Examination of Witnesses (Questions 80-99)
MR HARRY
CAYTON AND
MR MEREDITH
VIVIAN
1 FEBRUARY 2007
Q80 Dr Naysmith: That takes us back
very nicely to Mr Cayton's suggestion that Devon may want a different
structure from what happens in Manchester. He will recall what
was said at the time Primary Care Trusts were being set up. One
of the main reasons for them was that different communities might
have different priorities and spend their money on different things.
Nowadays, what seems to be driving everything is the postcode
lottery. One must have an identical patient experience no matter
where one is; if not, one puts up one's hand and says it is a
postcode lottery and it is unfair. How will we balance those factors,
because with LINks when people can say they want this or that
in one part of the country and something different in another
it will become more difficult?
Mr Cayton: There is an inherent
tension between the national agreement that we want a National
Health Service, where people become very exercised because there
are variations in availability of medicines and so on, and the
same people saying they want local accountability and control.
We need to continue a strong public debate about what are the
things that are held at the centre in respect or which we say
it is appropriate for the centre to define standards, frameworks
and the matters that all health economies must deliver and what
are devolved to local level. For instance, if one were in Bournemouth
one would expect and hope greater resources to be devoted to services
for older people because that would reflect the demographic make-up
of the community. There will be other places where many young
families live and one wants to see more resources going into maternity.
It is those kinds of balanced arguments that one hopes LINks would
be able to engage in with commissioners on behalf of the community.
Mr Vivian: We are not always talking
about LINks, because clearly the NHS has responsibility here.
We should not expect LINks to do everything all the time. Thinking
back to the commissioning framework published in July last year
in which commissioning was described, it was quite explicit that
PCTs should engage people in the assessment of health needs in
their areas, in prioritisation in terms of the big issueswhat
people think are the most important mattersand in decision-making
about how money should be allocated and then listen to or understand
the response of people about their experience of those services
that have been commissioned. There is a cycle or loop of listening
to people, engaging with them and feeding it back and starting
it all over again. LINks can help that, but in the end it is a
job for the PCTs. The duty to report back on what they have done
is an important facet in ensuring that PCTs are explicitly accountable
for this activity.
Q81 Chairman: You have pointed out
rightly in relation to the current mechanism that the ground for
this type of informed consultation is that we hope everybody agrees
or disagrees. Is it right that effectively even with consent one
can stop it at ministerial level? Are you not building into the
system distrust because people think that for all their endeavours
at local level and everything else someone can come along at a
later stage in the process and say, "I am sorry, but that
reconfiguration will go ahead even if you are against it"?
Is there not some contradiction in that?
Mr Vivian: You are saying that
the person who can do that is a minister?
Q82 Chairman: And/or the independent
committee that is being set up to take decisions referred to it?
Mr Vivian: The independent reconfiguration
panel is an advisory body; it cannot make decisions but makes
it advice available to ministers to enable them to make the final
decision. It will weigh up the evidence based on a number of factors,
for example whether the change has a negative impact.
Q83 Chairman: I understand that.
But is there not a contradiction between having that power and
asking communities to take decisions about their local health
services? I do not want to justify it; I just wonder whether there
is a simple answer to it.
Mr Cayton: First, I do not think
that we are asking them to take the decision but to engage with
the people who will take it, that is, the PCT. Second, your point
is correct. Part of the problem for uswe considered it
in the expert group, although it was not in our remit or appropriate
for us to make recommendations on itis that the NHS locally
is not democratically accountable, whereas the NHS nationally
is democratically accountable to Parliament through ministers.
Unless and until one reserves that issue the validity of saying
that consultation with the community is, as it were, a mandate
from the community for or against change is rather more difficult.
At least with the electoral process we all know that that is a
mandate. Even if only 25% of the population votes in a particular
election we do not doubt that that is a mandate because everybody
could have voted. That is not the same thing in terms of consultation.
You are right to put your finger on a sore spot, but it seems
to me to be one of those many ambiguities that exist in the way
we organise health and social care.
Q84 Chairman: What about the mandate
of an elected overview and scrutiny committee?
Mr Vivian: That is the other side
of the coin, in that the way this Government has attempted to
tackle that issue of democratic accountability is to give explicit
power to those people who are locally elected so that they are
able to ensure that local NHS organisations must give account
and be accountable to them so that local people have elected representatives
with a degree of clout in the local dynamic. That is precisely
why they are there and why there is a connection being made locally
between the scrutiny committees and their powers of referral to
the Secretary of State. There is a cycle or loop in place that
can work, but in the end government policy is that wherever possible
those decisions should be made locally. Indeed, when the Secretary
of State gets a referral from any overview and scrutiny committee
she may well ask the NHS organisationthe guidance says
so explicitlyto consult further or open it up again if
she is not convinced that the process was good enough in the first
place.
Q85 Mr Amess: My question is concerned
with more active volunteers. The old community health councils
used to have about 5,000 volunteers and the new forums will probably
have the same number. There is no doubt that LINks will sign up
more members, but do you think there will be that many more truly
active volunteers?
