Democracy and Accountability  in the NHS Plenary session reports

WORKSHOP ONE: PARTICIPATION LED BY CHRISTINE HOGG AND DONNA COVEY

Should health authorities be directly elected?

In Kidderminster we have 19 elected members on Wyre Forest District Council, with 42% of the poll.

At present our democracy is too “top down”.

Christine Hogg: Language does matter. “Community” is stronger than “patients”. A community approach recognises that there may be many different interests., and may imply that people want to see value for their taxes. Good CHCs have encompassed these different interests, including patients and others. CHCs have taken a wide view of health. A patients forum is much more restrictive.

Martin Rathfelder: The notion of community needs some unpicking. People may be members of many different communities.

Everyone is potentially a patient.

Public health is not just about the NHS. How would the new arrangements encompass public health?

Gavin Ross: CHCs campaign about issues in Primary Care like dentistry and PCTs. How are they to be covered by forums?

Cedric Bristow: Being a member of a Health Authority is demanding and difficult work. If people were elected they would need real training. Complainants are often bamboozled by managers and professionals. CHCs are a real asset to the complaints procedure.

Tony Arnold: CHCs have managed to deal with the stigma of mental illness effectively.  Many of these patients are unable to shout for themselves.

Sally Brearly: Patient is a role we all play from time to time

Christine Hogg: Who chooses who should be consulted? A lay member of a body is not the same as a consultation process. Are naïve amateurs useful? How are lay people accountable? Where do they get their information from?

Donna: We are stakeholders firstly as taxpayers, secondly as users or patients – mostly periodically, thirdly as voters.  The distinction between patients and citizens is false.  The collective voice is important.  Politicians or Chief Execs must not be allowed to play citizens off against patients.

David Spilsbury:  None of the monitoring exercises local CHCs organise would happen under the section 10 proposals.  His Community Health Council runs a programme of activities actively examining a range of services.

It is important to elect people from the voluntary sector.  Lay representatives on PCGs is no substitute for community involvement.

Nicky Joule:  How are lay people to be elected, trained and supported?  How is the process to be held together?

Pauline McNicholl:  Electing people is not identical with democratic involvement.

CHCs play a big part in preventing mishaps because of their monitoring visits.  Forums will not be effective unless they have real power.

Doug Naysmith: It is important to address the variations in standards of provision, but we must also recognise that CHCs also vary

Jos from Norwich: The proposal to abolish CHCs is rather different from what was contained in the Labour manifesto (which he read out)

Joan Penrose: The GLA health commission with Trevor Philips are looking into the Community Health Council issue.

David Spilsbury:  Is against random selection for the Patients Forum, but accepts that there is variation in the standards of CHCs.

Donna (led a discussion on principles against which the proposals to replace CHCs should be based) which came up with this list, based on those agreed by the 4 nations meeting:

  • Free at the point of use
  • Perceptibly independent
  • Accessible – geographically and culturally
  • An integrated service
  • Statutory rights
  • An evolutionary improvement on existing systems
  • Service wide
  • Enabling for individuals
  • People focussed
  • Representative
  • Locally responsive
  • Transparent and accountable, particularly in the appointment process
  • Properly resourced
  • With a National body

Gavin Ross: Must be able to embrace the eccentricities of local leaders.  Must have a continuing commitment.

Martin: There are problems with self-appointed community leaders such as the Patients Association.  Could Scrutiny Committees be the employers of PALS and co-ordinate the Forums?

Trust employees will not have enough clout to be effective

CHCs could set up the new organisation

WORKSHOP TWO: LOCAL DEMOCRATIC ACCOUNTABILITY

Andrea Jones, Chair of Trafford MBC Scrutiny Committee: The old style local government of the 20th century – decision-making was done by committee. Political parties dominated local government and made decisions. Many local authorities were one party states and there was no real scrutiny of the decision making processes.

The new arrangements offer choices – many councils are going for the cabinet and scrutiny model. Decision-making will be undertaken by the executive and it will be scrutinised by other councillors, an exciting way forward. Scrutiny committees will have the power to call in decisions before they are made, and can make recommendations and review long term policy. Scrutiny committees will not be whipped and therefore they will be non political. They will not have pre-meetings and will be able to select their own chair. Scrutiny will require very different skills, and people are only just beginning to learn how to do it. There will be a new learning process around a huge agenda. If local authorities also have to scrutinise the NHS, they will need assistance and expertise to help them, for example, professional advice and involvement of former CHCs.

