absence of acceptable remedial action LINks need to be able to raise their concerns at another level;

    —    As indicated above, there are NHS Trusts which cover a number of local authority areas and their accountability should be to all the LINk areas they serve.


    —    LINks need to be able to identify best practice from around the country AND make enquiries to see if a problem they have identified is purely local or, in fact, has arisen in a number of areas;

    —    There is also the possibility that the issues identified by LINks are the result of a national policy and the only way they can be resolved is if that policy is amended or scrapped;

    —    In the absence of a national "route" for LINks this is unlikely to happen.


Local Authority structures including Overview and Scrutiny Committees:

    —    There are different powers and concerns for these bodies so they each have to recognise these differences and try to establish suitable relationships;

    —    Both LINks and OSCs will have work programmes and, at the very least, they should share these with each other;

      —  In doing this they would know whether an issue which has been brought to the attention of a member of the LINk or OSC is already being considered and whether or not there is scope for joint working;

    —    Unfortunately you cannot force LINks and OSCs to work co-operatively, even where this would be sensible. There are issues of capacity (OSCs have work passed to them by local Cabinets, as well as having a statutory duty to look at particular LA policies) and they may not be able to take on extra work. Equally, LINks will have competing demands on their time and face the same problem;

      —  This reinforces the need for a national route for LINks—if OSC declines to investigate a topic the LINk thinks is appropriate for the OSC the LINk needs an alternative way of tackling it.

Foundation Trust Boards and Member Councils:

    —    Until such time as a Foundation Trust Board can demonstrate that it uses its membership fully and effectively to identify local priorities and needs it should be required to work constructively with LINks;

    —    Even when Foundation members are active and fully engaged the LINk could continue to provide an additional source of information to the Trust;

    —    Foundation governors have a different remit from LINks and, in fact, have very limited "powers" when compared with the current PPI Forums. Exchanging views and information—in the same way LINKs and OSC should—would encourage constructive engagement with the Trust as a whole;

    —    Gateshead Health NHS Foundation Trust is a good example of what can be achieved where the PPI Forum has the right to appoint a Governor and this individual is able to take issues back and forward between the Governors and PPI Forum and identify the best route to investigate and resolve problems.

Inspectorates including the Healthcare Commission:

    —    Information from inspectorates can be very useful to LINks;

    —    Equally, the views of LINks could act as a prompt for inspectorates to investigate certain aspects of a Trust's service delivery in more detail;

    —    However, LINks should not, and cannot, be a tool of inspectorates. Where a LINk has the desire and capacity to help a particular inspectorate it should do so but no inspectorate should be able to force a LINk to do a particular piece of work.

Formal and informal complaints procedures:

    —    The volume of complaints, looking at social services and primary and secondary NHS delivery, would overwhelm a LINk;

    —    The NHS and local authorities have their own complaints systems (both formal and informal) and the role of the LINk should be to ensure these are widely publicised, easy to use and that the public can have faith in them;

    —    LINks should, however, have access to details of the types and numbers of complaints because they are an indicator of how the public perceives the service sunder consideration.

10.   In what circumstances should wider public consultation (including under Section 11 of the Health and Social Care Act 2001) be carried out and what form should this take?

  In the absence of details about the "strengthening" of Section 11 it is difficult to comment.

    —    The current requirement is that NHS Trusts consult over the introduction of new services or where there is "a proposal to make a significant variation" to an existing service. There should be a single national definition of the term "significant" and it should be agreed by patients as well as the NHS;

    —    It is important to ensure that Section 11 includes restructuring and reorganisation of the NHS. At the moment the NHS does not have to consult over these because they about "management" not service delivery. This is patent nonsense since changes to management structures have a direct bearing on an organisation's ability to deliver services;

      —  For example the recent PCT reconfiguration exercise. Some PCTs in the North East were merged but others, because of public opinion, were retained. However, those which did not merge were forced to make an equivalent management saving and have undergone a de facto merger whilst retaining their original names. The board and management structures, commissioning arrangements and HR functions have all changed;

    —    Consultation should take place over a reasonable period of time and take many forms to ensure that the widest possible audience is reached;

    —    Once consultation is concluded and decisions are made details of public comment obtained during the exercise should be released so that it can be shown that the NHS organisation took the comment into account;

      —  This should not be the Trust's own interpretation of comments received but the actual comments.

Gateshead Hospital PPI Forum

14 December 2006

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