Examination of Witnesses (Questions 340-352)
PROFESSOR ANGELA
COULTER, MS
FRANCES HASLER
AND MR
DAVID WOOD
22 FEBRUARY 2007
Q340 Mr Amess: You do not see yourself
as a trainer?
Professor Coulter: As a trainer
of LINks? Certainly in the Picker Institute we have indeed worked
with patient and public involvement forums to help them. For example,
we can help them with what the evidence says about what works
and what does not work, about what patients say to us because
we are doing research with patients all the time. We are very
happy to do some of that but we could not do it for all of them.
Q341 Dr Naysmith: The LINks proposals
involve the relatively new idea of having external hosts for what
are at the moment rather nebulous organisations but it is definitely
there that that is the proposal. This has raised the prospect
of potential conflicts of interest. How can this be avoided if,
for example, social care providers are encouraged to act as hosts?
Do you think that is a danger? Frances?
Ms Hasler: You would need to be
able to build some very effective Chinese walls if it were provider
organisations that were taking on this role, but there are lots
of examples within the voluntary sector. The voluntary sector
is quite good at being both a provider and a lobbyist, it is part
of the tradition within the voluntary sector. People in the sector
who have both of those roles are very clear when they are doing
one thing and when they are doing another. There are various models
where different sorts of voluntary organisations have acted as
a host or a hub for places. The Council for Voluntary Services
model is one that already exists where many CVSs will provide
a home for all sorts of activity within a particular locality,
so there is one model that is already there. For example, in this
borough the CVS used to provide a home to the Health and Social
Care Forum that existed. There are ways that can be set up. There
are a number of social enterprise providers now that are in the
business of this sort of work, broadly speaking you could call
it advocacy, I suppose, and a number of them are interested in
this sort of a role. I think there will be ways of commissioning
this in a way that does remove conflicts of interest and generally
speaking we would have to make it absolutely clear that if you
were a service provider organisation as well as an advocate organisation
that was a clear and above board and on the table issue. People
in all sorts of places have to declare an interest.
Q342 Dr Naysmith: Do you think having
the administration located in an organisation like that provides
any benefits rather than a forum or a PPI having its own secretariat
and so on?
Ms Hasler: It ought to provide
benefits of continuity. One of the things about setting up lots
and lots of small independent organisations, independent of any
other organisation, is that you do not get any of the benefit
of using the expertise of the bigger body, or you have to go out
and shop for it, if you like. One of the ideas of thinking that
LINks would be hosted by existing organisations was it is just
a lot easier to get something off the ground if you have got a
solid base for it and you are not having to go out and create
it. We have heard a lot already about the difficulties of having
to keep on creating and recreating organisations and I think everybody
would recognise that. Certainly the loss of impetus from voluntary
board members when they have worked really hard to set something
up and then it has stopped, I know from my own experience, is
very real. LINks need to be created in a way that can be pretty
fast off the ground and going and people seeing a result for their
input, I hope.
Q343 Dr Naysmith: David, you have
probably got experience of this sort of thing.
Mr Wood: Yes. One of the things
I would say from inside the voluntary and community sector is
we can very often suffer from what I would describe as "mission
drift" because we chase after money. In anything we are setting
up there would have to be a proven track record, a history of
working in the area, all those things, a rigorous selection method
is going to be important. We have already heard today about some
of the issues where perhaps selection has not been as good as
it might have been. Anything that is done with LINks is going
to have to hit the ground fast and effectively because you cannot
mess about for a couple of years and then find you have chosen
the wrong one. I would certainly make those as overriders. In
terms of conflicts of interest, I am thinking of the sorts of
organisations that might have a conflict of interest and I would
overplay on top of that the mission drift: are they a provider
who has suddenly decided to become a host organisation for a reason
which may be financially driven? I would want people to have some
proven track record or proven experience if they were going to
become a host organisation. I would have thought that would remove
a lot of the possibility of conflict of interest.
Q344 Dr Naysmith: So you think that
could be a danger if what you are suggesting does not happen?
Mr Wood: Yes.
Q345 Dr Naysmith: It is not really
a patients' question but do you have anything to add?
Professor Coulter: I think the
big problem is going to come with commissioning. If there is a
real hope that LINks are going to have an influence on commissioning,
and I would imagine that ought to be one of their most important
functions, then there are real potentials for conflicts of interest,
yes, depending on who the host organisations are. This is the
actual model for PPI forums and it has not worked brilliantly,
so it is going to be terribly important that the lessons from
the PPI forums are learned and avoided with LINks.
Q346 Dr Taylor: This is really to
Frances. We have heard a lot about rights of access, or the opposite,
and in your written submission you were very, very cautious about
rights of access. Can you expand on that a little bit?
Ms Hasler: Yes. We expressed caution
rather than opposition because it is about how it is done and
why it is done rather than saying there should be no rights at
all for people other than ourselves to be going in. Social care
takes place in people's homes, either in a residential care home
or in their own private homes, which is very different from the
vast majority of healthcare that people have been talking about
today which takes place in public spaces, so one of our concerns
was the absolute control of this ought to rest with the people
whose homes are being talked about. It is very important that
you can control who comes in and out of your house and have a
choice. At the moment, inspectors are able to go into what are
effectively people's homes, residential care homes, under a very
well-defined brief. Inspectors have got particular powers for
particular reasons and they are very well-defined. One of our
concerns is what we have seen at the moment in proposals for LINks
is not particularly well-defined. The other concern is we are
working very hard in CSCI to fulfil the aims of government of
actually making regulation simpler and perhaps lighter touch.
