Select Committee on Health Written Evidence

94. Evidence submitted by the Southwark Patients Forum for Primary Care (PPI 54)

What is the purpose of PPI?

  1.  We are all Patients, or potentially so. Therefore, PPI is the means by which those who use the services provided, and pay for them via taxation, can:

    —  influence the decisions of both Commissioners and Providers;

    —  help determine local priorities between services when funds are not available to meet all possible requirements;

    —  scrutinise the quality of the services and the way in which they are being delivered;

    —  call those Commissioners or Providers of services to Local Account, when that is necessary;

    —  influence the local process of change when that follows from National decision of the Department of Health;

    —  have access to NHS facilities and/or Services and physically inspect what is being provided; and

    —  exercise a process of discipline against bureaucracy or wrongful use of powers by virtue of the right to demand information to a fixed timescale and to Inspect—it is not the inspection of itself that is important but that the power exists to conduct one ... which serves to focus minds when replying to questions.

  2.  PPI, and PPI Forums in particular, substitute for Direct Representative Democracy in a situation in which it is acknowledged that an Appointment System will always act to reduce legitimacy

  3.  The potency will always be at local level, but that potency can be enhanced by an indirectly elected system of Regional and National Forums.

  4.  It follows that there must be a funding level that permits adequate communication of the existence of PPI to all Patients so as to:

    —  ensure that there is awareness of such organisation;

    —  understanding of the role of PPI, and Forums;

    —  encourage the use of the local Forum as the most relevant resource for users to communicate both there aspirations and desires for local health provision and their satisfactions, or otherwise, with what is being provided (although this should not extend to individual complaints unless an appropriate specialist secretariat was provided); and

    —  allow of the Forum reporting back to its public what has been achieved. Such achievement, continually monitored and measured, would be a powerful contribution to improving legitimacy in the absences of direct elections—the lack of such resources and activity has been an undoubted weakness which means that PPI Forums could have been even more successful than has largely been the case.

  5.  It should be noted that Local Government Scrutiny Committees cannot substitute for PPI because:

    —  Local Government Systems introduce an element of Party Politics which is disadvantageous in a monitoring function in which it is wished that all of the public should be directly involved.

    —  Forums have the Independence which Scrutiny Committees lack.

    —  In Social care, Local Government Commissioners and Providers have a conflict of interest with a Scrutiny Committee, particularly if the issue became politically involved.

  All of the a foregoing presumes the existence and operation of an Involvement Model as is practiced by Southwark Patients Forum.

What form of Patient and Public involvement is desirable, practicable and offers good value for money?

  6.  Clearly, in a Democratic System of Government there is no substitute for directly elected Authorities (on the US model for some forms of Government) that are directly charged with determining Health & Social Care Provision, Commissioning it....and even extending to raising the funds to pay for that provision. However, such change is not on the Agenda and this response takes no account of it.

  7.  Accordingly, it is proposed that, within an Appointed System, the present arrangement of PPI Forums serve needs best, although there is a case for some change which is described in the response to the third question.

  8.  This argument is subject to the following:

    —  an operational style that embeds consultation into the management decision making process of the NHS Trust to which the PPI Forum relates;

    —  the recognition by that Trust that Consultation begins when ideas are first mooted and all options are open ... not when decisions have already been taken and when Consultation becomes defensive of those decisions;

    —  the achievement of the maximum possible legitimacy as is described in para 2.4;

    —  the PPI Forum being proactive in representing patient interests, hopefully, assisted by a flow of input from Patients and Public who are aware of the Forum and understand its role;

    —  Patients and Public believing that its input to the Forum will have a positive result which will be reported back to them...;

    —  the resources being available to allow of "Reporting Back" being achieved in a situation which:

      —  editorial in local media—particularly in big cities—cannot be guaranteed; and

      —  local Voluntary Networks are inadequate in reaching the public at large.

  Even so, some "reporting back" is better than none: so this lack, although undesirable, serves to minimise achievement rather than to deny of it.

The operating system of the Southwark Patients Forum implemented with the fullest cooperation of the Southwark Primary Care Trust

  9.  The objective of the operating system, worked out during 2006, embeds the work of the Forum into the day to day activities of the NHS Trust at both strategic decision making level, and policy implementation.

  There are five components:

    —  Meetings with the Executive Directors of the NHS Trust which take place six times per year in advance of Trust Board Meetings.

    —  Agendas are two way and allow of discussion of Board Papers ... before they are submitted to the Board (in this way, the Forum is treated pari passu with Non Executive Directors).

    —  Direct access to Trust Managers below Director level in order to explore policy implementation.

    —  A Lead Members' Brief System with the objective of extending both the breadth and depth of the Forums involvement in the work of the NHS Trust.

    —  This has been agreed upon by all Members of the Forum who take personal responsibility for achievement within their Briefs and are expected to be proactive.

