86. Evidence submitted by the Royal College
of Nursing (PPI 134)
SUMMARY
1.1 The Royal College of Nursing (RCN) believes
that the achievement of effective and efficient systems of care
depends upon the meaningful involvement and engagement of patients
and the public in the planning, management and delivery of health
services.
1.2 We also believe that the involvement
and engagement of patients, carers and practitioners is an essential
characteristic of the caring process which enables the development
of partnerships and the empowerment of patients, practitioners
and the public that we serve.
1.3 The RCN believes that the development
of government policy in the representation of patients and the
public must recognise and value these factors if it is to promote
effective representation of patients and increase the involvement
of the public in the provision of health services. However, the
RCN is concerned that rather than strengthening the representation
of the patient and public involvement in the planning, management
and delivery of health services, the advent of Local Involvement
Networks (LINks) will ultimately weaken the process that had previously
been developed.
1.4 The RCN believes that in order to build
and develop effective and meaningful patient and public involvement
mechanisms, it is crucial to ensure that they have the power to
influence the shape of the commissioning and provision of healthcare
services in the local area.
INTRODUCTION
1.5 The RCN has a membership of over 390,000
registered nurses, midwives, nursing students and health care
assistants. The organisation is the voice of nursing across the
United Kingdom and the largest professional union of nursing staff
in the world.
1.6 RCN members work in a variety of hospital
and community settings and play an important role in developing
new services. Involving patient organisations is important to
the work that the RCN has being doing over recent years when considering
the impact of policy on nurses and nursing practice. Central to
this is the impact on service delivery and patient care.
What is the purpose of patient and public involvement?
2.1 Public and patient involvement is central
to the Government's drive to increase patient choice and to promote
greater patient and public input to their services. That involvement
is a resource that will inform the thinking and decision-making
of service planners, commissioners and providers.
2.2 The involvement of patients and the
public in the planning and management of services and in the issues
of their individual care is an essential component of empowering
people to engage in the co-production of health.
2.3 Furthermore, increasing patient engagement
enables people and communities to take increasing responsibility
for their individual and collective health.
2.4 The overall purpose of patient and public
involvement must be to enhance the quality of services and to
ensure that the provision of public services is shaped to the
needs of patients, users and carers so that a more effective,
accessible and equitable service can be achieved.
2.5 As consumers patients have a right to
shape, choose and influence the services that they receive. Whilst
NHS services are free at the point of delivery, the RCN believes
that in a tax-funded service to members of the public, users of
services and health care communities should have a robust means
by which to influence and inform service delivery and planning.
2.6 It is the intention of government policy
that public service provision becomes increasingly diverse. As
a result the number of organisations providing health services
will increase and the range of sectors from which they are drawn,
(eg private, social enterprise and three sector organisations)
will be extended. In these circumstances, the RCN believes that
there is an ever greater need for patient and public involvement
in monitoring the provision and commissioning of those services.
Increasingly plural provision will require ever greater representation
of public interests if it is to retain integrity in and the confidence
of the communities being served.
What form of patient and public involvement is
desirable, practical and offers good value for money?
3.1 The form of patient and public involvement
adopted by public services is largely dependent on how providers
and commissioners are required to engage with them. That requirement
must apply across the whole of the respective public service.
For that reason the RCN believes that the models being proposed
within the Department of Health report "A stronger patient
voice" may weaken rather than strengthen the representation
and involvement of patients and the public.
3.2 Our primary concern is that whilst "A
stronger voice" seeks to strengthen the voice of patients,
carers and users in commissioning of services, it will do so by
weakening that same voice in service providers. We are anxious
that whereas the Patients Forums represented the views of groups
and communities directly to provider organisations, the LINk groups
that replace them will need to make their representations through
a third party, the Oversight and Scrutiny Committee.
3.3 Any patient and public involvement should
ensure that there is meaningful consultation with all areas of
the community including those in minority groups or with special
communication needs.