We are a bit concerned about anything that is going to look and
feel to providers like more inspection. In the proposals that
we had seen it was not very clear how this would look and feel
different from inspection from the provider viewpoint, or indeed
sometimes from the viewpoint of people who live in care homes.
One of the things we know from talking to people is that they
can quite often feel they are the ones who are being examined
when someone goes in. Although that is not the intention of inspection
it can often feel that way, and we are working quite hard to try
and make it not feel that way when we do our work. It was a real
concern that we had not got clarity about the parameters of this
and how it would be differentiated from what we do. We think that
institutions that are open to lots and lots of community involvement
are safer, better institutions; closed institutions can be places
where we do not know that people are safe. It is not saying that
people should not be able to go, particularly at the invitation
of people who live in services, to visit and to find out their
views, but it is about being very, very clear about why they are
going. We have introduced what we call "experts by experience"
who are people who have experience of using social care services
who go along with the inspector as part of the inspection process
and they can give a very good view of the service. Importantly,
they are also able to give voice to the people in those services
in a very direct way. If we could develop more things along those
sorts of lines we would feel a bit more reassured but we have
not seen anything like that in the proposals thus far. It was
not about having that expert by experience voice, which is what
we would be supporting.
Q347 Dr Taylor: Are your experts
by experience the successors of the lay inspectors you used to
have or do you still have lay inspectors?
Ms Hasler: We do not have any
lay inspectors who are not experts by experience, if you see what
I mean.
Q348 Dr Taylor: Experts by experience
are by definition lay people?
Ms Hasler: Yes, they are people
whose qualification for working with us as far as we are concerned
is they have some experience of using a social care service and
they want to work with us to help improve services, so they are
people with learning difficulties, they are older people, people
with physical disabilities, carers of older and disabled people
in some cases, who will join particular parts of the inspection
process so that they can talk to people who use services, sometimes
they assess the information that is provided to people who use
services, and when doing residential care they will be looking
at the environment and talking to people about how they experience
the environment of the service. They are doing something very
similar to the lay assessors, it is not a dissimilar role, but
there are bits of it that are different. The way that we use their
reports, for example, is different.
Q349 Dr Taylor: The residents would
find them easier to talk to than the inspectors themselves?
Ms Hasler: That is what some of
the residents have said to us. We evaluated this work when we
piloted and one of the comments was, "Thank you for sending
someone who understands me". A number of the experts by experience
are really good communicators. For example, a number of them as
a habit just carry around picture-based communication cards for
people who have learning difficulties, or some of the people with
sensory impairment who go in have got their own communication
aids. Going into an older people's home that is not particularly
set up for sensory impairment, sometimes the staff do not know
what the state of the art stuff is and if somebody goes in from
the community with state of the art communication equipment, that
is really valuable to the people who live there and to the staff
because then they can find out about it.
Q350 Dr Taylor: One of the points
that our first group of witnesses made was that it was very useful
for staff to have people they could talk to who were not part
of the official inspection structure. Is there anything similar
in social care or could LINks members fill that gap, if it is
a gap?
Ms Hasler: There are a number
of routes for staff to raise concerns already. In our own work
we do talk to staff and the experts by experience sometimes talk
to staff as well. From my perspective LINks would not necessarily
be representing the staff viewpoint. I do think there are a number
of bodies that do represent the staff viewpoint and individual
members of staff have got very many different routes into raising
a concern or giving feedback on how the services are run. What
I would hope is when we are talking about reconfiguring services,
staff have got a voice in that. Particularly frontline staff know
a lot of what works and what does not work and a well run service
will use the intelligence from their staff to help them model
what is going to work. I would hope there are good routes but
I am not certain LINks are the right focus for that.
Q351 Dr Naysmith: I do not think
the witnesses we had earlier were suggesting it was staff concerns
about their conditions, it was things that people had been recommending
would be improvements for patients that were not getting appropriate
attention and they had already raised them perhaps and this gave
them an extra way of making sure that something happened.
Ms Hasler: I would hope that LINks
are taking the ideas and intelligence from a wide part of the
community and from the staff if they see themselves as part of
that general feed-in. I think it would be strange if a LINk said
"We are not going to listen to what you have got to say because
you work in a service" because frontline staff have very
often got a lot of very, very good information. I would not privilege
their view above the people who use their services because, coming
back to your conflict of interest point, there are also evident
conflicts of interest sometimes when change is being mooted if
staff do not see that as being in their particular interest. You
need to be able to have something that is very clear, that LINk
is there to speak for the people who use the services and the
general public. I do think staff have got other sorts of mechanisms
to put their side of what they want. I agree, when people have
got ideas to feed in I would like to have them from everywhere.
Q352 Dr Taylor: Just to finish, I
think you said it might be possible for residents to invite LINks
in.
Ms Hasler: I would like to hope
it would be. Again, in open institutions, and many, many care
homes are very open to the local community and very vibrant, and
sometimes you go to some care homes and no-one is at home because
they are all out doing things in their local community, in those
sorts of places there are already good links. I would hope people
who live in care homes would sometimes want to influence the commissioners
of services through the LINk and that is one way they can do it.
Chairman: Could I thank you all very
much indeed and, once again, apologise for the lateness of the
hour. I do not know whether it is going to have an influence or
not on the legislation that is currently going through Parliament
but we are certainly hoping to have our report published before
it finishes its journey through Parliament and it may indeed influence
what is likely to take place. Thank you very much indeed.
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