Select Committee on Health Minutes of Evidence


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 issues—what people think are the most important matters—and 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 us—we considered it in the expert group, although it was not in our remit or appropriate for us to make recommendations on it—is 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 organisation—the guidance says so explicitly—to 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 activity—a bit like, I fear, being a member of a forum today when it has been through such a difficult time—why 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 Vivian—ministers have been as clear as they can be given the spending review—that 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 say—Mr Vivian will remember this from the meeting on Tuesday—that 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 about—it is very interesting that such provisions are in the Local Government Bill—is 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 kinds—for 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 effectively—and 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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