Select Committee on Health Minutes of Evidence


Examination of Witnesses (Questions 60-79)

MR HARRY CAYTON AND MR MEREDITH VIVIAN

1 FEBRUARY 2007

  Q60  Sandra Gidley: You seem to be hinting that there is a feeling within the NHS or Department of Health that perhaps the forums do not represent the public very well?

  Mr Vivian: If that was what came across I did not mean to say it. What I am saying is that it is very difficult to represent 400 organisations by saying simply they are good or bad. I have to say that to expect a small number of people to be able to hear from a large number of people and easily represent those views is a difficult job, and we think it is right to make that job rather more relevant at local level.

  Q61  Dr Stoate: Not for the first time and I am sure not for the last I am confused about commissioning. You have made quite clear how you see the role of LINks in overseeing commissioning decisions, but if you include the way that things are supposedly going with practice-based commissioning there is no need for practices to have patient participation groups; indeed, the majority of them do not. How exactly will GP-based decisions, even if they are locality-based rather than just practice-based, take any account whatever of what LINks are saying? There does not seem to me to be any mechanism whereby LINks can get themselves involved in decisions that could quite legitimately be made at practice level by a group of GPs and others in all good faith but with absolutely no necessity for them to listen to anything LINks are saying?

  Mr Cayton: I am sure you do not suggest that GPs would ever make commissioning decisions that were not in their patients' interests.

  Q62  Dr Stoate: Not deliberately.

  Mr Cayton: You raise a good point, but the overall plans made by GPs will have to be approved through the PCTs. The overall strategy on commissioning, even at practice level, will be overseen by the PCTs.

  Q63  Dr Stoate: Are you saying that the practice can make a decision in the patient's best interests as it sees it and the PCT can then say that it is not doing that?

  Mr Cayton: In terms of the overall strategy, what powers are you taking? What decisions will be delegated down to practice level and so on? This is a dynamic proposal. LINks will be immediately gathering information from the patient participation group in that practice, if it has one, and feeding it up to say it is not happy. It may well be you are right that at the moment they will not have statutory power to go in and stop the practice from behaving in a certain way, but if they start to raise that issue with the practice itself and with the PCT, if they ultimately raise it with the OSC, it seems to me that, given that dynamic and assuming the PCT and practice are acting with good intent and with the desire to work with and for their patients, they will find it difficult to persist in a practice that has such lack of appeal to their own patients.

  Q64  Dr Stoate: That all sounds fine, but first it does not assume that there will be any coercive power; it will be a persuasive power rather than anything else. Second, it is difficult enough to get GPs involved in the commissioning process. How realistic is it to get ordinary members of the public involved at that level to make any real difference?

  Mr Cayton: First, I do not particularly want coercion because I am interested in patient engagement, involvement and partnership in the health service. I am not really interested in confrontation, opposition and yarboo stuff around health. I do not believe that that is at all the point of the exercise. Second, I have attended a lot of patient participation groups in practices and many have a constructive engagement with their GPs. There is bound to be variability when we give local responsibility to people. There will be variability in the commitment, far-sightedness and imagination of GPs and also in the quality of patient participation groups and LINks, but I argue that unless we allow these mechanisms to be created and have incentives of various kinds in the system to achieve good quality we will not develop anything like the kind of dynamic dialogue that we would like to happen.

  Q65  Dr Stoate: You quite rightly say that patient participation groups are extremely well developed in some parts of the country and have a very persuasive effect on practices, and that is as it should be; in other words, there are already mechanisms for vocal groups of patients and others to get involved in the process via PCTs and practices directly. What will LINks add that currently does not exist?

  Mr Cayton: They add a voice to the patient participation group because that group in a practice can be a member of the LINk. It can have a direct part to play in the LINk and can share its experiences, good and bad, with other organisations. It gives the patient participation group the ability through the LINk to speak with a united voice to other practices that have some experience of commissioning across the whole system. We talk about networks. All we are doing is helping to create networks where people are empowered. We know from all sorts of community action that little groups of people get together and the more they do that and form larger groups the more influential and effective they become, and that is how community action works.

  Q66  Chairman: Mr Vivian and three Members of the Committee were in Central Hall Westminster earlier this week. Somebody stood up to say that in their PCT they had members of the current PPI forum sitting in on the individual decision-making committees about what services should be provided and how they should be provided in that particular locality. Do you think that is likely to change?

  Mr Vivian: It is very interesting, because that situation has absolutely nothing to do with the legislation or functions of the patient forums. There is nothing in the patient forum legislation that provides for that. What encourages that is section 11 of the Health and Social Care Act which says that NHS organisations have a duty to involve patients and the public in decisions that affect the operation of services. That is nothing to do with forums; that is the NHS doing what it is supposed to do.