3.4 Given the complexity of health services,
the ideal form of patient and public involvement will be one that
is flexible enough to encompass a variety of different approaches
whilst meeting the requirement to offer a robust and dependable
form of representation. The RCN does not believe that one single
model of involvement will suffice to encompass all that the ideal
public patient involvement network will cover, given the requirement
for health service organisations to offer meaningful consultation
on service change and reconfiguration.
3.5 The RCN believes that only by providing
a service which has the facility to meet those requirements for
consultation as a minimum can any form of patient and public involvement
be said to be desirable, practical and offer good value for money.
Where expenditure is required from the public purse to cover the
costs of judicial reviews or inquiries into the failure to consult,
that form must be considered to be undesirable, impractical and
poor value for money.
Why are Existing Systems for Patient and Public
Involvement Being Reformed After Only Three Years?
4.1 "A stronger patient voice"
says that a "strengthened system of user involvement"
will be created, promoting "public accountability in health
and social care through open and transparent communication with
commissioners and provider". Given our interpretation of
the purpose of patient and public involvement (PPI) the RCN has
concerns that this will not be the case and that existing systems
of PPI have not been given sufficient time or resource to "bed
in" effectively, nor has the model been fully evaluated.
4.2 Although the response to "A Stronger
patient voice" has now been published by the Department of
Health and we believe that the means by which it has been developed
indicates one of the deficiencies of existing systems of consultation.
The report itself was a "document for information and comment"
and did not, therefore, constitute a part of a formal consultation
process.
4.3 The RCN therefore considers that to
reorganise the system of patient and public representation on
the basis of a document of this nature is a missed opportunity
to consult fully on an essential aspect of public service management.
How should LINks be designed, including:
5.1 "A stronger patient voice"
indicates that there is variability in the levels of performance
of existing representative bodies such as the Patient Liaison
and Advice service (PALS) and patient forums. The RCN believes
that research[57]
has demonstrated similar variability in the performance of Local
Authority Health Oversight and Scrutiny Committees (OSCs). This
indicates, in our view, a lack of evaluation of existing services
and a lack of grounded research in the development of the new
policy. We believe that if they are to be successful, LINks and
their associated systems must be based upon grounded research
and have the benefit of ongoing evaluation of their effectiveness
in representing the interests, views and preferences of the communities
that they serve.
5.2 Ultimately, the success of LINks will
depend heavily upon the partnership between patients, carers,
communities, practitioners and other health services staff. It
is essential in responding to this report to emphasise that people
who are employed in the provision of public services are, in themselves,
citizens, members of communities and users of services. We are
concerned that they, through the representation of their professional
bodies and staff side organisations, continue to play an active
role in the development of democracy in public services.
5.3 The RCN believes that whilst there may
be a desire on the part of government to "localise"
services which represent the interests of patient and publics,
it is essential that they are designed around strong minimum standards
that recognise their responsibility to ensure public representation
in the process of service change, reconfiguration and development
Remit and level of independence
5.1.1 The RCN believes that any future model
of patient and public involvement must have political teeth and
a meaningful voice at local and national level. Staff working
in health services need to be familiar with and have confidence
in the new system in order that they refer patients and carers
to its services. The RCN believes that positive experiences of
the service should encourage future participation by individual
and that the role which staff have to play in achieving this should
not be ignored or their training in its application under-funded
5.1.2 The RCN does not support the current
vision of LINks as the new mechanism for patient and public involvement
because it adds layers of bureaucracy for no tangible benefit
and has fewer powers than its predecessors. We are concerned that
since the demise of Community Health Councils there has been a
gradual watering-down of the powers of patient and public involvement
networks.
5.1.3 In short, the RCN is concerned that
rather than overcoming existing democratic deficits in the management
of health services, LINks may exacerbate them and that the rapid
reorganisation of public representatives in health services will
reduce support from the communities they serve, whilst having
insufficient authority to hold an increasing range of provider
organisations to account.