Paul Walker, SHA Vice President: Paul has been appointed and anointed throughout his professional life. This was wrong and inappropriate.

Just after the split between commissioning and providing, he believed that the commissioning role should have been given to local government. Then he retired and became a councillor in Bristol. He was the health lead, and they set up scrutiny arrangements before it became statutory. He found his experience of local democracy off putting. Most councillors do not read their papers anyway, so to give them a huge new area of work will be purely tokenistic. He has therefore moved away from the notion of involving councillors.

He remembers the start of CHCs, which everyone thought was a super idea. However, they are very variable and very under resourced. Then he served for four years on a CHC. He still thinks they are a good idea and that they should not be abolished but resourced properly. They should not be the pygmies dealing with a behemoth. There is a need to keep what we have and develop it.

What form should democracy take? Health authorities and NHS Trusts should be elected on a health ticket, attached to CHCs? Should health be democratically accountable at every level – national, regional and local? Yes, but then there will be the issue that the system will retain postcode prescribing. The NHS can either be a monolithic organisation directed from the centre, or one where there is discretion and democratic decision making. Paul personally could live with postcode prescribing. He now works in Wales, where there is no NHS Plan as yet. They are to keep their CHCs. Also, they still have independent as well as party councillors.

Maggie Mansell, Croydon Councillor: Councillors have had to rethink processes as well as structures and to ask questions that were not asked under the old system. Maggie loves the idea of elected health councillors, but it is unlikely to be a runner. There is no reason why a CHC together with elected councillors could not be a sub-committee of the Council and be the specialist health scrutiny sub committee, along with members from the voluntary sector and the patients’ forums.

What will they be scrutinising? They can ask for information from council officers and from health service officers, which will require health and local authority co-operation. They should also meet more than twice a year.

Guy Routh, NHS Consultants’ Association: Guy supports democracy at all levels, but that alone will do nothing to change NHS culture. The assumption is ex..ing (?) to NEDs and work out how we get it through NEDs. The same would happen with elected health councillors – so we need more openness in the NHS. What is democracy? Also, there are difficult decisions in health around the availability of resources. He agrees CHCs should develop a supporting role but with proper training, resources and genuine involvement

Michael Varman, PCG Chair: Michael is preparing for PCT status in a powerful partnership with the City Council and the three PCGs to change health care in Nottingham, whether the local NHS wants its or not. They have a very unhealthy population compared with the neighbouring constituency. The key issue is that unless the population owns its own health, nothing will change. There will be three locally accountable organisations within the PCT, working closely with local government and drawing NEDs from each locality if possible, who will be accountable to that patch. The snag is that the population does not access what will benefit them. For example, there are twice as many heart problems in the area with half as much treatment when compared with the neighbouring constituency.

How to engage the population in health decisions? On joint walkabouts problems are raised, but they are not about health care but about community safety, housing, pollution etc. The government lays down targets via national priorities for health care, and also for local government. They may not be the same, but they have to turn these concerns into a response in the HImP, e.g. from concerns about crime to ensuring more use and take up of drug services. So democracy is needed, but we also need to work out how the population gets to own its own health.

Shirley Goodwin, Public Health Director: Local accountability will be important in the larger Health Authorities. Shirley is looking at Section 31 flexibilities in the Health Act to share the public health function between health and the local authorities.

If the responsibility for public health were returned to local government, would that not partly answer the question around the need for democratic accountability? Giving commissioning and the responsibility for public health to local government could assist local people to own both their own health and their local council. This could also lead to a better turnout in local elections and more interest in the electoral process.

Julia Knight, PCG lay member: Julia is disappointed at the government tenor of democracy. CHCs could become scrutiny committees. There is a lot to say about building on the work of good CHCs, and bringing the poorer ones up to scratch. But councillor members of CHCs are not always the best. They have no time to do the work and some are unable to separate their CHC role from their party political role. Elected local health boards would be a good idea.

Democracy is difficult, but we must start somewhere. To do otherwise will be patronising. People have a right to know what is being done with their taxes.

