Examination of Witnesses (Questions 260-279)
MR NIGEL
EDWARDS, MR
DAVID STOUT
AND DR
BRIAN FISHER
22 FEBRUARY 2007
Q260 Sandra Gidley: I do not think
car parking comes under clinical governance.
Mr Edwards: No, but we should
record it as being a key strategic issue in many places. Is the
acid test not whether this is an issue that is of concern to patients?
The thrust of your question is right. You should not be using
this mechanism as a substitute for your own internal management
systems, but I think on the other hand it is quite legitimate
if this is an issue where patients and the public have very strong
views. We know that hospital cleaning comes fourth in the list
of how would you choose your hospital under the Choice regime
and infection is third and the public should be given an opportunity
to voice that. A recent and, I thought, rather impressive example
of where foundation trusts have involved their patients in this
was where one of the foundation trusts in Cheshire did a poll
of its members on visiting policy and had 5,000 responses. That
was visiting policy in respect of controlling infection by not
having too many visitors visiting the hospital. That was a really
big engagement because this was an issue that was important to
patients, but you could have argued that that was just a simple
operational control of infection issue so why were they involving
their patients? I think I would be led by where patients want
to take you but not let it be a substitute for your internal management
systems. It is quite a difficult question.
Q261 Sandra Gidley: Is it not the
case though that a hospital is either clean or it is dirty and
it should be fairly obvious to the staff? I am digressing slightly
and we will get back to the point, but it strikes me that this
is something that patients should not need to mention. It should
be a given. Patients should not need to have this top of the list
of things they investigate.
Mr Edwards: This is true, except
that one of the things I have always noticed when being shown
hospitals in this country and overseas is that coming to them
with a fresh pair of eyes and with a slightly different perspective
you see things that the staff have ceased to notice. It is very
easy to become habituated to things and when you come to them
afresh you say, "How on earth has this happened?". It
is not just a matter of whether it is clean or dirty; it might
be, "When do you clean it and what impact does that have
on the patient's day?", if you start cleaning at six in the
morning, for example? There are some quite legitimate questions
and that fresh pair of eyes I think is quite valuable.
Q262 Sandra Gidley: Dr Fisher?
Dr Fisher: Just because it is
called clinical governance does not mean that it should not have
a patient user input, and in fact it is essential that it does.
If you are looking at rheumatological services you might want
to look at how the urethra trexate is dealt with or the drugs
and so on are dealt with, but you also want to know are patients
improving, to what extent, what are their views on it, and it
is perfectly legitimate to be thinking about patient views as
part of a clinical governance process. I think it is essential,
and there are again a number of techniques that can be used to
define good practice from the patient's point of view and to be
used as a performance monitor for clinical work.
Q263 Sandra Gidley: That sounds very
positive so far.
Mr Stout: If you stop listening
to the patients—why would you stop listening to patients?
I agree, if you were wholly reliant on that as the only way of
knowing what was going on that would be pretty worrying, but to
deny that listening to patients is a good thing seems an odd approach.
Q264 Sandra Gidley: You say, "If
you stop listening to patients", which is quite interesting
because Tesco, for example, is a very successful organisation,
presumably because it gives the public what it needs, people go
back, yet they do not seem to need customer involvement networks
and forums in this way.
Mr Stout: What Tesco's does is
that it can analyse your spending patterns as an individual consumer
and make offerings on that basis. They have sources of data which
are testing people's opinions and I am pretty confident that they
do find ways of getting their customers' views that help them
run their organisation. Do they use the techniques the NHS use?
Possibly not. Are there things we can learn from? Almost certainly
yes.
Q265 Sandra Gidley: So the NHS perhaps
should be looking to what Tesco's does?
Mr Stout: I would not solely focus
on Tesco.
