65. Evidence submitted by the NHS Confederation
(PPI 142)
The NHS Confederation is a membership body that
represents over 90% of all statutory NHS organisations across
the UK. Our role is to provide a voice for the management and
leadership of the NHS and represent the interests of NHS organisations.
We are an independent organisation.
The NHS Confederation welcomes the opportunity
to give evidence to the Health Select Committee on patient and
public involvement. This evidence sets out our views, based on
feedback from a cross section of our member forums.
KEY POINTS
In today's climate of patient choice and system
reform, patients can vote with their feet. But this is not enough.
Patients and the public must be allowed to have a say about changes
in services at the outset, not at a point when decisions have
already been made.
The way we involve patients and the public at
the local level must be robust but flexible, enabling a variety
of mechanisms to be used depending on the needs and circumstances
of communities and their populations.
Patient and public involvement should empower
patients and the public and make the NHS work differently. If
individual citizens are to feel they are in the driving seat of
the public services they use, then there must be opportunities
for them to express opinions and have them heard, and to select
outcomes which are particularly appropriate to them.
The NHS Confederation welcomes the expansion
of LINks and the abolition of Patients' Forums, as they should
provide a more effective platform to involve patients and the
public in health and social care. However, these networks need
to be sufficiently independent and strongly embedded in the local
NHS to work effectively.
We consider the valuable skills and competencies
of those people already involved in Patients' Forums to be vital
and ones which should not be lost. These people should be actively
encouraged to participate in the new networks.
We see the duty on each local authority to create
and develop LINks as an opportunity to develop NHS organisations'
ability to reach the most deprived communities, which local government
has traditionally been better at achieving through more developed
consultation mechanisms.
1. What is the purpose of patient and public
involvement (PPI)?
1.1 The purpose of involving patients and
the public is to ensure that local populations get services that
match their needs and requirements and that they have a say in
how those services are planned, structured, implemented and delivered.
1.2 There is an important difference between
involving people and consulting people. Involvement should be
part of everyday practice for both commissioners and providers.
All NHS providers of services should have a duty to engage and
involve patients and the public but, particularly where service
review or change is considered, only commissioners, with their
accountability to the local community and links to Local Authority
Overview and Scrutiny processes, should be duty bound to formally
consult. Commissioners and providers should ensure that the need
for, the design and the quality of local health and social care
services are regularly market tested, including surveys to measure
patient and public satisfaction.
1.3 In addition, it is important to note
that involving patients and involving the general public are not
identical processes but require quite different approaches. What
matters to the patient usually focuses around their care and treatment
whereas the public tends to look at issues from a position of
value for taxpayers' money.
2. What form of PPI is desirable, practical
and offers good value for money?
2.1 Involving patients and the public is
by no means a new concept, but one that has undergone a number
of changes in recent years to ensure that it adds value to the
planning and delivery of healthcare. In the past, involving patients
and the public has been seen as a good thing, but it has not been
firmly embedded within everyday business practices and processes
in the NHS.
2.2 Learning from past experience and the
Patient Forum model tells us that we should be developing a model
that allows patients and the public real opportunities to influence
their local services in innovative and flexible ways that suits
them. This must be underpinned by greater accountability and independence
for those involved in this work. This means allowing LINks to
be more flexible than the Patient Forums in terms of how they
organise themselves and their membership and what work they undertake
as the priorities and levels of enthusiasm will vary between local
communities.
2.3 Involvement and engagement on an on-going
basis means ensuring that patient and public satisfaction and
experience is regularly surveyed and measured to ensure innovative
ways of involving members of the community in issues that matter
to them.
2.2 The foundation trust model is emerging
as an important way of incorporating patient and public involvement
into the heart of an organisation's governance. The 54 authorised
foundation trusts now have over 1,000 staff, patient, public and
stakeholder governors and half a million members, with the number
set to grow dramatically over time as more acute and mental health
trusts are authorised.
