Examination of Witnesses (Questions 248-259)
MR NIGEL
EDWARDS, MR
DAVID STOUT
AND DR
BRIAN FISHER
22 FEBRUARY 2007
Q248 Chairman: Good morning, gentlemen.
Could you introduce yourselves?
Dr Fisher: I am a GP in south
east London and I am PPI lead for the NHS Alliance.
Mr Edwards: I am director of policy
for the NHS Confederation, the membership organisation for the
organisations that make up the NHS, including voluntary and independent
sector providers.
Mr Stout: I am the PCT Network
director within the NHS Confederation, providing a network of
all the PCTs across the country. I should say that I am four days
into the job. Previously I was chief executive of Newham Primary
Care Trust in East London, where I was chief executive for the
last six years.
Q249 Chairman: A question to all
of you: do you think clinicians and managers take PPI seriously
enough?
Dr Fisher: I think their intentions
are good. They would like to; they see the importance of it. Over
the last 10 years or so in the NHS it has become clear that clinicians
are hearing much more clearly what local people are saying to
them, but I think their remains a real deficit in clinicians and
managers responding to what local people are saying to them, so
listening has improved but responding to that has not improved
and there is evidence for that.
Mr Edwards: I would endorse that
and have not very much to add to that, to be honest.
Mr Stout: I would also agree.
From a commissioning perspective which, from a PCT end of things,
I should probably focus on, PPI is fundamentally about doing the
job properly. Do we always get it right? No. We know we need to
improve.
Q250 Chairman: How far do you think
it is their fault and how far is it a reflection on the work done
by the local PPIs? Do you think they do take it seriously in some
parts of the NHS as opposed to others?
Dr Fisher: It is very variable.
There are some areas and some sectors that have done fantastic
work, and you have heard some of them already, but it is very
patchy. I would not say it is the clinician's fault exactly but
it is quite scary, actually, both being a clinician listening
to what local people are saying and being a manager listening
to what they are saying. It is not an easy process and it threatens
one's control, one's power, and I do not think it is recognised
how delicate a process that can be. So it is a challenge, it needs
to be managed, and clinicians need to be supported to understand
and respond to it.
Mr Edwards: One of the issues
about this whole policy area that has been of some concern to
us is the tendency to confuse two related, but quite different
sets of functions. One involving patients in talking about their
experience and how we can improve that and make it better, and
talking to the public, which may be more about the overall design
of services, the setting of priorities, perhaps a more general
set of questions. They require quite different mechanisms and
have quite a different focus. There has been a bit of a tendency
in the way that policy and machinery has been constructed to confuse
those two. The public, if they are not currently using the health
services, may be quite difficult to engage because they have other
parts of their lives to be getting on with. Those of us who work
in health services may think it is most important but members
of the public are interested in a whole range of other functions,
and different mechanisms need to be found. Both in policy terms
and sometimes in terms of mechanics we have not been clever enough
about devising the mechanisms that particularly target the right
group for the question we are trying to answer.
Mr Stout: That is absolutely right,
and there is also a distinction between patient and public involvement
in providing services and the patient and public involvement required
for commissioning services and, again, there are some distinctions
on how that could and should operate. Historically, perhaps, we
have rather muddled those up and not made those distinctions as
clear as they might be.
Q251 Chairman: At a previous inquiry
session, Dr Day from the Harrogate Foundation Trust told us that
PPI must offer: "very reliable data which is replicated and
which is reliable and not anecdotal and certainly not one of the
loud voices being heard exclusively". Do you agree? Do PPIs
provide this?
Dr Fisher: I agree that the data
on which recommendations from local people are made should be
as robust as possible. There are lots of different ways of getting
that information; there is a huge amount of national and international
data on things that patients would like in general; the Picker
Institute delivers a lot of information about that, for instance.
There are lots of surveys that have been done in similar populations
to the ones in one's own PCT. So there is quite a lot of robust
general information on which you can base decisions. If you are
talking about very local issues with one particular hospital or
cluster it is much more difficult, and this issue of representativeness
is really difficult. I would suggest that getting representative
information from local people is a chimera, really. I do not think
it is possible to get it. You have to work on the best data you
have which I have to say is what we do a lot in any case in clinical
areas. If you are listening to what GPs have to say, for instance,
you are not necessarily getting a representative sample. But it
is really important not just to listen to the loudest voices,
and there are simple ways of making sure those are not the only
voices you hear.
