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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