2.3 Foundation trusts are working with their
governors and members in a wide range of ways to give patients
and the public opportunities to shape their services. This includes
governor and member focus groups on key aspects of the patient
experience, surveys, governor-led constituency meetings, open
days, health awareness events, newsletters, dedicated websites
and e-communications. These involvement mechanisms have resulted
in changes in practice for foundation trusts and created a culture
where patient and public involvement is a mainstream part of the
day to day work of the trust.
2.4 Processes that are well thought through,
coordinated and add value to the way services are planned and
delivered will provide good value for money.
3. Why are existing systems for PPI being
reformed after only three years?
3.1 PPI Forums and the Commission for PPI
in Health achieved a great deal, but the successes were not consistent
across the country nor did they allow for sufficiently flexible
arrangements to enable a more representative part of community
to take part. The remit of the Patient Forums was not clear and
there were conflicts between delivery and the public's expectations
of what they could realistically achieve.
3.2 Involving patients and the public require
quite different engagement methods and without recognising this
any measure would inevitably be met with severe challenges. The
NHS Confederation therefore wants to see a more coherent vision
for involving patients and the public, underpinned by defined
roles, remit, and accountability. But we want the functions and
areas of focus to be determined locally. There is no one prescriptive
model that could satisfy the needs of all communities. It is therefore
vital that LINks are set up with sufficiently flexible arrangements
and independence so that they can undertake their role effectively.
4. How should LINks be designed, including
— Remit and level of independence
As mentioned above, it is essential that the
remit of the new LINks is clear and defined to avoid confusion
that will not only lead to disappointments in terms of delivery
but will also prevent meaningful recruitment and appointment to
posts. It is vital that the LINks are and are seen to be independent
as they will need to provide a balanced approach and use their
influence in ways that does not place them too close to the issues
affecting individual NHS organisations. This means being objective
and not positioned too closely with any particular NHS organisation
within the area. Placing the LINks within Local Authorities is
a way of insuring this independence, as long as the role of the
OSC is also clear and not extended to scrutinising strategic NHS
decisions or outcomes. The role of the OSC must be concerned with
processes and the role of the LINk independent in so far as it
is there to facilitate better involvement and engagement and ensure
any issues linked to local politics are resolved.
— Membership and appointments
The NHS Confederation believes that membership
of LINks should be inclusive and reflect the diversity of the
community it serves. It must reach out to minority and deprived
communities through sophisticated involvement mechanisms and support.
The case examples attached highlight some of the ways in which
trusts are already using innovative methods to reach out to minority
groups. In order to avoid conflicts of interest, membership should
not be extended to include NHS or Local Authority staff.
Funding is clearly a fundamental part of the
success of the LINks. The funding given to Local Authorities should
be ring-fenced to ensure that it cannot be absorbed into other
initiatives. Dedicated support and expertise is required to make
them a success and there should be clear connections with Patient
Forum members etc to ensure continued learning and development
so that all experience gained in the last few years is not lost.
To avoid being overly prescriptive, something
which the Patient Forum model has been accused of, the focus of
the LINks must be determined locally according to local populations
and requirements which will rely on robust and up to date information
obtained from a wide range of sources. LINks will need to engage
with as wide a stakeholder community as possible to ensure they
act on the best available information. This could include engaging
with PALS, relevant community groups, support groups, local transport
and anyone else who may have an interest in the planning and delivery
of services. The LINks should be seen as both the seeker of information
as well as a source of information to be utilised by others such
as commissioners.
It is essential that the powers of LINks are
defined in law, for example the relationship with the Overview
and Scrutiny Committees, in order to clearly set out their consultation
powers ie the right to be consulted. They should not have powers
of inspection as the Forums did, as this appears to be an unnecessary
duplication of the right of the OSC to scrutinise and challenge.
— Relations with local health
Trusts
LINks should make every effort to inspire cooperation,
collaboration and participation from local stakeholders as mentioned
above. It is essential LINks form close relationships with all
local health bodies and act as the "mechanism" through
which good engagement, involvement and consultation takes place.
