Select Committee on Health Written Evidence

38. Evidence submitted by the Health Advocacy Partnership (PPI 99)


  1.  This response to the Health Select Committee Inquiry into future patient and public involvement arrangements is by submitted the Health Advocacy Partnership (HAP).

  2.  HAP is a not-for-profit Forum Support Organisation (FSO) operating to support PPI Forums that currently operate in Bath and North East Somerset, Bristol, Gloucestershire, North Somerset, South Gloucestershire, Swindon and Wiltshire. These forums monitor the activities of acute trusts, a reconfigured ambulance trust, mental health care trusts, both reconfigured county and unitary based primary care trusts, and a specialist national trust.

  3.  HAP is a member of Volunteering England; the Democratic Health Network (operated by the Local Government Information Unit of the Local Government Association); and the South West Rural Network.

  4.  Previously, HAP has contributed responses to the Department of Health's consultations on the Our Health Our Care Our Say White Paper and also the subsequent consultation on A Stronger Local Voice.

  5.  This response is based on experience acquired by HAP staff over many years of supporting public involvement under both the former Community Health Council and current PPI Forum arrangements. Though written from a support organisation perspective, we have tried to outline a practical vision of how future public involvement might effectively engage with local communities and individuals.

What is the purpose of patient and public involvement?

  6.  The purpose of patient and public involvement is to contribute the views of local communities, voluntary sector groups, individuals, service users and their carers to the design, development, delivery and assessment of local health and social care services. However, patient and public involvement is truly effective only if it is perceived that service providers really do take account of the comments made in their service planning, implementation and delivery decisions. There are still too many examples of NHS providers perceived as carrying out "tick box" consultations, which ignore local resident views. Such exercises are often viewed as shams because the local perception is that decisions have already been made. There are also examples of Trusts using current statutory PPI mechanisms—Forums and overview and scrutiny committee (OSC) arrangements—as a substitute for real involvement indecision making.

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

  7.  The credibility of future public involvement lies in the public knowing that the proposed LINk arrangements will be permanent and not transient, and that participants in public involvement are voluntary and independent from service provider influence. The attempt in the Local Government and Public Involvement in Health Bill to address the main shortcomings of the present public involvement system and to firm up the link between health and social care is welcome. The devil will be in the detail of how exactly the duties on providers will be delivered and how providers will be held to account through OSCs and the proposed Local Involvement Network (LINk) arrangements.

  8.  The shortcomings of the present patient and public involvement system are perceived to be:

    —  it ties statutory involvement arrangements through Forums into individual local health Trust providers;

    —  it breaks the ability to track the experience of patients and their carers through their treatment pathway when more than one Trust provider is involved;

    —  it exposes voluntary Forum members to local "political" and "interest" pressures from within local communities, pressures from Trusts to address NHS agendas;

    —  it limits member ability to take more strategic views of local health care provision;

    —  neither PPI Forums nor local OSCs are perceived by local communities and residents as being inclusive or representative; and

    —  the differing approaches and priorities of both Forums and local OSCs fail to deliver cohesion and any strategic vision of the health and social care needs of local communities, which enables Trust providers to adopt a divisive "tick box" approach to their public involvement role and dilutes the voice of local people.

  9.  Successful public involvement needs to be the eyes and ears and voice of the public. It can only partially be viewed as customer care activities, for it must adopt a more "critical friend" relationship with NHS or other service providers—being ready to both commend and challenge as appropriate. This can be integrated into other forms of citizen involvement to achieve good value for public money. Desirable and effective public involvement must be fully inclusive, offering practical ways to enable all local communities, interest groups and individuals to contribute their views—in ways that are most convenient to them—about the provision of their local health and care services. It is highly desirable that the public involvement is seen by the public and service providers alike as a vital element of both commissioning and delivery of health and social care at the community level.

  10.  The NHS needs to recognise that Trust structures to deliver such services are largely irrelevant to the local population. What is important to residents is the timely and efficient free delivery of quality health and social care at the point of need—with access to appropriate Trust contacts to raise issues of concern or complaint. Desirable and practical forms of public involvement can deliver good value for money but only if they actively seek to integrate the feedback and contributions of all those with an interest in health and social care provision.