    —  The remit of the Forum has been shared among the Forum members according to their interests and area of expertise.

    —  Members have freedom to act with the full authority and backing of the Forum within their brief.

    —  Members report back to the Forum at meetings in the form of written reports which are discussed and endorsed.

    —  Any changes to Lead Member's Briefs are discussed and agreed at Forum meetings.

    —  The NHS Trust, at Executive Director and Management levels, are kept informed of these Briefs.

    —  Forum Members being full members of Operating and improvement Groups such as Urgent Care, District Nursing and GP Referral (in which the Forum Member sits with GPs considering Demand Management which is significant in impacting upon Patient interests).

    —  Continuation of presence at Public Trust Board Meetings with a "seat at the table" and the right to speak and ask questions, pari passu with Non Executive Directors.

  At the present time, The patients Forum and The NHS Trust are jointly seeking media communication of this partnership working, using the resources of the Trust, in, an effort to interest the public at large and so enhance the legitimacy of the Patients' Forum's involvement.

Why are existing systems for Patient and Public Involvement being reformed after only three years?

  10.  There is a case for change but not to the extent that the Government has proposed which initially removed all powers of Inspection and even now removes the direct link with an NHS Trust that is critical to any process of monitoring and local calling to account.

  11.  What previously has allowed of:

    —  a right to an answer/information in 20 days put to the related Trust;

    —  attendance, in many cases with a "seat at the table", at Board meetings; and

    —  inspections of all establishments (but now to be limited to NHS facilities but NOT Private Sector facilities—which of itself arouse suspicions) will now be reduced to an arms length relationship to Commissioners to a timescale and interface that is bound to be longer and very impersonal.

  To this extent, what the Government states to be A Stronger Local Voice in fact becomes a very much Weaker Voice.

  12.  The change that is valid relates to Hospital Trusts since it is an undoubted fact that Foundation Hospital Membership Councils/Governing Bodies do provide for duplication.

  13.  This does not apply to Primary Care Trust Forums and one simple change could remedy the situation. The Government has gone to great lengths to align PCT areas with Local Government areas to allow of joint Health and Social Care delivery ... and has made much of the co-terminosity.

  14.  Therefore, Southwark Patients Forum proposes that a local LINk be associated with its local PCT and Social Care Organisation with the powers to operate in the same way—as PCT Forums do now (including the right of inspection of Private Sector Providers....hopefully using the model of Involvement developed in Southwark.

How should LINks be designed?

  15.  As suggested in para 4.5, LINks should, de facto, take over the role of PCT Patients' Forums and have the same level of remit and independence (but include Social Care).

  16.  Membership and appointments should be via a Commission which should be administrative only....a larger form of the current support organisations with no role in policy or determining practice.

  17.  However, it should be noted that there is a conflict of interest between LINk membership and the activities of some Voluntary Sector Organisations who may also be Providers. This conflict is enhanced if their representatives are Executives rather than Volunteers.

  18.   Funding must be sufficient to support the work including that required to enhance legitimacy (para 4).

  19.  The area of focus, statutory powers and relationship with local Health Trusts has been defined above. Since Hospital Trusts are but one of a number of Providers there is no reason to treat them in any other way ... their internal democracy can be delivered by Members' Councils as all hospital will eventually become Foundation Trusts.

  20.  There should be both Regional and National Bodies elected from local LINks representation.

How should LINks relate to and avoid overlap?

LA Structure (including Scrutiny Committees)

  21.  This has been dealt within para 5.

Foundation Trust Boards and Members Council

  22.  See response at paras 12 and 19.

Inspections (including The Health Care Commission)

  23.  Present arrangements for Forums are satisfactory since HC Representatives are appointed to engage with Forums and often attend meetings. It should be the duty of the Chair to seek to enhance this relationship.

Formal and Informal Complaints Procedure

  24.  If this means Patients individual Complaints these should be handled by the PCT.....overseen by the Healthcare Commission.

  This would be subject to:

    —  The PCT overseeing all Complaints in relation to their Commissioning including those within GP and Hospital Systems (both NHS, Voluntary and Private Sector).

    —  The PCT should have the statutory duty to coordinate complaints and issue a consolidated report—open to discussion—with the LINK.

    —  The LINK should use this Report as a Management tool in assessing the quality of service delivery and of any need for investigation within its inspection powers.

  This is not currently possible for the PCT Forums (or for that matter PCTs) since Complaints disappear into PALS, GP Systems and Hospital System. There are no powers of consolidation within present NHS Regulations—only a Developmental Annual Health Check Standard exists and this is not being pursued as a priority in the current year.

Section 11 etc powers

  25.  A LINk should have the power to determine a S11 criteria which was specifically ruled and in the North Derbyshire Judicial Review.

Barry Silverman

Chair, Southwark Patients' Forum for Primary Care

January 2007

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