The NHS Confederation would support the proposal
for national coordination and oversight of the work of the LINks
but not the creation of a separate body to undertake this function.
5. How should LINks relate to and avoid overlap
with
— Local Authority structures including
Overview and Scrutiny Committees
LINks should have a close relationship with OSCs
to ensure that the two cooperate. LINks should be able to participate
in OSC activities such as reviews and OSC should likewise be able
to feed their experiences and lessons learnt into LINks. Where
matters are referred by the OSC to the Secretary of State for
Health, there ought to be a limit on the time the Department of
Health can take in responding to ensure that no unnecessary delays
are experienced.
— Foundation Trust boards and
Members Councils
When there is a critical mass of foundation trusts
there will be well over a million members and thousands of governors.
As well as being committed to the development of their own foundation
trust, members and governors are also interested in far wider
issues of health and care than simply those issues covered by
their membership organisation. As such, they represent a dynamic
force in communities and offer a good opportunity to make a strategic
input in health. LINks should build on this resource and develop
strong relationships with foundation trust wider governance structures.
The way this is done should be determined locally rather than
through nationally prescriptive guidance.
— Inspectorates including the
Healthcare Commission
LINks should provide information on engagement
and involvement to the Healthcare Commission as part of the Annual
Health Check. However, this arrangement must ensure that there
are no duplications for information requests placed on health
bodies.
— Formal and informal complaints
procedures
The NHS Confederation thinks that the LINks should
oversee complaints made to NHS organisations but not necessarily
be the receiver of such complaints.
6. 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?
6.1 The NHS Confederation believes that
involvement and engagement with the local population and service
users should form part of the everyday working practices of both
providers and commissioners. This is vital not only to ensure
that patients and the public have a real say in services that
matter to them, but also to ensure that services provided match
the needs of the population. This should be done through testing
patient experiences and satisfaction regularly, using surveys,
conducting research etc. This requirement could be included in
the contracts that commissioners have with providers for example.
6.2 The duty to conduct public consultation
on substantive changes and reconfiguration of services should,
however, fall on commissioners, not on providers. The reason for
this is that it is the commissioner who is responsible for the
services provided and accountable to the local community. It is
vital to note the distinction between on-going involvement and
market testing to ensure services are fit for purpose and the
need for public consultation on reconfiguring services. To require
providers to undertake public consultations on changes to services
would add considerably to the bureaucratic burdens and would not
necessarily add value to the concept of patient and public involvement.
6.3 Where public consultations are necessary,
ie where there are significant changes to the provision of serves,
they should be conducted with the full involvement of both LINks
and OSCs and planned in a way that allows the local population
to have an input in decisions made, and not merely as a tick-box
exercise.
ADDITIONAL COMMENTS
In addition to the above points, the NHS Confederation
would like to stress the importance of robust governance arrangements
for LINks. It is essential that the lines of accountability are
clear and that there is some form of performance assessment of
the LINks that will ensure they are meeting their obligations.
Although we understand that non-prescriptive arrangements for
LINks and their roles may be favourable to ensure they have the
flexibility to be creative and effective, there need to be robust
ways of holding them to account and how poorly managed LINks will
be dealt with.
Attached at Annex A are two PCT case studies
which have been particularly innovative in involving young people
and carers, something which has traditionally been difficult to
do and examples from a number of Foundation Trusts about how they
have engaged patients and the public through their new governance
structures.
NHS Confederation
January 2007
Annex A
RICHMOND AND
TWICKENHAM PCT
Mystery shopping project on sexual health services
information used by young people
This project demonstrates a supportive way in
which young people can be involved in actively evaluating services
using a "Mystery Shopping Project" approach. This method
involves turning up at services presenting as an ordinary service
user, and then completing a survey. The aim of this piece of work
was to listen to, take seriously and act upon the recommendations
offered by young people. The project involves both consultation
work and participation of young people.