Catriona Morton, GP: Catriona has no local democratic involvement. She would probably be one of the resources. When they discuss issues like CHD, alcohol, and mental health issues, the patients want the same things, for example, local alcohol services, prescribing of Zyban, CVD clinics.

The local community want to improve their health and have a consensus of what is needed. They achieve better results at primary care level than at hospitals, but they need more resources, more appointments, earlier appointments, more GPs. Patients think the health centre is the focus for accountability and when they are told to go to the patients’ forums, they are not interested.

Maureen Smith, Occupational Therapist, Surrey. Maureen raised the USA town meetings model, where they have annual elections on everything, including major budgets such as education. Solutions are often identified at town meetings, and the closest model here is the CHC. However, there is a danger of voter fatigue.

Nursing care at home will not work because it is not resourced sufficiently, yet nursing homes are disappearing. These adversely affect members of a hidden vulnerable group.

Ian Syme: They have two social services departments, one City Council, and one health authority, all of them underfunded. Stoke Health Watch members attend board meetings of every body and ask questions. Health is at last becoming more open, but is still very defensive.

We should be aiming for perfect information from perfect data, from both the health authority and the local authority. The cabinet system is not truly democratic. We can’t ask questions at local authority meetings, although we can at health authority meetings.

Dave Parry, man in the street: The esoteric language is not understood and must be modified as a part of the culture shift. Wyre Forest was very officer led. Then the hospital issue emerged, and 19 of 42 councillors are now Health Concern councillors. Some medicos fell by the wayside but another adjusted his language and dialogue. Now there is an up to 48% turnout in local elections. The GP has an important role to translate medical jargon, unlike consultants and the health authority.

Donald Roy, Wandsworth CHC Chair: Donald agrees that the extension of the Access to Public Bodies Act was very effective. But it is hard work using lay CHC members. These lay members sit as of right at each PCG, Trust and health authority board meeting and are not bound by collective decision-making. The abolition of CHCs means that in future there may not be the people at each board doing the monitoring. The local press do not have the staff resources, and do not understand the issues.

In Tory authorities like Wandsworth, we face the situation where councillors on the CHC serve their Group and/or are there to discredit the CHC. They asked the local authority to work together with the CHC on scrutiny, but were told that the existing structures are sufficient. PCGs and CHC have shared a common agenda around public involvement and community development. However, the local authority does not share it, and has often been positively opposed to it.

Jane Haworth: The council members on her CHC are superb. Democracy, yes, but which democracy? Much is based on the unitary model, so what happens in the shire counties? Who should come together in that partnership? If it is left to the health authorities, there will be no agreement. We need to look at the trust catchment areas and draw in people from each local authority. The public also has a responsibility to try and keep themselves informed.

Fiona Campbell, Democratic Health Network: Who are CHCs accountable to? Who elects them? How about direct election to CHCs, or to whichever body calls CHCs to account?

Geeta Patel: Geeta is a founder member of a diabetes self help group. They cannot leave the issue to health services, which are primarily directed and delivered to white people, although four times as many black people have diabetes. PCGs and PCTs are new organisations and have an ambitious programme to carry out the health agenda of local communities. HAZs act as the leader on the public participation work stream. A lot of people feel totally disconnected from the democratic process as they have no experience of it. Her group also did a gender audit of those decision-making bodies in Wolverhampton that did not hold themselves to be accountable.

Woman, 1974 CHC founder member: CHCs had speaking rights in 1974, then a period without them, and now have them again. She has doubts about scrutiny panels. They will have a different role from the CHC. Scrutiny takes place after the event, CHC scrutiny takes place before decisions are made.

Judith Blakeman, KCW CHC Chair and K+C councillor: We have not yet touched on the role of the ILAFs. Perhaps these could be elected, with effective statutory powers of scrutiny over the larger health authority economies?

Gordon Worrall, S. Birmingham CHC: Gordon believes in an independent patient watchdog, whatever it is called, but it should have the word patient in the title.

Local authorities should be the body to be consulted on strategic issues, not CHCs, which have only an indirect system of election and appointment. Under the old system, the attendance and performance of councillors on the health authorities was generally poor. Election is not feasible in the short term under this government, so for local authority scrutiny, there is a very strong case to co-opt people from the CHCs. Local authorities should welcome this as an additional source of expertise and experience.

