Select Committee on Health Written Evidence

98. Evidence submitted by UNISON (PPI 105)


  1.1  UNISON is the major union in the health service. Our health care service group represents more than 400,000 employees in the NHS and staff employed by private contractors, the voluntary sector and general practitioners.

  1.2  UNISON has a proud tradition of working with patient groups and through Community Health Councils to aid the development of local health initiatives, and therefore welcomes the opportunity to put forward comments and ideas to this inquiry. We submitted a reply to the Department of Health's A Stronger Local Voice consultation in September 2006.

  1.3  The UNISON/Oxford West & Abingdon composite passed at Labour Party Conference in 2006 included action point 5, "the Government to ensure that structures for patient and public involvement work effectively and that the public have a genuine say over commissioning and configuration decisions." This indicates the high priority UNISON attaches to this expanding area of health policy and we are encouraged that the Health Secretary has responded quickly by establishing a new Stakeholder Forum to expand consultation and dialogue with the unions.

2.   What is the purpose of patient and public involvement?

  2.1  Public and patient involvement (PPI) serves an increasingly important purpose for a number of reasons. Most importantly, in recent years we have witnessed the gradual undermining of local democratic accountability in the health service. The plan is for all hospitals to have the chance to become foundations trusts by 2008. The greater autonomy from traditional scrutiny that foundation trusts enjoy has made a mockery of the claim that they would increase the accountability of hospitals to their communities. Likewise, the increasing involvement of the private sector, where the main responsibility of companies providing services is to their shareholders, runs contrary to building a stronger voice for patients and the public.

  2.2  PPI should also be a driver of greater equity in service provision by allowing the disadvantaged within society a chance to voice their healthcare needs that they may otherwise not have had.

  2.3  In the longer-term, PPI should also be a means of boosting public health and, by extension, safeguarding the future of the NHS. If local populations become more actively involved with their own healthcare there is a better chance of boosting awareness of healthy lifestyles. The Wanless report argued that this was the only way to ensure the future economic sustainability of the NHS. [63]

  2.4  The Government and other commentators are right to emphasise the rising public expectations of the health service. [64]This has been brought about in part by the marketisation of the NHS in which patients are treated increasingly as consumers. Faced with constant reference to the mantra of "patient choice" it should come as no surprise that patient and publics are ever more exacting in their desire to achieve the type of health service they want.

3.   What form of patient and public involvement is desirable, practical and offers good value for money?

  3.1  UNISON wants to see the new system provide a real opportunity for local communities to have a proper say in who delivers their healthcare, particularly where controversial decisions about outsourcing services are concerned. An excellent recent example of this is the situation within North East Derbyshire PCT where local resident Pam Smith was left with no option but to go to the High Court, and subsequently the Appeals Court, to challenge (successfully) the decision to allow United Health Europe to take over the running of GP services. In the future, proper public involvement in the decision-making process needs to take place before NHS contracts are awarded, with meaningful involvement throughout rather than tokenistic consultation towards the end.

  3.2  The new local involvement networks (LINks) need to be properly independent and have the ability to take action. More than this, there needs to be a recognition that consultation processes will only produce genuine accountability if the final decisions actually reflect the wishes of the local population; a duty to consult is different from a duty to act on the results of consultation.

  3.3  Strengthened forms of collective PPI which view patients as citizens should be favoured over the narrow consumerist logic of the "patient choice" agenda. Health is more than a commodity to be consumed by users; it requires patients to be involved in shaping the form their healthcare takes from the start of the decision-making process and through rights of access derived from the public ownership of the health service. The choice model does not encourage democratic accountability as patients effectively shape services through their actions as consumers. Unfortunately, as the recent Involve/NHS National Centre for Involvement report on health democracy has acknowledged, the choice agenda "potentially undermines the argument for user involvement as a more egalitarian mechanism for securing these outcomes." [65]The current marketisation of the NHS mitigates against the type of collective patient and public involvement that LINks are expected to undertake.

4.   Why are existing systems for patient and public involvement being reformed after only three years?

  4.1  It is important that this question has been asked. UNISON opposed the break-up of Community Health Councils (CHCs), which allowed patients and the public to be meaningful stakeholders in the delivery of their healthcare. Whilst an acknowledgement that the current system of patient and public involvement may need sharpening is welcome, the decision to abolish the Commission for Patient and Public Involvement in Health (CPPIH) has been greeted with dismay by staff at the CPPIH, which has only been in existence since 2003. Some staff working for the Commission were previously employed by CHCs, and having been through one set of changes three years ago, they have since experienced more restructuring (between September 2005 and February 2006), and now the latest proposals have left them facing a third round of reconfiguration in as many years.