5.1.4 We are concerned that if LINks and
Oversight and Scrutiny Committees (OSCs) focus their attention
primarily on the commissioning of services, there will be insufficient
representation of patient and public concerns about provider organisations
in an increasingly plural market.
Membership and appointments
5.2.1 The RCN believes that one of the most
crucial factors in gaining the support and participation of communities
and individuals in the LINk groups will be their relevance and
perceived value in local communities.
5.2.2 If future models are to capture the
imagination of the public and encourage active engagement they
must be valued and have influence.
5.2.3 There is a need to find creative ways
of engaging communities in patient and public networks. Lessons
could be learned from the good work done by Local Government on
encouraging broad engagement in local elections.
5.2.4 The membership of the LINk group should
include all potential users, not just actual users of the service.
5.2.5 The RCN would like to highlight that
healthcare professionals are members of the public and as such
tax payers, service users and service providers. As such, we recommend
that there should be public, patient and practitioner involvement
in the shaping of health services. The practitioners could be
engaged in these forums as expert witnesses or non voting members.
Furthermore, nurses are front-line providers and can act as patient
advocates, bringing experiences of many patients to such a network.
Funding and support
5.3.1 Whilst the Department of Health White
Paper "A stronger local voice: A framework for creating a
stronger local voice in the development of health and social care
services" seeks to address the issues of independence, transparency,
and engagement, it does so without acknowledging the prevailing
political or social context. For these reasons we believe that
a heavy onus will fall upon the organisations charged with developing
LINk groups and Local Authorities to recognise and understand
the organisational pressures and political features that apply
in a health service which they do not control or fund. The RCN
is concerned that they will not have the resources or experience
required to do so.
5.3.2 By widening the breadth of health
service issues that will be considered by LINks and OSCs, the
Department of Health will be creating administrative and cost
pressures in public services. Although there is reference in the
report to a start-up fund for the development of LINk groups,
there is no reference to the source of revenue funding for the
operation of the scheme and any system which will seek to draw
down funding from a NHS which is already facing many local cost
pressures will only serve to redouble pressures upon managers,
practitioners and services.
5.3.3 The RCN want to seek a commitment
from the Government for a defined sensible and sustainable budget
for LINks which ensure that they are able to function, develop
and grow expertise, not just to meet up on a regular basis.
Areas of focus
5.4.1 LINks should have an open agenda which
will enable representation of issues of concern from a broad range
of patient and public interests. The LINk group should also have
access to and the benefit of expertise from a wide range of organisations
engaged in the provision, commissioning and management of health
services including Institutes of Higher Education; Patient Interest
Groups; Royal Colleges; and Trade Unions.
Statutory powers
5.5.1 We believe that the present powers
of the OSC are sufficient to support their future role in representing
patient and public interests. Increasingly, RCN representatives
are working with OSCs to address issues of concern regarding the
provision and commissioning of health services, however we are
aware of variation in the systems and means by which OSCs operate.
5.5.2 The RCN are concerned, therefore,
that LINks will need the facility of dedicated time and representation
within the systems and agenda of OSCs if they are to effectively
represent the interests of an increasingly diverse population
across the full scope of their remit in health and social care.
This is an issue that would need to be addressed within legislation
if it is to be addressed effectively.
5.5.2 Furthermore, the RCN is concerned
that in focussing too heavily upon commissioning issues, LINks
will have insufficient power to hold providers to account and
that there would be too many steps involved in addressing patient
and public concerns regarding the services that they receive.
This too is an issue that would need to be addressed within legislation.
5.5.3 Although we believe that the powers
of OSCs are significant, as the bodies to which LINks would report
their issues of concern, the RCN believes that patient groups
need to have a system of empowerment. This would require, we believe,
harnessing the powers of OSCs so that issues of dispute can be
more easily resolved through arbitration at local level rather
than being referred through to the Secretary of State and the
Independent Review Panel. The RCN believes that the present system
has become excessively delayed and discredited in the eyes of
public and community groups.