  11.  A range of public involvement activities can work together within local communities to secure high quality health and social care services. There is evidence that statutory PPI, scrutiny and regulatory bodies can work with other interest and voluntary sector groups, local initiatives such as Expert Patient Programmes, Friends groups, and also Foundation Trust membership and governing bodies. It is desirable that public involvement is perceived to have proactive geographic and strategic responsibilities in relation to the design and development of health and social care services to reflect the real experiences of patient treatment, in addition to a reactive role to comment about the delivery of local services. It is therefore important that public involvement has the capacity, statutory powers and professional support to track health and care services within communities, irrespective of provider delivery involvement—with the added value ability to become a national, regional and local voice of the public.

  12.  Local public involvement initiatives must have the ability to contribute the public perspective to the activities of OSC scrutiny reviews and inspections and reporting by regulatory bodies—such as the Healthcare Commission's Annual Health Checks—and to respond with a public view to service crises as they arise. This can practically and effectively be achieved through public involvement monitoring and report activities, supported by lay visits and local surveys. However the delivery of desirable, practical and value for money public involvement can only be achieved if it is perceived by local communities to be effective in influencing the decisions of service providers. Effective public involvement cannot exist if Trust, local council and other service providers only pay "lip service" to their responsibilities to involve local people.

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

  13.  It is reasonable to question if value for money has been achieved from the expenditure of public funds on public involvement over recent years. If data were available, it would be interesting to carry out a best value comparison of public spending for the last three years of Community Health Councils (2000-03) with the first three years of PPI Forums (December 2003-06) in terms of the public involvement outcomes achieved and their impact in influencing change within the NHS. The present franchising arrangement to support PPI Forums adopted by the Commission has created an unacceptably high level of bureaucracy and associated costs without delivering a consistent approach to public involvement across England. There is not even a common procurement approach adopted with Forum Support Organisation contracting arrangements, resulting in very different support arrangements being available to voluntary Forum members.

  14.  The remit of current PPI Forums is linked to monitoring a single Trust provider and excludes social care, thereby limiting their ability to accurately reflect real patient treatment experience. Current membership of Forums does not accurately reflect the diversity, interests and health needs of local communities. Experience indicates that a significant number of Forums have struggled over the past three yeas to maintain the requirement of at least seven members as described in clause 2(1) of the Patients' Forums (Membership and Procedure) regulations 2003 (SI 2003 No 2123).

  15.  Very low numbers of voluntary members—most of whom work very hard on an individual basis to perform the requirements of their appointment—often result in Forums being exposed to "political", "interest", and even personal agendas. This can make it hard for Forums to respond effectively to the difficult decisions that Trusts are making to address their funding, operational and resource pressures.

  16.  The integration of health and social care necessitates changes to public involvement arrangements at local level. A review of the current public involvement system is therefore welcome. It is very important, however, to draw upon the evidence of good practices developed over many years by Community Health Councils and most recently by PPI Forums.

How should LINks be designed, including:

Remit and level of independence

  17.  The remit for LINk activity should be to monitor and report from a public perspective, with recommendations, on both the commissioning and delivery of health and social care facilities and services to their local communities. Use of current technology and on the ground resources can enable communities, groups and individuals to have easy access to their local LINk for information about health and social care provision, and to share their comments. Local resources and support must be available to enable those without access to technology to contribute in other ways.

  18.  Analysis of future public involvement activities shows that every LINk across England will need to consider a wide range of issues of health and social care provision, which fall into seven common themes:

    —  acute care;

    —  ambulance care;

    —  community-based care;

    —  continuing and chronic care;

    —  mental health care;

    —  public health care (and health promotion); and

    —  social care.

  19.  Patient treatment experience often crosses one or more of the above themes. Participation by more than one service provider in this treatment experience causes confusion. It must therefore be a remit for public involvement to ensure that individual care management, accommodating all of the various aspects of service provision, are efficiently delivered for the benefit of patients, their carers and relatives, and the public purse. There is also the common theme of addressing the funding, management and resource pressures facing service providers. Whilst it is possible to address these separately and in isolation, such an approach fails to tackle the "knock-on" impact of isolated decision making on other service delivery and detracts from the need to provide integrated, seamless health and social care within a community. Another remit of public involvement must be to ensure that adequate and easily accessible information is freely available to bring about a significant culture change in service delivery and ensure that communities, local residents and service provider staff are in a position to make informed choices and decisions

  20.  It is important that providers properly engage at an early stage of service design with local public involvement. It therefore becomes necessary to overcome the problems of perceived "confidentiality", which frequently cause providers difficulties with early disclosure of their plans. This might be overcome by making future Local Involvement Networks (LINks) arrangements also subject to the provisions of the Public Bodies (Admissions to Meetings) Act 1960. By making LINks responsible for a geographical area rather than provider based, it will enable local public involvement to retain independence from Trust and other provider organisations.