Q252 Chairman: You did say that you
should have the data and the data is available, but the real question
is do they, in practice and in your experience, have the data
as opposed to it being available and they should have it?
Dr Fisher: Yes, it is available.
A good PPI forum or a PPI part of the PCT should be able to get
that within 15 minutes. It is not difficult to get it. The King's
Fund will provide it; lots of places will provide the data. Again,
even if you provide it you could provide a very efficient set
of information to the PCT. But I would like to make a point about
practice-based commissioning in that you might be able to provide
to the practice-based commissioning group but at this point there
is no onus on them necessarily to have to do anything about it.
The data is important, but however good the data is there is still
another question about whether people respond and whether they
are in any sense accountable.
Mr Edwards: I would agree with
that point of view. You might well use anecdotes to inform hypotheses
that you then go and test and collect the data. It would be probably
unwise to discount all useful anecdotal evidence. It can be a
very useful source. If it is all you rely on, however, you are
likely to run into quite severe difficulties and you should then
perhaps go and test this. And it may be that some of these anecdotes
and stories that you pick up may point you in directions that
are well worth investigating, even though you may find there is
nothing there.
Q253 Chairman: Do you think you have
seen evidence where PPI has used data as opposed to could use
data?
Mr Edwards: We certainly heard
evidence from the previous witnesses. I think there are some issues
about the rigour you need to do the sorts of studies, such as
the quite impressive sounding one we heard described, which are
methodologically demanding as well as having some quite significant
resource implications but, if these are important questions that
either providers or commissioners should be asking, then it might
well be that if there is an issue about, for example, waiting
times in a genitor-urinary medicine clinic and the need to go
and find user opinion, a commissioner or provider that was presented
with some early signs that there was an issue would be well advised
to go out and research that properly themselves, maybe through
helping the patient's forum or the PPI machinery to do that.
Mr Stout: We need to be clear
who is responsible for what. To expect PPI forums or LINks to
do everything that your question suggested I think is a little
unrealistic. To expect PCTs and commissioning services, as Nigel
says, to undertake effective review of data and get hold of information
having been alerted to a problem by a PPI forum or a LINks is
entirely reasonable. On the other hand, getting down to a very
local scale and talking about PPI in the sense of "I am a
patient; you are my clinician", then my anecdote is important.
You want the patient/clinician relationship to be absolutely based
on anecdote; you want big commissioning decisions to be influenced
by the stories you hear and then followed through with a slightly
more robust objective assessment. We are in danger of doing what
we said earlier and seeing PPI as one thing when it is many things.
Dr Fisher: There are data crunchers
that should be available to LINks or PPI forums. Public health
in the PCT, I understand—and I still have not quite grasped
all the bits of LINks—that the local authority should be
providing statistical support and so on, so there are people around
to do it.
Q254 Chairman: Do you understand
LINks? Is it more than a concept in your view? You mentioned it
together in passing there between PPI and LINks.
Dr Fisher: Yes, I think it is.
I suppose the way I feel about it is that I can see what is required;
I can see the functions that need to be performed; and I can see
how they ought to be performed. What the name or the title is
for this I am not really bothered, but there are serious characteristics
of a good patient and public involvement service that LINks could
have a good handle on if it is resourced adequately and supported
adequately.
Q255 Chairman: And presumably has
the ability to get the data and everything—
Dr Fisher: Obviously that is the
easiest bit. The data, I think, is the easiest.
Q256 Chairman: Do you understand
this, Nigel? Do you think this is a read-over in terms of what
PPIs are doing now as opposed to what LINks will be doing at some
stage in the future?
Mr Edwards: Perhaps I can respond
to that in a couple of ways. When you read the guidance on LINks
there are some interesting questions about governance and leadership
and how they are going to operate and exactly what they are going
to do, but we have taken the view that public and patient involvement
is now such a key part of what both commissioners and providers
have to be doing that what we should be judging them on is the
effectiveness of how they do that rather than their compliance
to a particular structure and model. People should be able to
develop appropriate mechanisms, because what may be appropriate
in, for example, David's old patch in Newham may be very different
from what you might want to do in a rural county council such
as Norfolk, which we heard about earlier, so people need to be
held to account for the effectiveness of what they do, and not
just their compliance with structural arrangements. There is one
other point which is worth making, which is that while LINks are
commissioner-focused and local authority-focused and we would
absolutely support that and it is in line with the way that much
of the healthcare reform is going, hospitals and other providers
are not going to stop doing public and patient involvement. It
would be extremely foolish of a trust to say, like the Bristol
one we just heard about, "I have an effective mechanism for
engaging the public and I am now going to dispense with it because
there has been some other change in some other part of the forest".