Dr Fisher: I think what the private
sector does actually is quite important, not that I know very
much about it, but my understanding is that Nike, for instance,
does use quite a lot of group work and does go out to kids on
the street and ask them what they want and also, "Look: this
is a model. What do you think? Would this work for you?",
so I do not think that is in principle very different. You are
talking about face-to-face work with people. You have to go out
on the streets to get people whose opinions you want. In fact,
I think the LINks approach, which I see as potentially having
a community development kind of feel to it, could be extremely
useful in that regard, and I see the far more diffuse nature of
LINks, the possibility that you would be working with a range
of voluntary groups which would have outreach approaches to a
range of different people, as extremely positive. It is one of
the things, I think, that CPPIH wanted to do in the end but was
not able to. I think this example of the private sector is very
apposite.
Q266 Dr Taylor: What really bothers
me is that we are hearing all the good things and we are not hearing
any of the bad things. We have heard that patient and public involvement
forums can be fun if you work with the right people. In your submission,
Nigel, you have got under section 3, "Why are existing systems
for PPI being reformed after only three years?", and you
say that forums and the Commission have achieved a great deal
but that the successes were not consistent across the country.
Can you tell us why they were not consistent? What we have heard
is from very good, effective forums and we all in our own patches
probably know how good our own forums have been, and the key has
been the collusion, the working together, between the forums and
the trust, the board members, the chief executive, so what has
been going wrong where it has not been working?
Mr Stout: I will happily give
a perspective and I cannot say I can speak for every PPI forum
that has not worked well. Some of the root causes of the problems
in some PPI forums, and it is worth saying, as you have already
said, that some work very well and some work less well, is partly
the speed at which the whole process was set up. The shift from
CHCs to PPI forums was done, on the face of it, in quite a hurry
with perhaps less detailed planning for what exactly these forums
were there to do. So there has been some degree of ambiguity about
role and function. There are clearly some issues around support,
as we heard from some of our colleagues earlier, in that the support
for the PPI forums when put in place was pretty variable, and
certainly my experience in London was, as you have already heard
from Southwark, that it was not very effective, certainly to begin
with. You had members joining these organisations who were not
quite clear how they were going to work and then becoming disillusioned
and leaving and a constant turnover of membership, which obviously
does not lead to very effective development of the sorts of partnerships
you are talking about. More latterly, I think the point raised
again by our colleagues from the PPI forums earlier about the
uncertainty about the future of these organisations for a relatively
extended period has not helped any of that. With that kind of
starting point you can perfectly understand why the successful
forums will have been based on individuals who managed to overcome
all of those hurdles and in some parts of the country that simply
will not have happened. I think those are the sorts of things
that have led to difficulties.
Q267 Dr Taylor: So would you agree
with a lot of people who have spoken to us that we should not
be abolishing the whole thing; we should be building on what we
have got?
Mr Stout: If by abolishing the
whole thing we threw away all the learning and the people who
have got involved and suddenly drew a line under that and said,
"We are not interested in your work any more. Thanks very
much for the last three years", it would not be a good idea.
Q268 Dr Taylor: Is that not what
we are risking?
Mr Stout: I think there is a risk
of that. What I would be looking for in order for this to work
effectively is, as far as one can, to minimise that risk by welcoming
existing forum members into the new structures and, which I think
is happening, having a proper debate about how the new structures
will be set up rather than rushing straight into it. I grant you
there is a bit of a conflict there. The longer you take over setting
up the new structures the more uncertainty you create and potentially
the more people walk away, so I think we have to have a balance
there. I would hope that we can build on the good experiences
in setting up the new structures and recognise that the world
of the NHS has changed over the last few years. Foundation trusts
did not exist a few years ago and we did not have half a million
members of foundation trusts, and you cannot ignore that and say,
"Oh, well, we will leave PPI forums as they are". I
think we are looking for it to evolve in positive ways rather
than having a complete hiatus from one system to another, which
is perhaps how you could categorise the CHC to PPI forum shift.
Q269 Dr Taylor: Should the effectiveness
of PPI involvement—and you have said it has got to be a
key part—be a part of what the Healthcare Commission inspects
upon? If we had hospital standards still should it be one of the
standards?