  Q67  Chairman: I suppose the real question is whether anybody can now look round and say that because of the legislation that is currently going through Parliament the attitude of the National Health Service will change, if it is the PCT itself that has driven that model as opposed to the PPI forum.

  Mr Vivian: It is not the forum that is driving that model; it is the NHS, so I do not believe there is any change. My guess is that LINks will probably support that way of working even more effectively because they will have a far wider range of people from which it can draw that kind of additional activity. I do not know how many people have said in their responses to you that so much is expected of forum members and they spend so much time doing what they have to do. If there are seven or eight people in a forum that is entirely understandable. If a LINk is made up of a much wider set of local people that resource can be deployed much more widely.

  Q68  Mr Amess: The Healthcare Commission has demonstrated that patient and public involvement is a very expensive exercise. What is your answer to the charge that LINks are a way of doing the job on the cheap by using volunteers?

  Mr Cayton: I think that to say that volunteers are "cheap" is a terrible thing to say. I believe that volunteers are part of our national culture. Volunteering is a very important part of culture in our society. Voluntary organisations are run by thousands of volunteers. I had 27,000 volunteers when I was with the Alzheimer's Society, and Diabetes UK has over 160,000 members. People serve on school governing bodies. What we are trying to do is take the money we have and redirect it so that all of it goes down to local level. Local people can use it within the frameworks that we want to set for good governance and financial management. There is no reason why a successful link in the future cannot start to raise funds for itself locally, for instance by being commissioned to do work on behalf of the community. If the social services, the local authority and PCT want specific pieces of work done in terms of, say, surveying particular communities or engaging with them on a particular issue, they can pay extra to do that. We are creating a permissive, not a prescriptive, model. We deliberately did not suggest that LINks were called LINks for health and social care because I would like to see community transport involved in it, for example. Transport is a major issue for many people who use health and social care, particularly those with disabilities. I want to see LINks opening up the whole question within a particular local authority of how to bring together health, social care, transport planning and all the issues that affect people's wellbeing.

  Mr Amess: I think you answered that very silly question extremely well.

  Q69  Jim Dowd: The memorandum that you submitted to us alludes to a point referred to a few moments ago. It says: "It is important to note that the term `membership of a LINk' may be misleading. It will be possible, indeed sometimes desirable, for people to feed their views and experiences into a LINk without seeing themselves as `members'." We have received evidence from other bodies highlighting the role of the patient representative. I accept that sometimes the representatives are no more representative than of one patient, but is this a formal attempt to reduce or eliminate the previous role of patient representatives?

  Mr Vivian: We want LINks to be able to capture a wide range of views and experiences. I can do that by, for example, having a website by which people can feed their views into the system. A LINk can capture that and weigh it up; it can receive feedback from local panels and complaints made to local services. People can fill in comment cards and take part in public meetings, forums and so forth. There is a very large array of mechanisms by which people can feed in their views. That does not make them members of something; they are contributors to and participants in the exercise. Some people will want to do something specific. They may want to visit an NHS facility and assess the range and nature of the quality of services provided there. Others may want to sit on PCT decision-making boards or whatever. There are lots of opportunities for people to become engaged in it. They may still not see themselves as members of a LINk but certainly the people who are engaging in LINk activities. At the top of this pyramid of involvement we see a need for some sort of governance arrangements whereby a smaller core group of people says that they are the ones who essentially will be stewards of the particular entity or organisation. It is they who will be responsible for how the money is spent and decisions are taken about staff and so forth. That is why we do not like to talk about membership. People's interest is pertinent to their own degree of energy, enthusiasm and commitment. Some want to be members; some want to be participants, and so forth. That is why we talk in those terms.

  Mr Cayton: We have tried very hard to counteract this view, but I put on record that there is every desire on our part to have as many members of existing patient forums who wish to be actively involved in LINks to be so involved. We have no desire for that expertise and commitment to be lost and we see no reason why they should not play a significant role in LINks. The nine pilot sites that we are looking at are being built from existing patient forums and practices. I can understand the pain and sense of rejection of some patient forum members, but it is absolutely untrue that we do not want them to be part of the new system if they choose to be.

  Q70  Jim Dowd: I understand that. Mr Vivian, you said that you did not want to talk in terms of membership of LINks, but the paragraph prior to the one I just quoted starts, "We hope that the membership of LINks should be locally determined rather than centrally so." There is an ambiguity here which I cannot quite get to the bottom of. What do you see as the membership of LINks? Whom do you see as being involved hopefully at the core of LINks?

  Mr Vivian: I think that is the nub of it and that is not for the Department of Health to say. It is for local people themselves to decide.