  21.  Independence from provider interests does not move LINks outside either the NHS or local government. Appropriate governance arrangements will be needed to facilitate relationships between participants within each LINk, with other health and social care stakeholders, and to drive forward constructive activities with measurable outcomes. A Code of Conduct for participants with a Complaints Procedure are considered essential tools in any governance arrangement.

Membership and appointments

  22.  It is important that LINks are perceived to be as inclusive as possible. Though each LINk will differ according to local needs, there are enough commonalities of approach nationwide to enable a basic job description and code of conduct framework for participants to be formulated.

  23.  It is essential to ensure commitment to LINks by developing a "sense of belonging" where each contribution is valued, and participants receive feedback about the effectiveness of their public involvement in influencing service provider decision making. There needs to be no limit to the numbers that can participate in LINk activities—either in relation to local health and social care provision or by contributing to commissioning, delivery or ethical debates and decision making over wider geographic areas. Most people are currently engaged in public involvement because they have or have previously had a very personal user or carer interest, or they have an "axe to grind" about some aspect of local health provision, or simply because they like the status and kudos. Effective engagement in public involvement activities stems from personal interest. Participation by communities, groups and individuals is likely to be founded on personal interests according to the issues that seem relevant to their local community at the time.

  24.  LINks should be able draw on the experience, expertise and interests of hundreds—even thousands—of local people acting either as individuals or collectively within community or interest groups. Current PPI Forum members should be invited to participate in LINKs to make use of their past experience and ensure that committed and continuous public involvement is maintained, especially during the transition period. There must be sufficient flexibility, resources and capacity built into local LINks to facilitate the ability for contributions to be made on an "opt-in, opt-out" basis as appropriate, without any other commitment required from the participant. Participants in the future may simply want to share their experiences or comments; to contribute answers to surveys; to ask questions and have them answered; to attend public discussions or meetings; or they may be willing to contribute their time and energies to some specific activity with clear terms of reference, a limited timescale and clearly defined outcomes.

  25.  LINk activities can be delivered through a variety of media—electronic, telephone or in person. There need be no requirement for more formal structures operating through committee arrangements that many find difficult to understand and relate to.

  26.  It is also questionable if the term "member" is appropriate to LINks. Membership implies a degree of exclusivity that is not compatible with facilitating the widest possible involvement of the public in health and social care provision. For the vast majority of individuals, it would be inappropriate to hold any personal data other than basic contact details. Certainly the current bureaucratic application and appointment system to Forums and the requirement for expensive Criminal Record Bureau (CRB) checks should not apply. There is scope for a limited number of individuals—perhaps held on a regional register—to undertake monitoring visits to health and social care premises. These "visiting" individuals should be subject to achieving approved standards—including satisfactory current CRB certification, participation in regular training and periodic appraisal. The criteria could be developed using the experience of the Appointments Commission. Access to individuals on the approved register should be available to obtain evidence to support LINks activities or as part of OSC or regulatory body reviews.

  27.  There is currently no requirement or incentive for employers to release staff to engage in public involvement activities. This could easily be overcome by making participation in LINks a "public duty" in line with such other recognised activities such as elected office or jury service. Leave of absence for employed members to participate in LINk meetings and activities can only happen if legislation provides for individuals to take paid leave from their place of employment. The support of employers will also be needed to make this happen. Added value to employer and employee might also be enhanced by recognising such public involvement participation for accreditation (external?) as personal, professional or corporate development—particularly when linked to defined project activities with measurable outcomes.

  28.  Clear definition of LINk roles and responsibilities, combined with a degree of continuity of purpose and clarity in communication will also assist to keep participants motivated. This can be reinforced through appropriate training and team building. An added advantage is that the larger the local LINk "constituency" in terms of numbers of participants involved, the less likely it will be that vested interests can exert undue influence on the outcomes of LINk activities.

