Select Committee on Health Written Evidence

86. Evidence submitted by the Royal College of Nursing (PPI 134)


  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.


  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.


  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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