Mr Edwards: There is something
in the standards. It is rather unspecific in terms of how it is
measured. I understand that these standards are due to be revised
in line with our policy position on this, which is that people
should be held to account for the effectiveness of their involvement
and then it would make sense for the Healthcare Commission to
be talking to all of the people involved in patient and public
involvement to test the effectiveness of that and whether people
feel that they are adequately involved, that they have a voice
and that they are not just listened to but that they feel they
have some impact on decision-making and the quality of services,
yes, absolutely.
Q270 Dr Taylor: So that should be
one of our recommendations to come out of this report?
Mr Edwards: I think it would be
in line with the way the NHS is moving. The NHS is moving, as
you know, slowly from a top-down target driven system to one which
is more based on standards. The advantages of a standards-based
approach is that it would then impose that standard on all NHS
providers rather than just those that happened to be NHS bodies,
so it would also include independent sector treatment centres,
social enterprises and a variety of the new bits of the architecture
that is starting to emerge and I think it would be entirely consistent
with that. If what we are saying, and, David, I do not know if
I am reflecting your views here, is that to be an effective healthcare
organisation, whether a commission or a provider, you really need
to have very good mechanisms for understanding what the public
you serve and the patients who use your services feel about what
you are doing and what direction you want to take, then why would
you not want to be measured against that for how effectively you
do that? I think that is perfectly reasonable.
Mr Stout: I have to say I absolutely
agree with that; that must be right. I guess the question is,
what are you measuring? What we would like to move away from is
measuring the process, a tick-box mentality, to a rather more
sophisticated measurement of it, but that it should be part of
the assessment must be absolutely right.
Mr Edwards: It is not, "You
have a committee". It is, "The people who are involved
report that they have a positive experience of having been involved
and can point to examples where they made a difference",
rather than, "Show me the minutes", which has been a
bit of a tendency for quite a lot of the regulatory machinery
that we have had, which has been very interested to see the paperwork
but not measure the output.
Dr Fisher: You were asking two
questions. One I think was about fun and one was about effectiveness.
In terms of fun, I think one of the difficulties that the previous
witnesses described was that essentially this is about committee
work, that is, hard graft, and what is important about the possibility
of LINks is that we are looking again at a much more diffuse process
and that this idea of not exhausting people is really important,
not exhausting clinicians in doing all this work, not exhausting
managers and not exhausting the public and the patients, so dipping
and in and out of this stuff is really a vital part of the process.
We need to develop techniques and approaches for not only harvesting
people's opinions but also getting the change that does not involve
people in years of hard graft, and I think there are ways of doing
that. There are examples through various approaches that make
that more likely to happen than not, so this idea of dipping in
and out and brief liaisons I think is quite important as a mechanism
of approach.
Q271 Dr Taylor: Can you point us
to some of those approaches?
Dr Fisher: I can give the Committee
information if you like.[1]
Q272 Dr Taylor: That would be helpful.
Dr Fisher: I can send you that.
The other thing about effectiveness is really crucial to this
debate. I would entirely endorse what has been said about the
Healthcare Commission. I work on their Expert Reference Group
in trying to get these standards to be as meaningful as possible,
and in my view it is about change. You need to be able to demonstrate
that you have not only listened but you have also to some degree
changed as a result of what local people have been telling you,
and that seems to me to be the key bit that needs to be in the
standards. There needs to be a legal change in my view that puts
an onus on healthcare organisations to respond to what local people
are saying. This is the sort of theme I have tried to say a couple
of times, that, looking at the Bill that is going through, it
is extremely weak and I would urge you to make it stronger. I
am not a legislator, I do not know what it should look like in
detail, but there should be a demand on healthcare organisations
to respond within a certain time to local recommendations. That
response needs to be proportionate to the recommendations. No-one
is saying they have to do everything that local people say; that
would be entirely wrong, but there needs to be a clear debate
with the people that are making the recommendations and that does
not appear in my view in the Bill.
Q273 Dr Taylor: The word "nebulous"
has been used to us on many occasions, and you used it indeed
in your written submission. Certainly we have taken that point
absolutely. Moving to overview and scrutiny committees briefly,
Nigel, can I clarify one point in your evidence because you are
saying on the third page under "Statutory Powers", "It
is essential that the powers of LINks are defined in law",
and you go on to say that they should not have powers of inspection
because it is duplicating what overview and scrutiny committees
mean. Surely you meant the Healthcare Commission.