Mr Cayton: It depends on how much
fun it is. If being a member of a LINk is a miserable activitya
bit like, I fear, being a member of a forum today when it has
been through such a difficult timewhy would somebody bother?
Any organisation that wants to build its membership needs to provide
support, encouragement and love for its members. You are right
that there is a challenge to be faced. How does one build LINks
that are sufficiently dynamic and engaged with people and do work
that people believe matters and care about? I go back to Communities
for Health in Newham. I have been involved in this for two years.
I believe that it is an extraordinary project which grew out of
the discovery that within the community schools, faith groups,
housing associations and employers all had an interest in health
and people within those communities were prepared to be champions
for health. Communities for Health has designed a model where
each community commits itself to a set of healthy living activities.
It may be teaching children about good diet; it may be helping
Asian women to cook without using saturated fats, because women
are the most powerful tools for changing health in families. About
30 organisations are now part of it and it is growing all the
time, because it is bottom up and community-led and people enjoy
it.
Mr Amess: I hope that your words of wisdom
are listened to. When we draw up our report we will reflect on
how to make it more fun.
Q86 Dr Taylor: Turning to resources,
we have heard that the NICE Citizens Council is working fairly
well. One rather thinks that it must have enormous resources.
I have not yet seen the evidence from NICE which hopefully spells
that out. It has been said so far that you will spend approximately
the same as on PPIs which the commission has divided up. It has
decided that it will give about £180,000 per LINk which it
feels will not be nearly enough if one is to involve a large number
of members, provide office space and a certain amount of support
staff and meet the expenses of volunteers and training. Is there
any likelihood that one can go part-way towards meeting the forecast
of £424,000 rather than £180,000?
Mr Vivian: One of the added value
issues around LINks is that the Bill sets out that each local
authority will be required to put in place arrangements to procure
the host which will then set up the LINk. Part of the money available
needs to go towards the local authority to enable it to perform
that role. Nevertheless, even taking that into account what we
can do with the available funds is make them go much further by
stripping out part of the current bureaucracy between the Department
of Health and the front line, ie activity by patient forums. We
want much more money to get into the hands of those people who
will actively engage in this kind of activity.
Q87 Dr Taylor: Are you saying that
more than that £180,000 will come from the department?
Mr Vivian: More of the £28
million currently available will reach the front line.
Q88 Dr Taylor: The £180,000
is calculating for that?
Mr Vivian: That is right, but
longer term it is difficult to say how we can make sure that more
money reaches the front line than is currently available or goes
into the PPI arrangements. This is part of the Comprehensive Spending
Review which is currently under way and will not give its view
until July. We cannot say precisely at this stage what levels
of funding might be available. I imagine the commission would
say that hugely more money should be made available because it
has always made clear that to enable it to do its job it would
like much more money. I suspect that if every bit of the public
sector was asked whether it would like more money it would say
that it could do a fantastic job if it did. That is the nature
of making public sector funds available. We in the policy team
certainly want as much money as possible to reach LINks and we
shall be putting in bids appropriately, but in the end that is
a decision which needs to be taken right across Whitehall under
the Comprehensive Spending Review.
Q89 Dr Taylor: I was rather worried
by Mr Cayton's statement that it would be up to LINks to earn
some money, because I would hate to see personnel involved in
raising money rather than doing their work.
Mr Cayton: I did not say that
it would be up to them to earn money. As this is permissive planning
there is no reason why if they were approached by a PCT asking
them to do a specific piece of survey work they should not agree
to do it but say they needed an extra £10,000 for that. I
am absolutely with Mr Vivianministers have been as clear
as they can be given the spending reviewthat we want to
put as much money as we can into making sure that LINks operate
effectively at local level, but we cannot say how much money we
will be given to do the job. I know a lot of local voluntary organisations
that are extremely effective on a lot less than £180,000
a year.
Q90 Dr Taylor: Can you at least sayMr
Vivian will remember this from the meeting on Tuesdaythat
the money which goes to local authorities will be ring-fenced
or that the amount they have been given will be publicly known?
Mr Vivian: This is a very important
issue. It is tempting to think that it must be ring-fenced and
local authorities cannot get their hands on it. What this is all
aboutit is very interesting that such provisions are in
the Local Government Billis a recognition that local authorities
need to make decisions about local priorities and they are governed
by locally elected representatives. The central perspective here
is that we should not provide them with money but say that there
are some constraints about how they spend it. Nevertheless, the
second point you make is right: the amount of money that we make
available to local authorities will be a known figure.
Q91 Dr Taylor: It will be widely
known?
Mr Vivian: Yes. I go further and
say that in their annual reports the LINks will be required to
say how much money they have received from the local authority,
so not only will people know how much the local authority was
given; LINks will have to say how much they have received.
Q92 Dr Taylor: The local MP could
then tackle the council for not providing what it had been given
for this purpose?
Mr Vivian: That is the purpose
of it.
Q93 Charlotte Atkins: How will accountability
work in practice? We have received quite a lot of evidence from
people expressing concern that local authorities and trusts may
have control over hosts and volunteers. Clearly, we do not want
that to happen, but we also do not want these organisations to
be taken over and be completely dominated by particular interest
groups. What is the balance, and how will it work?
