Examination of Witnesses (Questions 280-299)
MR NIGEL
EDWARDS, MR
DAVID STOUT
AND DR
BRIAN FISHER
22 FEBRUARY 2007
Q280 Jim Dowd: If you do how do you
see the interface between the patient and the user at GP level?
Dr Fisher: I think there are a
number of approaches that could be tried. Again, the fundamental
problem is that a practice does not have to do anything really.
We are encouraged to do a survey and we are encouraged to respond
to the survey results, but we do not have to, so again accountability
at every level is really very weak. There are lots of examples
of practices doing really good work and there are examples of
patient participation groups, there are examples of patient panels,
there are examples of ad hoc work with local organisations, local
voluntary organisations and so on, so there is a range of options
that practices can use, and there are some wonderful examples
of practices responding very rapidly and sensitively to local
opinion, so yes, there is quite a range.
Q281 Jim Dowd: Where those exist
is the difference between the service they provide to their patients
measurable against those practices that are less enlightened?
Dr Fisher: You mean, do they provide
better care?
Q282 Jim Dowd: Does it have an effect?
Other than involving people does it have an effect on the service
provided?
Dr Fisher: If there is a general
question, "Does PPI affect services in general and what do
we know about it in primary care?", the evidence is moderately
weak that PPI in general makes a substantial difference to services,
and I do not think there is any evidence that PPI improves the
outcome of care so that you get better cardiac outcomes or something
like that. My understanding is that there are a large number of
apocryphal examples where things have been changed but if you
are looking at controlled studies and so on there is very little
data that would help you come to any very firm conclusions about
it.
Mr Stout: An absence of data does
not mean it is not happening. It just means it is hard to prove.
Q283 Jim Dowd: Yes, but on that basis
nothing is happening anywhere. You cannot prove anything other
than saying, "We have not got the information". It does
not mean it is not happening.
Mr Stout: That is my point.
Q284 Jim Dowd: It might be that the
reason we do not get the information is that it is not happening.
Mr Stout: Both could be true;
that is right.
Jim Dowd: It does not get us much further
forward then, does it?
Q285 Dr Stoate: I hope you are not
right because otherwise it might make us all feel with all this
PPI stuff that it seems to affect outcomes, not one job, which
actually is alarming.
Dr Fisher: I do not think studies
have been done.
Q286 Dr Stoate: I just want to go
on to say that I hope studies prove that it is not just a waste
of time and I hope that we do show some genuine improvements in
patient outcomes. I accept that the danger is not there yet but
I certainly hope someone out there is trying to gather information
and will do so as time goes on to ensure that this does make a
difference.
Mr Edwards: Outcome is only one
bit of what we do, and the process of care and how you experience
the process of care is very important. You should probably really
be having this conversation with the next witness who is the expert
on this. It does seem to me that we can point to quite a lot of
examples where using user experience to change the design of the
process does produce some very good improvements in people's experience
of it. The four-hour wait, which was a target with many problems
and which was based on listening to patients, has certainly made
a major impact on people. We can see it because patients have
voted with their feet and gone to A&E in much larger numbers.
While outcome may be a debate, it is almost as important that
we also get people a really good process of care. Having had a
good process of care with a good outcome but then being treated
very badly, rudely, having waited and not been kept informed,
not having been treated with dignity, not having your pain controlled,
all the things that we know we do not do very well will not be
a great success, I think.
Q287 Dr Stoate: That is a fair point.
It is just that I have worked in the NHS for a very long time
and we have been extremely good at changing structures, we have
been moderately good at changing process, but we actually have
not been particularly splendid at changing outcomes, but that
is slightly off the subject of what I wanted to bring on. I really
want to come back to Brian. In your answer to Richard a minute
ago you said you liked the idea of a more nebulous structure where
people dip in and out. That seems to be where you are going, so
my question is around this suggestion that LINks are more to be
set up as information-gathering networks rather than representative
organisations in which people sit on endless boards and bodies.
Initially I thought that might be a weakness but are you saying
that might be a strength?
Dr Fisher: No, I do not see them
really as just information gatherers. I think that would be a
real mistake. The essence is what we have just been saying: change
needs to happen and if it does not it really is a waste of time.