This project was done in partnership with the
RT PCT Young People's Sexual Health Worker, Education and Children's
Youth Participation Worker, Voluntary Services, Family planning
services and Young People's Walk In Services in Richmond, GUM
Clinics from the Hounslow, Kingston and Wandsworth PCT's and young
people. 22 service evaluations were completed, and tangible recommendations
were made for the future delivery of services. A full report and
video of the exercise are nearing completion.
EALING PCT
Patients and carers choose a home tube feeding
service
Ealing PCT has used a tender process for home
tube feeding services that involved patients and carers. Home
tube feeding is successfully used for a large number of people
who are unable to meet their nutritional requirements orally for
a prolonged period of time. Ealing PCT and Ealing Hospital worked
together with service users in the tender process for an enteral
feeding contract. Companies set up a market place with stalls
in Ealing town hall and gave presentations to patients and carers.
The majority of participants were carers rather
than patients as patients needing the feeds tend to be either
very young or very old and it is usually the carers who use tube
feeding products. In the tender process carers were encouraged
to challenge the companies' claims about service quality—something
they are not generally used to doing.
The patients/carers' responses were weighted
over those of staff and this helped influence the final decision
which identified savings in the region of £220,000.
FRIMLEY PARK
HOSPITAL NHS FOUNDATION
TRUST
Foundation Trust Governor/Member Constituency
Meetings
Frimley Park Hospital is involving local patients
and the public—their members—in constituency meetings
which have now been running for over a year. These are led by
their governors, elected by the members themselves. Six constituency-based
meetings were held in the autumn of 2006 spread geographically
across the local area. Nearly 400 foundation trust members, patients
and members of the public attended these events. Each meeting
had a clinical focus and also incorporated a strategic planning
update followed by the governors conducting an Open Forum session.
A board member attended to hear the public's comments and take
questions.
Following the success of the meetings, governors
have agreed that they should be held two to three times a year.
Frimley Park is one of the first foundation trusts to hold members'
meetings. These are now seen nationally as an example of good
practice and others are developing similar ways of meeting, and
listening to, their local populations.
LANCASHIRE TEACHING
HOSPITAL NHS FOUNDATION
TRUST
Oversubscribed for "Focus on"
Lancashire Teaching Hospitals NHS Foundation
Trust has held a number of successful members' events based on
clinical subjects, which have proved so popular that each has
been oversubscribed. They have followed a "Focus on"
theme, so far covering diabetes, bowel cancer and the work of
its cancer centre. A networking session between members and governors
is included within the programmes and feedback forms are made
available.
STOCKPORT NHS FOUNDATION
TRUST
Championing youth governors
The constitution at Stockport NHS Foundation
Trust allows membership from the age of 16 onwards. However the
trust is keen to ensure that the views of children and young people
are actively heard. They have a dedicated appointed Youth Governor
on their Board of Governors, recruited from, and supported by,
the local Corporate Youth Service. They have also established
a Young People's Engagement (YPE) Committee—with membership
from governors and representatives from internal and external
agencies, chaired by the youth governor.
BROMLEY HOSPITALS
NHS TRUST
Preparing local people to become foundation trust
governors
Bromley Hospitals NHS Trust is in the preparation
stage of applying for foundation trust status. It currently has
a public, patient, carer and staff membership of 8,700. Its membership
is strong and the trust continues to recruit members and is actively
preparing local people to become foundation trust governors. Those
expressing an interest in becoming governors are invited to attend
potential governor workshops to introduce them to the trust. The
high level of interest has resulted in two evening workshops in
the last six months and a further one planned for January 2007.
SOUTH STAFFORDSHIRE
HEALTHCARE NHS FOUNDATION
TRUST
Governors' and Members' Involvement in Service
Development
Carers, as well as staff, at a mental health
in-patient facility for older adults at South Staffordshire Healthcare
NHS Foundation Trust are helping to improve facilities for patients.
They have recently been central to discussions and decisions on
such projects as creating a garden and a Reminisce and Relaxation
room for the use of service users. Members agreed that these would
be of great therapeutic value and would enable a calm and harmonious
environment to be created on the Unit.
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