  29.  Active and continuous local marketing will be needed to encourage the participation of communities, groups and individuals in LINk activities. Participation must be encouraged in both proactive activities initiated by the LINks, OSCs and service providers and also in the reactive issues that arise from time to time. Experience suggests that LINks will need a defined contact for their local community. This might be shared between a designated officer within the local "host" organisation and an individual nominated by the local LINk—possibly designated within the role of a Chair. Scope also exists for a named Chair to be appointed for each LINk for a predetermined period of time. This individual could be appointed by the Appointments Commission from applicants meeting agreed criteria or, alternatively, subject to election from amongst those registered as participants in local LINk activities.

  30.  Technology already exists to enable communities, interest groups and individuals to contribute comments, ideas and views on local health or social care provision; or to participate in their local LINk activities in ways they find most convenient and acceptable.

  31.  Consistent, continuous and high quality training—delivered to national standards—will be required to enable individuals and groups to participate in the activities of LINks. Training should be modular to be delivered electronically or in person through distance learning, seminars and workshops, or individual coaching. Key training will be regular "Induction" workshops delivered locally to describe "what is a LINK", statutory duties and rights; structure; support organisation and local working arrangements. More specialist training will be required for both LINk participants and "host" organisation support staff to enhance specific skills... Training can be delivered "in-house" or commissioned externally. Ideally training should be externally validated and certificated, leading to a recognised qualification that enhances an individual's personal development and social skills.

Funding and support

  32.  It is critical that adequate funding is provided to resource and support local public involvement activities, appropriate to each local community. All elements of supporting public involvement should be delivered to national standards.

  33.  Some core aspects of public involvement are likely to be common, wherever they are delivered—for example providing an interactive information "hub"; creating a brand profile for LINks; supporting aspects of training; participant training, and activities as appropriate, especially for those approved individuals or those "visiting".

  34.  The proposal that local authorities with social care responsibilities should commission external "host" organisations to provide support to local LINks is generally to be welcomed. It is essential to provide a real effective "host" organisation with a contractual remit to involve the widest possible cross section of the local community possible—amongst other responsibilities.

  35.  The Local Government and Public Involvement in Health Bill needs to be strengthened to reflect the Government's promotion of social enterprise and voluntary sector not-for-profit organisations as providers of such support. It is noted however than funding will not be ring-fenced but provided by means of a "specific grants" paid to each commissioning local authority. Recognising the need to recover their costs to procure and performance manage the "host" organisation, there should be a statutory limit on the amount that a commissioning local authority can "top slice" from their specific grant allocation for public involvement. The level should be subjected to testing and commentary by the LINk in their Annual Report—or by referral to some appropriate other body (Audit Commission or OSC) if deemed by LINk participants to be too high.

  36.  Funding and support should be appropriate to the needs of each LINk. The "one pot fits all" approach is not appropriate. Funding and resources need to recognise the impact of geography, urban and rural diversity, population density—and particularly reactive public involvement activities arising from local provider action to address funding, reconfiguration and resource pressures.

  37.  It should be left to "host" organisations to manage the staffing, premises and overhead cost elements of LINk support budgets, performance managed by the commissioning local authority under the contract arrangements. However, the "host" organisation should report costs of providing support to LINk activities to participants, who should be involved in setting spending priorities.

  38.  LINk activities should be focused on meaningful activities with measurable outcomes geared to meeting the health and social care needs of their local communities within the context of regional/national performance priorities.

  39.  It is not necessary for participants to be swamped with paper, nor is it appropriate for them to have deep understanding of provider issues, delivery structures or operating pressures. An efficient and effective interactive information "hub" is a vital element of public involvement to facilitate the sharing of knowledge and views. This could best be provided under national or regional contract arrangements, financed on a mandatory "buy-in" subscription basis from specific grant funds. Efficiencies and economies of scale can be achieved through regional and national activities, coordinated through Local Strategic Partnerships. Feedback of how contributions have been dealt with by service providers is essential and should be reported in the public domain and on the information "hub".

Areas of focus

  40.  Time and detailed planning is needed to successfully launch local LINk arrangements, drawing on the expertise of the NHS Centre for Patient Involvement and the Centre for Public Scrutiny to learn from the mistakes made when setting up Forums. There must be clear focus of all LINk activity backed up by expert support with clear points of contact. This can be delivered through a Work Plan that sets achievable targets with measurable outcomes geared to the resources and participation available, which would be reviewed on a regular basis.

  41.  Despite negative media coverage of financial and operational pressures, the NHS remains highly valued in the public psyche. A key focus of LINk activity should be work with local councils at all levels, with voluntary sector and interest groups, and with service providers to foster pubic interest and involvement in health and social care.

