Examination of Witnesses (Questions 160-179)
MS MARY
ADAMS, MS
ANNA COOTE
AND DR
ALBERT DAY
8 FEBRUARY 2007
Q160 Chairman: Two of the three examples
that I asked for and was give earlier really provided something
that is entirely consistent with current statutory guidelines
in terms of strengthening accountability. Is the real issue here
the local management's will to implement PPI's decisions? You
describe an example there where you have very few complaints and
PALS is an effective tool in your armoury, as it were, to get
things done. Is this issue a lot of time about will at local level
as opposed to the framework is not there?
Dr Day: Absolutely, I could not
agree more. Where it is the strategy of the board in any NHS organisation,
the board of directors in a foundation trust, they have to have
that high on their agenda, just as they would have risk management.
It is an effective part of the strategy of the organisation. If
you are trying to be a member facing the organisation, as we are,
then to ignore that category is foolish.
Ms Coote: One of the important
ideas behind the shift towards the LINks was initially—I
do not know if this has got lost—the idea that, rather than
setting up an "us and them" arrangement, one emphasised
the point that trusts themselves should take their responsibilities
seriously to engage with patients and the public and that they
should be the ones that really felt it was their duty, that they
did not just have to respond to a body that was there in the community
but that they had to do it, they had to make it happen and it
was very important not just because it was a good thing in itself
but it was actually good for them to achieve their objectives
as providers of healthcare. There was potential for the Healthcare
Commission to regulate the performance of trusts in relation to
how they do patient and public involvement, so to shift the emphasis
from there being a body there in the community that is supposedly
speaking for the community to the trust taking responsibility
much more fully, and then being regulated for how it used its
responsibility, how it deployed its responsibility. This is perhaps
another discussion but I think it is quite an important point.
Q161 Sandra Gidley: This is a question
to Dr Day because it is relevant to foundation trusts. Monitor
has suggested that many boards of governors have not yet "found
their feet", I think was the phrase they used, and the BMA
has said that foundation trusts are a failing area in terms of
PPI. Obviously, you can probably only answer for your own but
would you agree that PPI in most foundation trusts is inadequate?
Dr Day: I could not disagree more.
I could not disagree more. I can only speak personally, as you
are absolutely right to say. When we applied to be a foundation
trust, the real reason we wanted to do it was to improve and build
on PPI. It had other attractions as well but that was the key
one for us. It was to take the temperature of the local population's
wishes and to refine and develop where we are in health in our
locality, using that voice as a main lever. In order to do that,
we had to design our own structure, our own board of governors
because that is the way the Act allows us to do it, thank goodness.
We set up a small board of governors with a public majority on
it, an elected public majority, and we determined that first of
all, it would be called board of governors and secondly, it would
be a board and it would govern. Therefore we set up a whole raft
of work streams, with people on the board designing them and feeding
in from ideas that we already had, so that at the end of the second
year—we have just finished our second year as a foundation
trust—we can actually hold our heads up and say the board
of governors have made a real difference to health in our locality
and actually, they feel great ownership of it. One way that you
can say "Where is the evidence for that?" is to look
at where is the support for the work the governors are doing,
and I would say the first and obvious statistic is to look at
the membership numbers. We have about 15,000 members and they
are all opt-in members; they are not people who have been placed
in membership; they have all chosen to be members of a foundation
trust.
Q162 Sandra Gidley: Has that number
increased?
Dr Day: It is increasing. I have
to say that we are being cautious in the rate of increase simply
because it needs support and management, and it would be very
easy to go overboard and fall into the same trap that private
businesses have, which is over-extension. So we are increasing
our membership year-on-year and gently in areas where we perceive
a need to do it. In terms of real engagement, and the BMA's view,
for all I am a medical doctor, I would disagree with profoundly.
I think that actually it is one of the best success stories.
Q163 Sandra Gidley: But not all trusts
have that number of patients linked with them. What difference
has the increased numbers actually made to them? How involved
are these members?
Dr Day: We engage them passively
by my giving them communications, and I do that regularly, informally
and formally. We engage them by way of traditional things like
questionnaires, telephone surveys, we do exit surveys, and all
the marketing tools, for want of a better phrase, that any organisation
that is interested in feedback will do. We have at the moment
a bank of just over 2,000 individuals who have actually elected
to help us. They have written in and said "We are interested
in this area, that area. Would you like our help?" and therefore
when we are trying to do development work in a particular area,
let us say respiratory medicine for the sake of argument, we know
that we already have a ready-made, large cohort of members from
whom focus groups can be selected. Another example: publications.