  4.2  The dissolution of CHCs and now the proposed abolition of the CPPIH means not only the loss of experienced and skilled staff, but also effectively wipes away at the institutional level any collective understanding of the advocacy and rights processes of the health system. This will require many years of renewal and the re-equipping of staff and systems to put right.

  4.3  In the wider context, with the decision to abolish the CPPIH originating in the Arms Length Body Review, the latest set of proposals provide a further opportunity to review the validity of a process which is already causing massive disruption for staff at NHS Logistics and elsewhere.

  4.4  The abolition of PPI forums was announced just eight months after they were set up, so whatever the failings of the current system it is hard to argue that it has been given proper time to bed down. The apparently continuous nature of the current health reform programme is not allowing proper time for discussion and pilot-testing, with new set-ups abolished or reconfigured before they have taken root. Staff working in these services are continually obliged to adapt to new initiatives and, in the worst cases, forced out of the system altogether. These changes are part of a wider trend in which a Government intent on introducing one reform after another finds itself in the position of deriding its own earlier reforms. This approach is allowing critics of the NHS to portray all health reform as a failure and creating a false impression with the public as reflected in increasingly sceptical opinion polls.

5.   How should LINks be designed?

  5.1  UNISON is glad to see that the Department of Health has responded to concerns (raised by UNISON and others) about LINks' powers of access. UNISON members involved in patient forums had voiced concern that the original A Stronger Local Voice (ASLV) consultation meant the possible loss of statutory powers to visit services, a valued means of gathering at first hand the operational reality of service delivery and the patient experience. UNISON is therefore glad to see that the new Local Government and Public Involvement in Health Bill makes provision for a duty on service providers to allow LINks to enter and view premises. A major concern, however, is that the list of organisations that constitute "services-provider" does not explicitly include private sector companies. [66]This is an important omission that needs to be remedied. The power of LINks could be extended still further to allow them access to contracts drawn up with independent providers of healthcare services, as a means of closing the accountability gap that has been opened up by the involvement of the private sector.

  5.2  Although the Bill contains very little detail on the exact design of LINks, there are positive areas contained within ASLV and the subsequent Department of Health reply to responses. The system should allow for a more joined-up approach covering health and social care; it should allow the voluntary sector to contribute knowledge and expertise rather than simply providing services; the loophole that meant the public did not have to be consulted on changes to existing services would be closed; and, importantly, the proposals contain an explicit reference to consulting with all staff who may be affected by changes to local health services.

  5.3  But there are a number of areas where the proposals for LINks that have emerged so far could be redesigned or where a rethink may be necessary. A major area for concern is the organisational make-up of LINks. The community and voluntary sector has much to offer in terms of innovation and plugging those gaps in provision which the NHS cannot, such as Marie Curie's hospices. The expertise and knowledge such organisations will bring to LINks will also be valuable. With the Department of Health increasingly keen for commissioners to procure services through voluntary organisations and social enterprises, however, there is potential for a serious clash of interests. The Government's reply to the ASLV responses states that "these issues are commonly dealt with by voluntary organisations that are both lobbying groups and also provider of services." [67]This may be so, but being a lobbying group is different from acting as a scrutineer (as well as a provider of services) which is the situation voluntary organisations could find themselves in. Such a situation would be magnified further if these organisations have additional responsibility as the hosts of LINks. If these plans do go ahead in their current form, then a robust system of checks and balances must be brought in to ensure fair play, alongside adopting existing good practice examples such as Registers of Interest, as referred to by the Government. [68]Similarly there is a potential question mark hanging over the independence LINks will have from their sponsoring local authorities. Careful monitoring and transparency will be needed.

  5.4  Plans for LINks to cover local authority areas should provide benefits in terms of an overview of the referral and movement of patients between different parts of local health and social services, but there are potential drawbacks as well. UNISON is concerned that the more diffuse nature of LINks could mean it is more difficult for staff organisations and other bodies to engage in a coordinated way. The current system of forums based at institutional level arguably makes it easier for patient and publics to hold decision-makers to account. In a geographically large area covered by one LINk the danger is that individuals are discouraged from taking part due to the practical realities of travelling larger distances. Similarly it may be harder for people to relate to the health needs of an area that is further from the part of the world of which they have direct experience.