  42.  Common themes to focus LINk activity are described in paragraph 17. These can be covered through a series of task groups that report their efforts periodically to public meetings in their local communities.

  43.  The realities of patient choice, support for long-term conditions, the interface between health and social care providers, case management, and out-of-hours services are all legitimate topics for public involvement examination to provide local evidence to underpin national and regional service initiatives.

  44.  The health sector has often been perceived as a largely silent voice when planning community services. It is important that LINks are seen to play an active role in local community planning initiatives supported by all tiers of local government. To obtain a complete picture of the local health economy and local treatment pathways, LINks must focus their monitoring and report activities on both the commissioning and delivery of health and social care services. Common and consistent national and regional promotion of LINks through the media must be supplemented by regular, active marketing to local communities through engagement with local councils, voluntary sector and interest groups.

  45.  The effectiveness of public involvement will ultimately be measured by the extent to which government, local authorities and service providers are perceived by local people to heed and act upon feedback from LINks. There is a role for LINks in active local campaigning to enhance health and social care provision. LINks must be seen to support and assist the public to get their concerns aired. Creating or facilitating a public platform is not the same as "political" campaigning, which is best left to the new role envisaged for locally elected councillors.

  46.  LINks exist to be the eyes and ears of the public and to get the public's voice heard—independent from service providers—to report and provide evidence of local concerns. Their strength lies in their statutory rights to be heard, to ensure that answers are provided by service providers, and to refer to others if these are not satisfactory or forthcoming.

  47.  Continuous ongoing efforts are needed to encourage young people, ethnic minorities and other "harder to reach" groups to contribute in ways they find most convenient. In particular, LINks should start working with young people through citizenship, personal and social education so they become active citizens for life. Other areas of focus for LINk activities are:

    —  facilitating communication between the public and LINKs;

    —  providing information and case studies to help participants work effectively;

    —  covering generic local health and social care issues;

    —  working with other organisations in Local Strategic Partnerships;

    —  encouraging people to comment and feedback at "source" of treatment;

    —  providing "lay" voluntary perspectives to local inspections and service reviews; and

    —  engaging in Focus groups and public meetings.

Statutory powers

  48.  Statutory powers of the proposed LINk public involvement arrangements, as outlined in the Local Government and Public Involvement in Health Bill (2007), largely mirror existing powers. Clarification of the "Section 7" duty to consult the OSC on substantial variation and the "Section 11" duty to involve patients and the public in the design, development and delivery of services are generally welcome.

  49.  The additional power for LINks to receive a response from providers to reports, and from local OSCs to formal referrals, can only enhance the credibility of public involvement as an effective agent for change. The decision to retain the right of access to provider premises for the purpose of monitoring and reporting with recommendations amongst the statutory powers of LINks is also welcome. It would be helpful to recognise provision for announced, familiarisation and short-notice visits in future regulations—and to clarify all the premises that are affected, particularly if public involvement is to be extended to social care and other service providers, including GP and dentist practices. Statutory public involvement powers should be extended to include the 10 Strategic Health Authorities.

  50.  Social care providers are subject to best value scrutiny under internal OSC arrangements. There should be a statutory arrangement for LINks to receive copies of appropriate reports and to monitor how recommendations are being addressed. The current duty of PPI Forums to monitor the activities and reports of Trust Patient Advisory Liaison Services (PALS) should be restored to the powers of LINks—not least because PALS influence is being downgraded in many Trusts.

  51.  Many PPI Forum members would argue that there should be a duty placed on service providers to acknowledge and work with future LINk arrangements.

  52.  LINks should be recognised as a statutory stakeholder within the local health and social care economy, encouraged to operate within parameters agreed with Local Strategic Partnerships and eventually through contractual arrangements delivery through Local Area Agreements.

  53.  Considerable effort has been necessary to build relationships between Forums and Trusts -and there have been many examples of providers seeking to play Forum members off against their OSC counterparts. This needs to be extended to achieve a collaborative rather than competitive relationship. The concept of "best value" being introduced to health as well as social care is welcome.

  54.  Though public involvement on a geographic basis is largely strategic, it is important to be able to monitor treatment experiences on an individual basis—particularly in relation to care packages that might involve a number of different service providers. There should be a statutory right—with the patient's consent—to receive details of packages of care in order to independently verify how they are being implemented and the quality of delivery. This could be a specific role for specially trained staff of the "host" organisation—but with anonymous trends being reported to LINks as a basis for future work-plan activity.