We often get in the Health Service allegations that we have NHS-speak
and that we have our own internal language and we do not communicate
well with patients. We must address that, and one way we do address
that is by looking at our publications and our patient information.
We use members specifically as reader groups for that, so we might
design a particular, let us say, an orthopaedic hip replacement
piece of advice. We then give it to our readers group from our
membership and say "Is this actually user-friendly? Is it
in terms that are comprehensible? How can it be improved?"
Q164 Sandra Gidley: It sounds to
me as though LINks will not have much impact on what to do.
Dr Day: Frankly, it will not.
I do not want to make that too much of a negative comment because
we have a very good patients forum and I would be very sad to
see that disappear. If LINks is its successor body then let us
grab, as I have said in my evidence, the very best of the Community
Health Councils and the patients forums and put those into LINks
and build on it. Let us not reinvent the wheel. Let us grab what
we have got which is good.
Q165 Sandra Gidley: Once all hospitals
become foundation trusts, will LINks be redundant to a certain
extent?
Dr Day: No. There are still going
to be commissioning groups, and I see a very important role for
LINks, particularly in commissioning groups, but I have to say,
and I have said it, that for me and efficient board of governors
will perform as well as LINks will in commissioning.
Ms Coote: The thing about an opt-in
board is that people who do not think about getting in touch will
feel that their voices are not valued and will not opt in, so
I think the board membership model for the foundation trusts is
a really valuable one. It needs development and sometimes it is
very good and sometimes it is very, very poor, really a bit like
any kind of arrangement, and it will probably apply to the LINks
and to the forums, but it needs to be supplemented by some special
effort to reach out to groups who are often most vulnerable to
ill-health and whose voices are seldom heard. The FT board process
does not actually fix that problem, so it does need to be one
in an armoury and I think that a possible strength of the LINk
model is (a) that it can easily incorporate FT boards, as it can
PALS, and also that it can reach out proactively to groups in
the community that would not necessarily come in to join a forum,
an FT board or indeed have anything to do with PALS.
Q166 Sandra Gidley: Do you think
there is potential there for perhaps doing more work, such as
in the last question in the last session where we were talking
about reaching out to black and minority ethnic communities?
Ms Coote: Yes, and we do this
ourselves. We have a network of seldom-heard groups around the
country who represent different kinds of groups, but it is not
by any means perfect and it will need a lot of refinement. With
all of these things, I think stability and some sort of long-term
security for a set of arrangements from now on at least is really
essential so that we can identify what is wrong, work on it, get
it better and let people get accustomed to what needs to be done
in each local community, especially if it is going to be quite
a diverse set of outcomes, which I actually approve of. I do not
think we should have some sort of national uniformity, I think
it is about evolution and diversity, but that requires patience
and learning, an exchange of information and time to pass for
these things to work, and it is the same with the FT boards as
it will be with anything else.
Ms Adams: I see the LINks very
much as being for a geographical area where the members of the
foundation trust are for an organisation, so it is quite different
and I think you need both and they can complement each other.
Also, as well as the point about stability, there is a point about
maturity because I think we will just begin to see overview and
scrutiny committees mature and become really effective and with
patient forums too, just given a little bit longer, I am sure
it would have continued, the same for the patient advice and liaison
services linked to that would have been a bit more resource and
a bit more support perhaps from the organisation, so it is this
sense of maturity; it takes a long time to relationship-build
within an organisation or across the community to get the trust
of the people that you are trying to support, so the time is very
critical.
Dr Day: Yes, I would certainly
agree with that.
Q167 Charlotte Atkins: I would like
to address my question first to Dr Day. It seems to me that, of
the issues that the PPI forums address, cleanliness is an obvious
example. Surely this does not require some sort of unique patient
perspective. It should be something, should it not, that is dealt
with by clinical governance? Why are patients getting involved
in that? Is it not just a way of, to some extent, trusts side-stepping
their particular role in clinical governance?
Dr Day: To answer your question,
if you stand outside any of the large supermarkets in the UK on
a Saturday afternoon and say to the people coming out of the supermarket,
"What is the management for?", they will look at you
as if you are from another planet. If you stand outside that same
supermarket and say, "Tell me about hospital cleanliness",
they are all experts. I think in a sense that answers your question
because people are very, very interested in what they think they
can influence. Perhaps I can sort of develop that and say that
in our trust we have what we call "medicine for members"
sections and we asked our members what they wanted to talk about.
No surprise, the first top two were, yes, cleanliness and the
second one was car parking. If we leave the other topic for a
bit later on in this conversation, cleanliness is something where
I think we need to give the public assurance that, yes, we are
connected at the top of the organisation with what is required
where there is an objective assessment by experts such as a PEAT
assessment. But outside of that, then we want the members and
the members of the public to know that actually we are taking
it seriously and engaging them in it, and telling them all about
it seems to me a logical way of doing so.