  5.5  At the most fundamental level, the health reform agenda may mean that current plans for the design of LINks end up being an inappropriate vehicle for evaluating and scrutinising the commissioning and provision of healthcare. Following on from point 3.3 above, this is due to an apparent contradiction in Government policy which on the one hand is encouraging the local involvement aspect of LINks, but at the same time forging ahead with market-based reform of the NHS which favours larger and more centralised supply mechanisms, such as fewer and bigger PCTs and hospitals.

  5.6  Equality is one area where it remains to be seen whether the proposals have gone far enough. In ASLV the Government called for a more systematic approach for delivering a stronger voice at the national level, in part to promote equal access for less resourced groups. LINks need to be carefully resourced to avoid exacerbating current health inequalities. Equality issues are referred to in the Department of Health response to the ASLV consultation but it is not clear how the new arrangements will guarantee that disadvantaged or vulnerable groups will have a fair opportunity to be involved, as contrasted with those with experience of making the system work for them. It is important that the new arrangements are equality-proofed before being implemented.

  5.7  There are many other areas where greater clarity is needed. For example, how will members of LINks be recruited, supported and developed in their roles? And the question of funding is very important: it remains to be seen how effective LINks can become with the Government not planning to ring-fence the funds that local authorities can spend on LINks. If this is not changed, the new system will need to be monitored very carefully to ensure that LINks become properly viable organisations.

6.   How should LINks relate to and avoid overlap with Local Authority structures including Overview and Scrutiny Committees, Foundation Trust boards and Members Councils, Inspectorates including the Healthcare Commission, Formal and informal complaints procedures?

  6.1  As referred to above, it is possible that the independence of LINks may be compromised by aligning more closely with the work of local authorities, including Overview and Scrutiny Committees, so the new system needs to be careful to ensure a clear delineation of roles and responsibilities between the two.

  6.2  It makes no sense for informal complaints procedures to exist separately from the more formal work of patient and public involvement. The one can inform the other and vice versa. The new LINks should at the least be informed of the content of complaints, if not the personal details of those making complaints.

7.   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  In recent years there have been too many important decisions made about outsourcing and local reconfigurations without the right amount of public consultation, of which the Pam Smith case is just the most high profile recent example. Public consultation needs to take place earlier in the proceedings so that proposals for changes are no longer seen as a fait accompli with mere lip service paid to consultation.

  7.2  The Government's current proposals for PPI could be strengthened by including the need for contracts with all providers to include a requirement to involve and consult patients and public throughout the decision-making process. The earlier commitment to strengthen Section 11 (contained within ASLV) needs to apply equally to practice-based commissioners and non-NHS providers.

  7.3  Furthermore, the Government needs to look carefully at commercial confidentiality and the fact that financial matters in the private sector are apparently exempt from Freedom of Information requests. This needs to be addressed or the perception that commercial interest is taking precedence over the public interest will intensify.

  7.4  Recent suggestions that partnership working between the Government, employers and unions should be rolled out to strategic health authority and organisational level are very welcome. Within this the Government needs to ensure a more rigorous application of the requirements under Section 11 obliging NHS organisations to involve and consult patients, public, staff/unions and overview and scrutiny committees in decisions affecting the operation of services. As an example, where deficits are occurring and are leading to job cuts, the obligation to consult should act as a vehicle for ensuring that staff relocation packages are organised before announcements are made about closures or reconfigurations.


  8.1  More information is still needed on some of the specifics around how LINks will actually operate. The proposed new system does have some advantages but there are also problem areas that need to be addressed in terms of institutional independence. A wider question that needs to be considered is just how effective the new LINks will be, operating as local organisations in a healthcare environment increasingly driven by a centralising market-based dynamic.

  8.2  With the Local Government and Public Involvement in Health Bill expected to have its second reading in January 2007, it is imperative that the Commons Health Committee lobby the Government to, at the very least, allow the Committee to report the findings of its current Inquiry before the Bill becomes law.

Karen Jennings

National Secretary (Health Care), UNISON

January 2007

63   Derek Wanless, Securing Good Health for the Whole Population, Treasury 2004. Back

64   ippr, Public Expectations and the NHS, September 2006. Back

65   Involve & NHS National Centre for Involvement, Health Democracy: the Future of Involvement in Health and Social Care, 2006, p10. Back

66   Local Government and Public Involvement in Health Bill, Part 11, 156-Services-providers' duties to allow entry by local involvement networks. Back

67   Department of Health, Government response to A Stronger Local Voice, December 2006, p22. Back

68   Ibid. Back

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