An example: in Birmingham there were proposals for social services cuts due to under funding. The money was then given to the local authority by the health authority. The health authority had been given the extra money by the government for winter pressures.

Could CHCs be an intermediary body? Are they no longer needed? Should we look again at how to involve service users more effectively?

Workshop 3: Two sorts of accountability Chair – Mike Young

[Flipchart notes]

Health Authority accountability: Chair to Region

Local Authority accountability: Officers to Members

Terminology:  Service users, consumers, citizens, voters

Consumer movement has moved from individuals to citizenship – a useful contribution to the debate and to skills and mechanisms – understanding what it means to speak on behalf of others, as opposed to tokenism

2 cultures opposed – Local Authorities feed their electorate – postcoded local democracy  We need people finding the time to volunteer.  Set about trying to better things for others.  The NHS is the most closed shop.  Need something high-profile  to get people to know about CHCs.  How to get involvement?

Differences in culture – aren’t HAZ’s meant to get people together?  Bradford has done this around particular examples – e.g. diabetes, mental health.  NHS less approachable.

HAZ’s – in some areas do bring NHS and local authority together.  To get culture changes you do need people with the right attitudes and training and sharing best practice.

NHS compared with education – the relative importance of  national (standards) and local (operational).  Do they (NHS and education) pull in different directions?

Lets make some constructive suggestions.  Look at the wider determinants.

  • Locally how do we get to “hard to reach” people?
  • Community Development trains local people to ask about local needs. Statutory bodies can then fund more of that, as well as what is needed
  • Scrutiny -Too many bodies to scrutinise?

Intermediate beds – in rural areas this is mainly private and may be difficult to access because of transport problems. All these changes have been thrown at us and major mistakes will be made.

Local Authority/social services accountability – differences between professionals and elected members.  Information exchange is needed at various levels. Good staff and community should be able in influence decisions about services.  Recruitment and training makes a lot of difference.

Everything starts at the patient. Boards aren’t effective.  Too much paper and meetings.  Too many silent people.  Need a powerful knowledgeable person with roots in the community.

Inequality of access to health services is an NHS issue, not an LA issue.

Accountability should publicise decisions and reasons for them.

Asking people what they want leads to people expecting you can promise it.  Can we (NHS or LA)? Is this why fewer participate in public activities?

Accountability in Local Authorities – are they credible as representatives if they don’t deliver services? (though Best Value doesn’t rule out local authorities as providers)  Las aren’t always good at listening

Democratic deficit – should we address it by moving public health back to LAs from health management?  Public health got separated from Local Authority and  floated  off.  Need for training in PCTs etc to look at the big picture, but also in Las.  Where things are working well you can build on that. Where will Councillors get time and resources to do scrutiny with?

Not enough consultation with people about the services they want.  They’ll have ideas about how services can be delivered.  Voluntary sector can give their view but could be funded to ask more widely.

We should be talking more about citizenship.  We all have that responsibility.

Address cultural diversity much more, especially in areas of small minority populations, in consultations and in accessibility of services.  Social Services and NHS should not make service delivery more complicated.

Accountability and citizenship: some areas high turnout to vote while others are very low because life is hard. Communities may not be articulate and may be excluded from the democratic process so we need other ways of being accountable, e.g. by asking people what they feel affects their health.  People know money is limited and don’t have unrealistic expectations.

Some local community plans are the result of  consultation. Some Local authorities have joint posts with health authority.  But how can local authorities do scrutiny – not enough time and not well enough informed.

Will scrutiny committees work like the health select committee?  Could have enormous impact if publicised and televised.

Some local authorities think scrutiny will give better control over  NHS consultants.

The way we consult with the community is very important, especially personal contact rather than the traditional public meeting.  We need to listen more and not go in with pre-conceived ideas.

Workshop 4: Delivering an effective NHS

Chair: Helen Groom, GP

Ron Singer, salaried GP, outlined concerns about:

  • poor communication between patient and professional carers, and between professional carers and relatives
  • Intensive Care being a nightmare for relatives
  • insensitivity of conducting investigations on trolleys in corridors = an uncaring environment; doctors disputing treatment over patient’s bed
  • parents with children often having to wait too long at GP surgery.