The other point that is really important to make is that, as the
number of foundation trusts grow, there is built into their governance
the mechanism of governors and members, and we have all been very
taken by how foundation trusts, their governors and members have
really taken that model. Perhaps to some extent to a level of
involvement and engagement that was not fully anticipated by some
of us when the policy was first introduced. So there are other
dynamics as this process is evolving other than just the LINks.
The LINks potentially could add some real value to that by providing
over-arching structure and some input into commissioning but there
are all of these other mechanisms too and we need to be encouraging
providers and using methods like the Healthcare Commission standards
and their inspection process to ensure that people are being able
to demonstrate that they are fully engaging their local public
and their patients.
Mr Stout: The direction of travel
with LINks seems reasonably clear and has clearly been evolving
over time and I think sensibly evolving. There seems to be an
effective dialogue that says that when LINks started as an idea
it was pretty vague but I have to say it has become quite a lot
clearer to me over the last few months and the direction of travel
seems right. Clearly some of the devil is in the detail and the
specification for what LINks has to do is pretty critical. I absolutely
agree with Nigel and I do not think that specification should
be saying how to do it, but what should be clear to the local
authority commissioning the host organisation is what it is they
are supposed to be commissioning? What is the output we are trying
to get out of this? The more that is defined clearly, the more
effective LINks are likely to be. But on direction of travel I
think I am reasonably clear where it is going.
Q257 Chairman: Nigel, you mentioned
Bristol. It was mentioned earlier about the funding of the forum
and the question of independence, whether it was funded by the
hospital trust itself or by some other body. What is your personal
perception of that? What do you think the public's perception
of that would be?
Mr Edwards: It might be worth
distinguishing between foundation trusts, who have patient involvement
at the heart of their governance, and non foundation trusts, of
which there will be an increasingly shrinking number, of course.
Foundation trusts, I guess, have to treat their members and governors
as sovereign. In other words, they have to respect their independence.
Q258 Chairman: Yes. This is not a
foundation trust. Therefore there is a question now about if a
change takes place now in terms of who is supporting and resourcing
and funding that particular forum, if that is not on offer in
a few months' time, is there a question mark about its independence
or, indeed, the public perception of its independence if it becomes
supported and resourced by the trust itself as opposed to some
other organisation?
Mr Edwards: That is an interesting
question. I am not sure to what extent the public are aware of
how these organisations are currently funded. They are, of course,
still funded from the Department of Health. I think I am back
to my "by their acts shall ye know them" philosophy
here which is that you will be able to tell whether these organisations
have some form of independent voice from the way they behave.
There is clearly an issue, if I am a trust and I have a patients'
forum which I am funding, I think it is hard to present it as
independent, but if I want it to be effective and if I do not
treat it as though it has the ability to challenge me to make
statements which may not be awfully comfortable, then I suspect
that what we will find is that people will vote with their feet,
and you will very quickly not have an effective patient involvement
mechanism. So, we are a bit short on cast iron guarantees of independence,
I will give you that, but in terms of the imperative for organisations
now to make really sure of the growth of choice and so on and
much more local scrutiny and accountability, you would be very
foolish not to have a system which allows you to get a clear independent
voice in addition to LINks perhaps within your own organisation.
Q259 Sandra Gidley: The PPI forums
are supposed to offer a unique patient perspective but many of
them have found themselves dealing with issues such as hospital
cleanliness, infection control and feeding patients. Is that not
really using PPI as a substitute for good clinical governance?
Mr Edwards: If you look at the
sort of polling that Angela Coulter has done and MORI have done
on patient experience, the sorts of things that come very high
up the list as important to patients, as I am sure you will all
be aware, are precisely some of those issues. You failed to mention
car parking which is one of the other ones that frequently comes
up.
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