  55.  There should also be a power for LINks to monitor and report on how service providers respond to outcomes of complaints. This is currently lacking in arrangements for support provided by the Independent Complaint Advocacy Service (ICAS). There is precedent for such an approach in the role of the complaints service previously offered by some, but not all, Community Health Councils.

Relations with local Health Trusts

  56.  It remains the responsibility of service providers to engage with stakeholders, patients and users, carers, and the community as part of the routine customer care activities. The geographic basis of future LINk interests breaks a direct relationship with Trust providers, but contacts will still need to be maintained in order for LINks to carry out their monitoring of the development and delivery of treatment pathways across local health economies. It is important that Trusts recognise the statutory public involvement role of LINks and fully comply with their requests for information and action.

  57.  Some Forum members would argue that formal stakeholder status should be extended to formalise LINk relationships and even representation with service providers and OSCs. Though this might improve dealings in the short-term, there is a significant risk of conflict of interests arising.

  58.  It will be necessary for LINks to work together—particularly on ambulance, mental health issues, or specialist service issues—with Trusts to monitor the development and delivery of treatment pathways across local health economies, even when they cross local communities. There is a role for LINks to advise Trusts in the preparation of their patient prospectus, and also to contribute questions for inclusion in patient surveys.

National coordination

  59.  Ability to contribute to national and regional reviews would enhance the credibility of public involvement as a significant influencer of public policy and service provision. This could be combined with a power to champion, as well as constructively challenge, national, regional and local policies, based on the evidence available from local communities. There is scope—and indeed it may be desirable—for LINks to cooperate at both regional and national level. This might be achieved through local subscription to a LINk National Association, offering a well defined structure that is able to independently administer governance arrangements. An added benefit of national coordination is to enable LINks to contribute in a coordinated way to the national forum of voluntary sector bodies that is being established to work with the Department of Health in the formulation of policy. National—and also regional—coordination is needed to enable LINks to contribute local evidence to campaigns testing provider performance against targets—for example A&E waiting times (Casualty Watch), infection control (Bug Watch).

How should LINks relate to and avoid overlap with:

Local Authority structures including Overview and Scrutiny Committees

  60.  If LINks are recognised as a statutory stakeholder within the local health and social care economy then they can operate within Local Strategic Partnerships, and eventually can negotiate contractual arrangements through Local Area Agreements.

  61.  Public involvement in health and social care could be recognised by regulation as an essential element of the community-planning aspects of strategic development, with close correlation to other activities such as spatial and transport planning. This would enable public involvement representatives to share in the work of Regional Assemblies in their activities, participating alongside other independently nominated representatives. There is also close correlation between LINk activities and other well-developed local authority involvement strategies, such as Citizens Panels and focus groups. Scope exists for some coordination of these activities—such as common questions included in Council customer care surveys—to achieve economies of scale in administration costs and resources.

  62.  The power of LINk referral of issues of concern to OSCs is welcome. At present there is no requirement to monitor how Trust providers respond to OSC reviews and recommendations—though there is evidence that action is taken. There is a role for LINks to carry out this function. This should be extended in relation to OSC reports on council provided social care services to provide an independent view of how such services are delivered.

  63.  Individuals on the "visiting" register could be contracted to provide evidence from one or more monitoring visits to contribute a public perspective to OSC reviews as required. Involvement of locally elected Councillors—particularly in relation to initiating "community calls for action" on disputed issues of health and social care provision—can be accommodated within the work plans of LINks.

Foundation Trust Boards and Member Councils

  64.  Dual participation in LINk and local Foundation Trusts should be actively promoted as complementary not competitive activities. Economies of scale can be achieved by local councils and Foundation Trusts sharing the cost of commissioning a locally-based social enterprise "host" organisation to provide independent support for both LINks and Foundation Trust members. It is probably not appropriate for LINks to be directly represented on Foundation Trust Boards or Member Councils, but there should be no bar on individuals serving in a dual capacity. Clear guidance must be available through the Code of Practice to avoid conflict of interest situations arising.

Inspectorates including the Healthcare Commission

  65.  LINks should provide a public perspective to the activities of regulatory bodies with interest in health and social care. Contributions from Forums are currently an essential element in the annual "Health Check" process carried out by the Healthcare Commission. This role should continue to be performed by LINks. Contributions about the delivery of health and social care within local communities will draw upon evidence relative to all the local Trust and service providers. Whilst composite LINk reports provide useful background information for the Healthcare Commission review process, it will also be necessary to furnish data specific to individual providers. This has very significant resource implications for the LINk "host" support organisation, which should be catered for in the proposed model contract arrangements.