Mr Edwards: The Healthcare Commission.
Q274 Dr Taylor: So that is a misprint,
is it?
Mr Edwards: Yes, I think it is.[2]
Q275 Dr Taylor: Thank you very much for
clarifying that. The next bit is that even if we take that for
the Healthcare Commission and not overview and scrutiny committees
you are diametrically opposed to the NHS Alliance, because the
NHS Alliance says,—this is LINks—"They should
sit on all key trust committees and have a right of inspection".
I would argue with the word "inspection". What we are
trying to push for is that they must have a right of entry, of
visitation, of assessment, and we have had the points from the
lady from Bristol that one of the real values is that staff can
talk to forum members and use them as allies and they can be more
free talking to them than members of the trusts themselves. Do
you still feel, as the NHS Confederation, that the LINks should
not have a formal statutory right of entry, not for formal inspection
but for assessment and talking to staff and patients?
Mr Edwards: There is a difficulty
here which is that as more organisations move towards foundation
trust status they will have their own very extensive internal
arrangements already in place for doing precisely that. If LINks
are focused on the local government commissioning agenda it seems
to me that the obvious solution to this is that they will need
to form very close linkages to the patient and public involvement
mechanisms that exist within the providers and that the proper
mechanism for doing that is through the providers' own arrangements.
LINks would want to draw that information in and work through
that machinery. I just see a real hazard here, first of all, of
cannibalising a relatively small number of people. We already
have a bit of an issue in some areas where, if you have a mental
health trust and an acute trust, there are a limited number of
people you want to get involved in this way. We have cannibalised
people's willingness between different and overlapping, and often
maybe unhelpfully overlapping, bodies. We really need LINks to
be focusing on the whole area and on commissioning policy, but
also working closely with the PPI arrangements within providers,
within surgeries or within hospitals, to draw that information
in, to draw material to their attention where that seems appropriate,
but not to try and replicate it. That may well mean from time
to time that it is entirely appropriate for them to go and visit
a provider, and there are some split views among some members,
I think it would be right in saying, but it is not immediately
clear to us why you would not want to have this type of organisation
coming to visit you and talking to people.
Q276 Dr Taylor: So the Confederation
view is that there ought to be right of access to provider units,
certainly for assessment if not visiting?
Mr Edwards: With this proviso,
that they need to be working closely with the PPI arrangements
within that provider and working through them where that is at
all possible, simply to ensure that we do not replicate the vast
numbers of inspections from the statutory side coming at you,
remembering that some of these large providers may well be liaising
with a very significant number of LINks. If you are University
College Hospital or Guy's and St Thomas', the number of organisations
you might end up dealing with is very large. We have some caution
about this and we want to see it perhaps contained in a framework
which gets the people who are involved in patient and public involvement
talking and working together in a way that leads to some co-ordination.
That is more the issue for us.
Q277 Dr Taylor: Are you saying that
the LINks members involved in commissioning should not be involved
in assessing provider units?
Mr Edwards: Not quite, no.
Mr Stout: I would not be as distinct
as that, I do not think, because part of commissioning is performance
management and part of performance management is getting patient
and public feedback, so to imply there is a whole different cadre
of PPI experts does not sound quite right to me.
Q278 Dr Taylor: Do you want to add
anything, Dr Fisher?
Dr Fisher: No.
Q279 Jim Dowd: Brian, in response
to Richard's question just now you described the current Bill
as "weak", and Richard said "nebulous". "Weak"
is probably one of the more weak descriptions, if you like, of
the Bill that we have receive so far. You mentioned the responsibility
and firming up the responsibility on healthcare organisations
to be involved in patient involvement. Do you define a GP surgery
as a healthcare organisation?
Dr Fisher: Yes, I do.
1 Ev 121 Back
2
The witness later confirmed that in the NHS Confederation written
evidence, under the heading Statutory Powers, the reference to
"Overview and Scrutiny Committees" should read "Healthcare
Commission" (Ev 171 HC 278-II 2006-07). Back
| 