Q168 Charlotte Atkins: So what you
are saying really is that it is more to keep the patient forums
happy rather than actually to affect your management?
Dr Day: We are sitting in a comfortable
position from what I would dare arrogantly to say is a good standard.
Where those standards may be open to question, I could well see
that the patient forums may very well want to be more assertive
in what they do and I would not blame them for that, I would welcome
it.
Q169 Charlotte Atkins: Well, certainly
the patient perspective might be, given that we have increasing
hospital infections and although obviously hospitals have significant
targets to get down infections, that it is still a problem and
it is a problem which clinical governance is failing to meet.
Dr Day: Well, again in my own
trust, which is one I know intimately, our figures for MRSA and
C.diff are exceedingly low, such that the Healthcare Commission
usually does not take much notice of them in our annual returns
because the numbers are so low. Nonetheless, it is a very important
issue and the hospital prevention and control of infection is
a very high priority, but of course cleanliness in hospitals is
not just about preventing infections, it is a lot more than that.
Q170 Charlotte Atkins: Anna, would
you like to come in?
Ms Coote: I do think there is
a sort of danger of the whole thing being reductive, that there
are scare stories in the media about hospital cleanliness and
aligning cleanliness and MRSA which, as you have recognised, does
not reflect what is actually happening there, so people get alarmed
about it and then they think they should go in and inspect hospitals
to see if they are clean or not, and I do not know that that is
really the best way to get the results that we all need. I suppose
what I am arguing for really is, rather than favouring allowing
patient forums or whoever they might be, LINks, to go in and inspect
for cleanliness, to have a much more informed dialogue between
whichever groups are interested and need to be involved in whether
or not a hospital is clean or whether or not there are infections
in the hospital and the people who are responsible for clinical
governance in their hospital, so you get a kind of mature dialogue
rather than a kind of set-piece, reductionist, good photo opportunity
for the local press. That is what we need to be working towards
really, so I think you are getting at something quite important
there.
Q171 Charlotte Atkins: Clearly what
we want is patients to be able to provide their patient perspective,
and clearly should they not be focusing on areas where the patient
has a particular perspective to offer and things like cleanliness,
infections and so on are not necessarily their area of expertise?
Ms Coote: I think there are lots
of areas where patients do not necessarily have direct experience,
but where, if they are properly informed, they will have an important
perspective that will be helpful and that they probably should
be involved in, so I would not like to see any interaction between,
say, a trust and the public being limited simply to where patients
have direct experience; it is about making sure that people who
are involved in discussions about what is happening in that trust
are properly informed and that their perspective is respected,
so it is a bit different from what you are suggesting, I think.
Ms Adams: I think as well that,
when you are in that relationship and you have patients and the
public coming in to look at something like cleanliness, there
is a reciprocal role because it is an opportunity for health staff
to educate people around infection and to take that message out
in a public health way into the community. Very often, if you
work with members of the public and ask them how best to get the
message out, they can suggest things that could be helpful to
put the message out, so it is not just a one-way street, it is
not just about inspections, but using the opportunity of that
relationship that you have got which I think can be helpful.
Q172 Dr Naysmith: I have a series
of questions for Anna and, just before we start, could I say welcome
back to the Committee and I hope that she finds the experience
this time a bit more worthwhile than the last time she was here
as an adviser, if you recall!
Ms Coote: Of course. How could
I forget!
Q173 Dr Naysmith: Talking about the
general powers of inspection and so on which some people think
LINks should have, your organisation, the Healthcare Commission,
in its evidence seems to be backing off and suggesting that the
powers of inspection would be a duplication of your work. Is that
the reason why you are not so keen on it?
Ms Coote: Yes, only if we are
absolutely determined and committed to involving local people
in our follow-up enquiries as part of the annual health check
and in our special reviews, so I do not think that the Healthcare
Commission can stand in for patients and the public, but, rather
than having two sets of opportunities for patients and the public
to be involved in inspections and enquiries, it would be more
sensible for it to happen through the enquiries that the Healthcare
Commission conduct.
Q174 Dr Naysmith: Do you think they
could help you identify the trusts that you need to look at a
bit more closely and go in and inspect?
Ms Coote: Indeed, yes, and we
do that anyway through the annual health check because we have
been inviting patients and public involvement forums, overview
and scrutiny committees and FT board members to put in their comments
as part of the annual declaration, and they help us to identify
the trusts where we think there is a risk and where we need to
conduct follow-up inspections and enquiries, so that is the first
point of our connection in the annual health check with patients
and the public.