Relations with local health Trusts
5.6.1 With patient and public representation
no longer being hosted by nor having a direct relationship with
NHS Trust, significant consideration will need to be given regarding
the promotion of positive working relationships.
5.6.2 Without the facility of access to
the Board meetings of NHS Trusts, LINk groups will need to develop
a system for direct representation of issues of concern to NHS
Trusts, like other provider organisations, so that matters of
concern can be addressed and resolved at local level. The advent
of NHS Foundation Trusts and the possibility of NHS Community
Foundation Trusts, with separate systems of patient representation
may limit the potential of LINks to address issues of concern
with these organisations.
National coordination
5.7.1 The Commission for Patient and Public
involvement in Health and its predecessor, the Association of
Community Health Councils had a role in terms of national co-ordination
and representation of patient and public issues and concerns.
The future model described in "A stronger patient voice",
offers no similar service. The RCN is concerned that this will
reduce opportunities for patient and publics to be represented
in the development of national healthcare policy. The report mentions
that "work is being undertaken to explore ways of creating
a stronger voice for patients, service users and members of the
public at national level"—the RCN believes that unless
these issues are addressed, the new model has the potential to
weaken rather than strengthen the system of representation and
involvement of patients, users, carers and the public in health
and social care services.
Other—Governance
5.8.1 The RCN has no fixed views regarding
the governance structures underpinning LINks groups but do believe
that they should be suited to the needs of the local community,
promote the principles upon which they are founded and that they
are either funded through a ring-fenced budget or achieve cost-neutrality.
How should LINks relate to and avoid overlap with:
6.1 Local Authority structures including Overview
and Scrutiny Committees
An informal or ad hoc relationship between the
Local Authority OSC and LINk is insufficient. It is essential
that LINk groups have dedicated time and facility within the working
agenda and committee systems of Local Authority OSCs. Without
opportunity to make formal representation on issues of concern
to patients and the public, especially in matters of service reconfiguration
and delivery, the potential influence of LINks would be diminished
shed and democratic processes severely compromised.
6.2 Foundation Trust boards and Members Councils
It is important that members of Foundation Trust
Board of Governors and Members Councils do not feel compromised
by their need to adopt a "corporate" role in representing
the interests of patients, carers and the communities that they
serve. In that respect they should have ready access to their
respective LINk so that they can ensure the concerns of individuals
and groups are recognised and addressed by an appropriate service
which is independent of the Foundation Trust.
6.3 Inspectorates including the Healthcare
Commission
6.3.1 The Healthcare Commission is an inspector
and regulator of services and there could be a conflict of interest
appropriate mechanism for patient and public involvements in the
NHS. If LINk groups are given the authority to inspect provider
organisations, there is a potential conflict of interest regarding
HCC and their ability to undertake unbiased consultation given
their primary role as service regulators. Furthermore, their may
be issues with the public's perception of the Healthcare Commission
undertaking both roles.
6.3.2 However, work from the Healthcare
Commission could and should inform patient and public involvement
eg the public should continue to have access to reports on providers,
and might even be used to identify areas for patient and public
consultation.
6.3.3 The RCN believes that further consideration
should be given to extending the remit of LINks so that they can
refer their issues of concern to the Healthcare Commission as
the regulator of services?
6.4 Formal and informal complaints procedures
6.4.1 There needs to be clear and transparent
mechanisms and processes for complaints to be made. However the
RCN would like to highlight that complaints are only one way of
involving patients. There should be other positive and productive
methods of involving patients.
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?
7.1 The RCN believes that the circumstances
as set out in section 11 of the Health and Social Care Act 2001
are appropriate and set out where public consultation is appropriate.
Royal College of Nursing
January 2007
57 ODPM-The Development of Overview and Scrutiny in
Local Government 17/10/02. Back
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