  Q71  Jim Dowd: Do you not have an optimum view?

  Mr Vivian: Yes. We would definitely like to have people in this governance arrangement, if we call it that, who are objective, are able to commit time and energy to it and have good relationships and are able to build partnerships with other organisations, VCS and public sector organisations. We want people who are able to appreciate that there are many views and ways to ensure that through good process those views can be collected and represented appropriately. We want people who are able to talk objectively on behalf of other people without necessarily grinding their own axe. Those are the sorts of people that I have in my mind's eye, but I do not think that we can frame legislation that will deliver all of that. We cannot say in the Bill that the people who sit on top of this organisation must be of this type. Indeed, how can we tell from here? That is the nub of the whole issue: we want it to be locally determined.

  Mr Cayton: To elaborate and perhaps clarify the briefing, we expect LINks to have members and for those members to be drawn from committed individuals and local community organisations. One may well have a governance structure that includes an electoral college of which local organisations like MIND, MENCAP or community transport organisations may be members, as would committed individuals. One then has a governance system that allows the appropriate election and appointment of a board, but what we tried to say in the briefing was that those people would not be the only ones who had a voice through the LINk. One would be able to have a voice through the LINk even if one was not strictly speaking a member. The LINk would talk to wider communities. Clearly, if one was in MENCAP one would be talking to its clients and families, even though those individuals themselves would not be members of the LINk.

  Q72  Chairman: At the moment it seems clear that large and vocal sections of the public are opposed to reconfiguration. Earlier Mr Amess mentioned A&Es, but there is also the maternity service in Greater Manchester which has been in the public domain for the past few months. One of the issues in that regard is the improvement in services particularly for premature babies if the reconfiguration goes ahead versus public opinion in some parts of Greater Manchester that it should not do so on the basis that they want to retain that particular establishment in their particular geographical area. What weight can one expect people to have in relation to this type of debate?

  Mr Cayton: It is very difficult, is it not? We know that hospitals in particular are iconic in communities. Dr Taylor is a living example of how iconic they can be. It seems to me that the handling of reconfiguration debates is an area where we still lack expertise and an understanding of how to reach what I call a socially sustainable decision, by which I mean one with which not everyone agrees but everyone can understand. There are examples of where that has been done well, but when one launches into rapid periods of change with inadequate sharing of information with the public one gets a reaction. I believe that we do that extraordinarily badly very often. Because the NHS and hospitals in particular are emotionally symbolic within communities they tend to get a high level of emotional response in planning. There was some discussion about this earlier. I hope that the NHS Centre for Involvement will help us with some of it. There is some research in both Canada and Australia about the particular kinds of methodologies for collecting voices, whether it is from general questionnaires down to citizens' juries and the importance of using the right methodology for the question one asks. To go back to the discussion about citizens' juries, they are good only at trying to deal with highly complex ethical policy issues; they are not good at dealing with representative views, whereas questionnaires when well conducted are much better in dealing with that. I believe that there are five stages to good public involvement. The first is to go where the people are; the second is to share all one's knowledge with them. Usually, people are suspicious and distrustful of consultation when they think the other side is holding its cards to its chest. One needs to put out all the information and be honest about performance and say why something is not safe and something else would be safer; one needs to say what one is doing about public transport and talk seriously about the costs. One needs to share with the public all the information that one has as professionals, listen to them, act and finally tell them what one has done and why. If people try to rush that process, or miss out part of it, or not take any part of it seriously, it will not work.

  Q73  Chairman: Are there any no-go areas for public consultation in relation to the shape or reconfiguration of local health services? Is there any cut-off in any of this?

  Mr Cayton: From my perspective, I presume that while we have a National Health Service there will always be powers that must be reserved to ministers either to deal with dilemmas where local resolution has not been possible or to set an overall strategy particularly in relation to finance, standards of provision or the range of things that the service must provide in a particular area. I refer to the whole business of setting standards and having national service frameworks. Clearly, those things need to be done nationally.

  Q74  Chairman: What would happen if a clinical case had been made and agreed upon but there was still vocal opinion against the closure of the local A&E or maternity unit? Would that still be a matter for a political decision?

  Mr Cayton: I express an entirely personal view here. As an exponent of patient, public and community involvement if the community really understands the choice it is making local politicians should take that seriously into account. That should include the local managers of the health service.

  Q75  Chairman: I remind you that you have the same protection that we have in terms of your evidence to the Committee. I take this matter quite seriously. It seems to me that there are some contradictions in this. We as individuals can have a voice if something is happening locally and then we can have a voice down here. There is a mechanism whereby even decisions that are taken locally can be referred—not all of them have to be—if the Secretary of State and those lobbying him feel that they are uncomfortable ones. This is a bit of an uncomfortable situation in terms of the reconfiguration of health services, is it not?