  66.  There is scope for a joint annual "Health Check" contribution to be made by LINks and their local OSCs. Individuals on the "visiting" register could be contracted to provide evidence from one or more monitoring visits to contribute a public perspective to regulatory body inspections as required.

Formal and informal complaints procedures

  67.  There is currently no requirement for either service providers or the Independent Complaint Advocacy Services (ICAS) to systematically and routinely share complaint information with PPI Forums, nor is provision made for this within the proposed powers of LINks. There is an added limitation in that details are currently provided only for "settled" cases, which may have taken many months—if not years—to resolve. This frustrates opportunities for early intervention when things go wrong—such as in the extreme cases of Shipman and the Bristol Childrens' Hospital scandals.

  68.  Good practice experience of the complaints services of the former Community Health Councils was to report themes of cases in progress. These trends provided an early "call for action" as evidence to underpin work plan action priorities. As previously indicated, this could be a specifically commissioned task delivered by specialist staff from LINk "host" support organisations or ICAS contractors, or a core task delivered at regional or national level.

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?

  69.  Wider public consultation should always be carried out for any major reconfiguration or service change that impacts on health and social care facilities and/or services provided to local communities. It is recognised that providers need to manage funding, reconfiguration and resource pressures but this does not negate the requirement for public involvement and consultation.

  70.  Local experience of NHS provider consultation exercises, including those under the provisions of Section 11 of the Health and social Care Act (2001), leaves much to be desired. Recent local examples include:

    —  a demand to achieve significant financial savings to address an operating deficit that occurred mid-way through a Section 11 consultation on service reconfiguration;

    —  closure of community hospital based maternity services by an acute trust facing midwifery staff shortages without the apparent prior knowledge and involvement of the Primary Care Trust which operated the facility;

    —  media reports of a closure threat to an air ambulance service operated in conjunction with local police, which is funded by charitable donations and not Trust funds; and

    —  announcement of a new Independent Treatment Centre (ITC) in an area subject to a major Section 11 service reconfiguration consultation, which puts at least five community hospitals at risk of closure—to be located within 20 miles of a newly opened acute Trust hospital operating another ITC, which has recently announced closure of a second ward taking out of service a significant number of beds.

  71.  These examples, which include actions by the Strategic Health Authority and even the Department of Health, only exacerbate public frustrations and anger. Service providers need to understand the difference between consulting on options and the need to consult again once decisions are made. Experience indicates that wide public consultation on reconfiguration or service options does not itself alleviate the public disquiet that may arise once a decision is taken.

  72.  It is suggested that a FOUR stage public involvement process should be mandatory:

    —  The first stage should involve stakeholders, patients and their carers, and professional staff in the development of options to be considered—identifying advantages/disadvantages and including an impact assessment.

    —  The second stage should involve and consult on the options identified (SIX WEEKS).

    —  The third stage should be time for the provider to analyse the responses to the public involvement exercise and to make appropriate decisions (FOUR WEEKS).

    —  The fourth stage should be a further consultation about the final decisions made with clear explanation from the provider about the factors that have influenced their decision(s) and the benefits that accrue to patients, users, carers and the community (TEN WEEKS).

  It is recognised that this suggested timetable has time and resource implications—particularly when a provider is seeking to manage an unexpected financial or operational situation.

  73.  The involvement of stakeholders, patients and their carers, and professional staff in the design, development and delivery of health and social care services should be continuous and a routine aspect of customer care management practices of all providers. The 20 week involvement and consultation timetable suggested above is not excessively more than current arrangements, and if underpinned by statute or regulation could be included in provider planning cycles—even in emergency situations. To rebuild credibility with the public, there needs to be an underlining commitment that—particularly in Stages 2 and 4—public involvement activities are not side-tracked by new factors that might significantly impact on outcomes or the decision making process.


  74.  The views expressed and suggestions contained in this paper reflect many years of staff experience in supporting both Community Health Council and PPI Forum activities. We have tried to present practical approaches to the issues raised by the Select Committee. The Health Advocacy Partnership would be pleased to provide any further information, in person or in writing, to assist the Select Committee with its inquiry.

Neil Westbrook

Health Advocacy Partnership

9 January 2007

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