Q175 Dr Naysmith: So you think that
you will be able to incorporate the new LINks in a similar sort
of way just as easily and just as well?
Ms Coote: Yes, and I am not suggesting
it is going to be easy because we do not know what they are going
to be like. We have set up two test sites, one in Leeds/Bradford
and one down in the south-west peninsula, where we are working
with local communities to set up local networks so that we can
learn from that experience how we can best work with the LINks
when they come in to play. We were doing that anyway actually
before the LINks came in because we realised that just working
with the forums and the overview and scrutiny committees did not
really get us connected with all the different interest groups
and the communities that we needed to be connected with, so we
were already working to expand our reach. We hope that this experience
will help us to get a bit ahead of the game so that, in our next
year's annual health check, we will be ready to work with the
LINks rather than the forums. The difference is of course, or
I hope the difference is that, rather than the LINks being there
in the community, saying, "We are the patient voice. Come
to us. We can speak for the patient in the community", they
are a network, a sort of junction box or a sort of facilitative
mechanism, so it is not quite the same process as just going to
the forum and saying, "Tell us what you think", because
we will need to know that the LINk has actually brought in the
views of those organisations that are part of that network and
I think that makes it more inclusive.
Q176 Dr Naysmith: I am still not
quite sure whether you want them to have the powers of inspection
or not.
Ms Coote: I personally do not
and the reason is because I feel the virtue of the LINk mechanism
is that it is not a kind of entity in itself, a body that feels
it speaks for the community, and I think that, since there is
another way in which patients and the public can be involved in
inspections, if you say the LINk can inspect, who is going to
do the inspecting? If the LINk is a network, it is not really
a body that is designed to carry out an inspection, but it is
a body that is designed to identify, and provide a conduit to,
all the interest groups in the community, say, an open invitation
to participate in follow-up enquiries as part of the regulatory
process.
Q177 Dr Naysmith: I know that you
employ very highly qualified staff and so on to do these inspections
and sometimes contractors for individual things that you are looking
at, and it is obvious that LINks and forums can duplicate that,
but, in my own experience, I have seen forums, and presumably
LINks would be able to do the same, going into hospitals and looking
at catering and looking at cleanliness and going round and speaking
to patients in waiting rooms and looking at wards and producing
very valuable stuff. You would not want them to lose the right
to do that, would you, even though they are not going in with
experts?
Ms Coote: Although our staff are
of course highly skilled, I do not think they would be doing their
job properly if they did not—I am going to get into trouble
now. Anyway, what we are trying to persuade our colleagues to
do is to build their capacity to work with patients and the public
when they go in to carry out their inspections, so it is not a
matter of there being one sort of professional type of inspection
and then you get the public coming in, but the way in which a
good professional will carry out an inspection will be partly
through involving patients and the public in that process, so
it is not a kind of either/or, these are not opposing things and
what we are trying to do is bring them together.
Ms Adams: I would actually agree
with Anna on that. I think it would be a very good way to have
better involvement in the inspection process led by the Healthcare
Commission rather than having two separate structures. However,
I think where it is important is actually doing surveys, LINks
doing surveys, like the exit polls and so on, making sure that
that happens for particular services so that they are getting
that information and are feeding it into relevant bodies and not
so much the inspection, which I think needs to be done carefully
and with support, and I think it is quite sensible to put it all
together.
Dr Day: One of the criticisms
of inspections is that they tend to be flagged up in advance and
one of the criticisms that comes from the public is, "Why
don't you make snap inspections, the orderly officer-type inspection?"
Q178 Dr Naysmith: Good forums do.
Dr Day: Indeed, but we would lose
that, would we not, if we went down the route that is being discussed
at the moment?
Ms Coote: They are not always
flagged up in advance though, the inspections carried out by the
Healthcare Commission.
Q179 Chairman: Just on that, Dr Day,
how feasible is it to have effectively two bodies that are statutorily
responsible for inspecting a workplace or a patient ward? It seems
to me that you have got the potential for it not being done at
all and then a bit of finger-pointing, or is that too simplistic?
The idea that the Healthcare Commission is statutorily responsible
for the inspection, would it not be confusing if somebody else
had the responsibility of doing that as well? Would there not
be the potential for great confusion about who is responsible
for the inspection of hospitals?
Dr Day: They are different roles
though, are they not, because the Healthcare Commission has a
more strategic, central role with grading performance and so forth,
whereas the immediacy of, in our case, members, board of governors
and our current patient forum, the responsibility is actually
to the board of directors and we want to hear now immediately,
this month, today what is going on and sort it out.
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