  Mr Vivian: I want to pick up that very issue. Local people have locally elected representatives who have been given specific powers to review and scrutinise the planning, provision and operation of services. The overview and scrutiny committees have the power to inquire about the nature of services, the change of provision and whether or not it is in the interests of local people. Therefore, people do have local representatives, and indeed the scrutiny committees have power to refer matters to the Secretary of State if they do not believe that the change is in the interests of the health service. The Secretary of State also has the ability to seek advice from the independent reconfiguration panels, so there are some levels in the system which give people a degree of security. It is an assurance that there is a process in place for scrutiny. As we know from last year, there is also the possibility of seeking judicial review on some issues. It is not as if there is nothing there to protect the interests of local people. The critical aspect is that inevitably any service change will not suit everybody, but what must be in place is a process which people believe in and can feel comfortable with because it has been followed and has been transparent and open.

  Q76  Dr Naysmith: I turn from that rather general question to the particular issue of the Bill and LINks. When talking about it earlier I could detect a slight difference between you as to what you thought LINks should be when established. As has been said, the Bill says almost nothing; it is lacking in details about what LINks should be. Mr Cayton would certainly be in favour of LINks designing themselves. Different things can happen in different places. Mr Vivian, I got the impression that you had a firmer idea of what you would want LINks to be. I know you said that it would depend on certain factors. Is that fair? You do not appear to be saying quite the same thing. There is room for that in view of the way the Bill is laid out.

  Mr Vivian: I said what was in my mind and I certainly know that that is also in the minds of a lot of other people because I have talked to them about it. That is the kind of picture that is beginning to emerge, but it is not the department's policy that that is how they must be. In trying to envisage it that seems to be how it will be.

  Q77  Dr Naysmith: Decisions have to be made about who will participate and whether decisions are to be made democratically when a voice comes out of the LINk. That has to be decided when they are set up. The question whether such decisions are taken during working hours or outside them can also have an influence. These matters must be decided at some stage. There is a suggestion that civil servants will provide guidance on it at some stage.

  Mr Cayton: My conception of this is very much linked to the governance models used in many voluntary organisations, particularly those that have branches and sub-groups within them. One has a defined membership, but that does not mean that those outside it cannot also participate in various ways. One also has defined rights of membership and a management board or committee of some kind which has internal accountability to the members as well as external accountability to funders. That is the normal arrangement in the voluntary sector. One is often accountable not only to one's trustees but, say, to a major trust or donor who has provided money for a specific project. I do not see a problem about LINks being accountable both to their membership and to a local authority for the delivery of the contract part of their work. I accept that there would be employed staff accountable to the board of management. That is my current vision drawn mostly from my voluntary sector experience. I also want to learn from the pilots that are currently being conducted. People who live in Devon may want a rather looser model perhaps with groups operating in north Devon and in Exeter and Plymouth, whereas someone operating in, say, central Manchester may be very happy with a tight and much more centralised model. It is for those variations that we want to be able to allow.

  Q78  Dr Naysmith: Will there be guidance on some of these things from the department; and, if so, when is it likely to appear?

  Mr Vivian: Part of this is all about communication. There are some things that are "musts". One must be absolutely clear as to what the legislation does say. It gives some detail; it is not bereft of any. For example, the functions are absolutely explicit and are listed. It says that LINks should report on an annual basis and specify who can provide support and so forth. We need to communicate clearly what the Bill says, but there are other elements which need to be dealt with, some of which are put in terms of, "We strongly advise you", or, "Here are some models that you might like to follow." The early adopter programme will help. We are also in the process of setting out a model contract specification for local authorities to use when they are procuring hosts for LINks. We believe that that specification is absolutely fundamental. The host requirement will in essence be how LINks come to life because it will be the host that is responsible for attracting people to join in and support the electoral process. To provide some timescale, from now on we shall be saying more and more about LINks and the process of establishing them under the Bill; we shall be running nine regional events from March to May where we shall invite patient forum members, local authorities and NHS organisations to come along and hear more about it. Towards the end of the year we will be issuing guidance in respect of which the NHS Centre for Involvement has been working alongside the department in terms of how best to be a LINk—what the key behaviours are, how best they can organise themselves and so forth. Model specifications will be going out in the autumn to support local authorities to procure hosts and so forth. There is a compendium of measures.

  Q79  Dr Naysmith: Quite a lot of guidance will emerge eventually?

  Mr Vivian: When it is ready and relevant, yes. There is no point in our saying what the Bill provides until it has gone through the parliamentary process. It must reflect the final position.


 
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