38. Evidence submitted by the Health Advocacy
Partnership (PPI 99)
INTRODUCTION
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:
— continuing and chronic care;
— public health care (and health promotion);
and
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.
CONCLUSION
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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