Select Committee on Health Written Evidence

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.


  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 and support

    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.

    —    Areas of focus

    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.

    —    Statutory powers

    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.

    —    National co-ordination

    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.


  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


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.


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.


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.


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.


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.


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.


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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