Just gathering information is not sufficient. We need structures
that are integral to these healthcare organisations and can make
a difference, not so much integral but independent, but they are
in there. One way or another they are involved with PCTs, they
are involved with hospitals and they make a difference. Hospitals
and the healthcare organisations have to listen to what they say
and they are involved in making a difference. Just gathering information
I think is not sufficient.
Q288 Dr Stoate: Are you then saying
that they should be representative organisations that have seats
on boards?
Dr Fisher: It would be nice.
Q289 Dr Stoate: Is that what you
are saying?
Dr Fisher: I think different places
will want to operate in different ways. What I do not want to
see is the example, which I found rather shocking, actually, that
the PPI forum from the previous witnesses explained, that they
turned up and the patient public involvement forum that they took
over had had no contact with a PCT at all. How can that be? What
kind of an arrangement is it where that is possible? I would like
to ensure that that is not possible to happen, that a LINk would
have to be listened to, would have to be involved. How they do
that I guess is up to the particular arrangement. In reality things
happen in committees. I guess people would have to be on committees
and be there to some degree, but there are other ways of doing
it, there are other ways of influencing decisions, and in particular,
if I could emphasise the practice-based commissioning aspect,
which at the moment in my view is a sort of Bermuda Triangle for
patient and public involvement; there really is very little happening
in it, we need to get LINks engaged in there, and I think the
structure of practice-based commissioning is different from PCTs
and is likely to be rather more diffuse. I see committee work
as maybe less important in there but I would not want to presume
to say that this is how everybody ought to do it. In Southwark
it might be different from Southampton.
Q290 Dr Stoate: That makes me even
more worried now because we are going straight back to either
some postcode arrangement where some areas do it well and some
areas do it badly, or even further back to the old Community Health
Councils where there were clearly extremely good CFCs and there
were clearly extremely ineffective CFCs, which is why the Government
started the process in the first place. The worry I have got now
is that if you are telling me that each area has to invent its
own wheel and have its own structures, its own circumstances in
its own particular way then we are getting absolutely nowhere
very fast indeed and spending lots of money in the process.
Dr Fisher: I do not agree.
Q291 Dr Stoate: What I want to see
is a structure where everyone knows where they are, everyone knows
exactly what their responsibilities and rights are and everyone
knows that if they do move from Penzance to Nottingham they are
going to get a similar level of representation, but you are saying
that is not going to happen.
Dr Fisher: I do not think so.
I hope what I am saying is that the first part of that last paragraph
of yours—
Q292 Dr Stoate: Perhaps we can check
with the shorthand writer what that was.
Dr Fisher: No, I am serious. The
standards should be the same everywhere. What people can expect
should be the same everywhere. The degree of involvement should
be the same everywhere. The outcomes should be the same everywhere,
but how that gets done I think is up to the local community.
Q293 Dr Stoate: I am still very concerned
that this is going to lead to more postcode arrangements, I really
am.
Dr Fisher: I think if you end
up structuring everything to the last degree you will end up stifling
it.
Q294 Dr Stoate: Do the others agree?
Mr Edwards: Yes.
Mr Stout: Yes.
Dr Fisher: And I think there is
an obsession with structures that has stopped a lot of things
happening.
Mr Stout: It comes back to the
rights and responsibilities. We should not confuse sitting on
committees with PPI. It is perhaps one means of delivering it
and there is nothing wrong with it, but if that is all we mean
by PPI it is very easy to tick that box and it might make no difference
whatsoever. I would be really careful about defining PPI in terms
of that kind of structural solution. I would be much more sympathetic
with Brian's approach about being clear what we expect PPI forums
to deliver, not the fine detail of the means of delivery.
Q295 Dr Stoate: Have you therefore
got any practical suggestions for this Committee on how they might
be set up, because again I need some clarity? I am not suggesting
we have uniformity necessarily, but we do need clarity; otherwise
it is going to be too easy for individual areas to say, "We
have sort of done that up to a point, and it is good enough for
us, and there you go then".