Mr Vivian: Let me say something
about the relationship between the local authority, host and LINk.
I am sure that Mr Cayton will say something about the second half
of it since he is very familiar with it. The local authority will
contract with the host. The specification that the Department
of Health is now establishing will set out what the host needs
to do. The host will be accountable to the local authority for
the money it has spent and will need to show how it is meeting
the contract. There is, however, dual accountability for the host.
The host is also the support provided to the LINk, so it is the
LINk which says how much money should be spent on certain activities,
decides priorities of activity and what reports need to be sent
to the PCT or the local authority. The power base is the LINk
but it is the host which must say how it is meeting the contract
specification. The LINk is certainly independent of the local
authority; it does not have to do what the local authority tells
it.
Mr Cayton: I think that getting
the governance right is very important; that is, making sure that
there is real public openness about the activities of the LINk
with publication of minutes and papers, open meetings and these
kinds of mechanisms so there is proper accountability. In all
the many networks that voluntary organisations create there are
always tensions between one big group and another. Are the people
with cancer getting more power than people with motor neuron disease
and so on? There are checks and balances in governance mechanisms,
electoral systems and so on that enable people who work in networks
to do this successfully. I trust the people. I think that by and
large voluntary organisations in this country do not behave in
a predatory or self-interested way, and certainly when they operate
in groups there are enough of them for the balances to be created.
One of the things that we will need to do in defining the contract
for the LINks is make sure that anyone who applies to set up such
a body has a sufficiently broad membership and community support
for doing so. We will not just hand it over to one individual
organisation or another; they will have to demonstrate that they
already have support from local organisations and a balanced governance
structure.
Q94 Charlotte Atkins: The issue is
not so much about whether one trusts the people; it is about whether
we trust local authorities or trusts not to be overriding and
dominant in terms of their dealings with volunteers and a whole
range of organisations. Clearly, there could be an imbalance of
power there.
Mr Cayton: In the expert panel
report what we proposed was a model where the money went through
local area agreements. That would have given us a level of independence.
That did not prove to be legally or financially appropriate. We
then went back to the idea of handing out the money nationally,
and that seemed very inappropriate. The idea of our having tried
to hand everything over to local communities and then run it from
the Department of Health seemed an even worse idea. Given that
local authorities have a long track record of handling national
grants of various kindsfor example, carer support grants
and so on have passed through local authorities very successfully
over the years and have often been handed out to the voluntary
sector effectivelyand that local authorities are democratically
accountable, it seemed to be the best way to go.
Mr Vivian: That is the analysis
of it and that is why we have come up with the model we have.
LINks have some power; they can require information from local
authorities and Primary Care Trusts, providers and so forth. They
can require responses to their recommendations from those bodies.
They have a specific referral power to overview and scrutiny committees
which have power over those very bodies. They can if they choose
contact local media if they think they are being swallowed up
or inappropriately influenced. I cannot imagine that a LINk will
be overwhelmed by a local authority or primary care trust; it
has more clout than that.
Q95 Jim Dowd: In the London Borough
of Lewisham, part of which I represent, there is a directly elected
mayor as well as an OSC of councillors. Would the arrangements
between the LINk and local authority be affected by that at all?
Mr Vivian: No.
Q96 Jim Dowd: They are directly linked.
The mayor has an independent mandate, as does the council?
Mr Vivian: There is no impact
at all. It may well be that the LINk may think that a very close
working relationship with the mayor is a good idea, and it probably
is.
Q97 Mr Campbell: Host organisations
are to be taken from the voluntary and not-for-profit sector.
The voluntary organisations' expertise, however, lies basically
in fund-raising, organising volunteers and campaigning. Do you
believe there is enough quality in those organisations?
Mr Vivian: To be clear, the hosts
of a LINk can be any type of organisation, but it will be for
the local authority to ensure that the one that gets the contract
is best equipped to do the job. It is likely to be a VCS organisation
but not necessarily so. It must be able to do a number of things
to carry out the job: it must be well connected locally, have
good relationships with organisations, be familiar with health
and social care and have a good track record in involving people
or representing their views. What the specification says is that
the organisation that gets the job is the one that can do it.
Q98 Mr Campbell: The most important
thing is that they have to be good opinion-gatherers as well?
Mr Vivian: That is absolutely
right and the specification makes that clear.
Q99 Mr Campbell: Do you believe that
the host organisations will be in that field?
Mr Vivian: Yes. From the soundings
that we have taken, there is a great deal of interest in this
on the part of the voluntary community sector. Having spent time
with some of those interested, they would be very well equipped
to do it. Some of the existing forum support organisations may
be interested, but that is not to say they are necessarily best
placed.
Mr Cayton: I suggest that many
local voluntary organisations have a wider skill set than that.
Many provide services locally and do regular surveys of local
services on behalf of their own client groups and produce reports.
One thinks particularly of the kind of work that the local MIND
groups do in challenging and reporting on local mental health
services. There is a lot of expertise in information-gathering
within the voluntary sector already, but undoubtedly some LINks
will have to learn and acquire new skills.
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