Mr Edwards: There are a number
of key events in the commissioning calendar, for example, if we
just take commissioning for the moment, where you need to be able
to demonstrate, for example, the publication of the PCT's prospectus
which is where it will set out its plans for the next year, where
the Healthcare Commission or some other body could easily put
a dipstick in and say, "Did people understand this? At what
point were they consulted? Was the first time they saw it when
it came out? Can you demonstrate to me a process?". I think
you can actually hang off the number of these events in the calendar,
the number of tasks that the various organisations need to do.
Foundation trusts have a similar calendar. Other healthcare organisations
will be doing the same thing. We are now required to do things
which need to have the clear involvement of the public. I think
you can go back and test the outcomes of that very simply.
Q296 Dr Stoate: It is just that the
use of the word "dipstick" when it comes to health management
may have more than one meaning!
Mr Edwards: It was not perhaps
the happiest use of that word.
Chairman: You will have to excuse him;
he is a doctor.
Q297 Dr Naysmith: Choose and Book
and Payment by Results, both of which are coming in at a faster
rate in various parts of the Health Service, obviously have financial
effects on provider trusts. It has been suggested that this could
lead to trusts being overly responsive to those patients who choose
to or are able to make choices and change providers. Some people
have suggested that LINks needs to be given enough power to stand
up to this kind of choice. What do you think of that in this kind
of rapidly changing scenario? Would LINks have a role in that
sort of thing?
Mr Edwards: One would hope, and
David and Brian may well have a view on this, that as patients
move through systems which have been well designed, which basically
are intended to make sure that clinical need is the determinant
of how you move through the system, one of the key jobs for the
commissioners is to ensure that that continues. I am slightly
sceptical that many trusts will have the ability to be quite that
nuanced in how they respond. The systems do not particularly allow
them to do that. There may be some issues about some providers;
for example, if you operate a stand-alone surgery centre there
may be some reasons to only take certain types of patients. I
think that is something that commissioners have to deal with.
I am not sure that LINks are necessarily the mechanism I would
be using. I would say that is a mainstream commissioning responsibility
that most providers, particularly foundation trusts and NHS trusts,
are unlikely to want to do for a whole number of reasons, not
least, to be honest, that if we were that able to control the
way our clinical workforce behaved many of the other problems
we have would not exist.
Q298 Dr Naysmith: What function do
you see LINks performing in this, if any at all? None at all?
Mr Edwards: In relation to choosing?
Q299 Dr Naysmith: Yes, the one you
just mentioned, with an independent provider, say, beside an acute
trust?
Mr Edwards: I would like perhaps
to defer to David on this. An obvious point of input is at the
point at which the PCT is talking about its commissioning intentions
and saying, "I am intending to buy surgery from this particular
provider, and part of the deal, you will need to be aware of,
is that it will not take people above anaesthetic score level
three, and there are certain restrictions on what it is able to
do but here are the details of it and we need your input from
the public and the various other people involved in the LINk to
tell us about this overall set of intentions that we have got".
Before you even decide to make the contract, you want to be involving
people through the LINks and indeed other mechanisms in the reasoning
behind your decision-making and why you have chosen to take that.
Then, as David says, as part of the management of the contract
you might well use LINks and a variety of other sources, not least
GPs and their own machinery, to get feedback on the performance
of that provider. Is that correct, David?
Mr Stout: Yes, you could characterise
commissioning very simply as a cycle which starts with a strategy
that you are setting out in your patient prospectus, goes through
to planning, how you are planning to implement that strategy;
through procurement, who you are selecting to provide the services
and then performance management, and I think there is a role for
patient and public involvement in absolutely every part of that
process. In the Choose and Book scenario, in which you are talking
about the procurement end, perhaps who is on the Choice menu for
your local patch (while we still have a Choice menu, that is),
I think it is perfectly reasonable to ask the question of the
PCT, "How do you involve patients and the public in making
that decision?", and a good PCT doing its job will be able
to say, "We have used these particular mechanisms and LINks".
Again, I do not think we should see LINks as being the only means
of PCTs delivering patient and public involvement because it overburdens
LINks a bit, but it would be one of the processes we would use,
I think. We would go to the LINks organisation and say, "We
are going through this process. Can you help us in the selection
process around procurement?", or whatever, and see how the
commissioning process could be populated by effective PPI forums
in every development of it.
| 