He welcomed most of the NHS Plan and other recent initiatives for primary care (NHS Direct, NHS On-line, Walk-in Centre, Pharmacists as first-line advisers, reorganisation of general practice) but expressed concerns about adequacy of finance, shortage of trained staff and implementation. Organisation of out-of-hours care through NHS Direct generally welcome, but need for short-cuts where client knows whom they want to contact. Dangers of higher rents for PFI premises, payable from revenue. NICE a brilliant idea but dodging issues of affordability – rationing must be more explicit.

John Lipetz, former NHS manager, said that the NHS Plan had great potential to improve the delivery of health services. Account had to be taken of the size and complexity of the NHS to ensure managers and clinicians could deliver health outcomes effectively and in an accountable way. The DoH and NHSE had distinctive roles, the former to set strategy, priorities and standards and to hold to account, the latter to deliver an effective service to high quality professional standards using best management practice.

Challenge is how to ensure effective management  responsive to local needs within such a  huge organisation. The common experience in the NHS of top-down management, driven by financial `bottom line’ pressures is not the way.  The key is genuine valuing of staff through team working, involvement and a bottom up approach. Workforce planning should be instituted across all functions to ensure that the right people with appropriate skills are available when needed.  Staff training  and development should be extended across all disciplines. NHS should have own staff college to lead this work  rather than rely on training bought in from expensive conference providers.  The Labour health team should be prepared to listen and to work out in consultation with organisations such as ours how best this management and organisational change can be achieved to meet the objectives of the NHS plan.

Peter Fisher, consultant, described need for good and immediate communications between professionals (compulsory use/delegation of bleep to PA) to enable GPs and consultants to be effectively available to each other to discuss patients. Written communications should be speedy (importance of medical secretaries as PAs). Inadequate communication with patients often due to lack of time to talk properly (staffing & funding implications), but patients and relatives need to know how to get information, discuss prognosis – through information booklets, national information; should be a mandatory duty of management.

For the Patients Forum/PALS system to be successful both patients and NHS staff would need to approach it in a spirit of cooperation, not confrontation. There would need to be a coordinating body, equivalent to ACHCEW

Discussion: how to make the NHS democratic, accountable and capable of delivering complex outcomes. Effect of clinical governance; influence of citizens/patients on outcomes; complaints procedures.

Points raised in discussion are grouped under headings agreed by participants as the main issues

VALUING THE WORKFORCE

  • humanise the NHS
  • pressures on clinicians/consultants must be recognised; burn-out common after 10 years, however enthusiastically they start. Consultants are under extra pressure due to cuts in junior doctors’ hours.
  • Managers should nurture not exploit junior staff; staff should feel valued; build on experience of small units with recognition of value of cleaner to clinician
  • management by consent (e.g. police operate the law, with the consent of the people)
  • Trust boards should play a role in improving staff relations/ethos
  • NHS is highly complex at local and national levels.  NHS culture should be changed to bottom-up

NEED FOR CONSISTENCY

  • need to judge success by outcomes which tackle inequalities
  • make use of bleepers mandatory: corporate management currently incapable of enforcing participation by clinicians, e.g. to ensure rapid contact e.g. between GP and consultant on urgent cases.
  • need for national norm for ratio of consultants to population – currently consultants + Trust have too much discretion about how many consultants to employ/not employ leading to manipulation of waiting lists/private practice
  • concern at role of Royal Colleges and Post-Graduate Deans in criteria for hospital/unit size (government hides behind guidelines) – with no accountability. Effect on mergers.
  • Scotland has `managed clinical networks’ v. English `hub & spoke’ model.
  • need for national service standards: central diktat + local flexibility
  • importance of organisational structures
  • need for changes in regulatory framework – GMC/UKCC often do not even check registration
  • use of PFI is affecting planning – bed numbers being determined by what can be afforded; harmful to strategic planning. Secrecy/lack of detail during consultation process
  • telemedicine seen as threat by some consultants (e.g. dermatologists)

CAREER STRUCTURES

  • need for career structure for professionals, e.g. MLSOs, Medical Secretaries (promotion to PA) so as to recruit and retain essential ancillary staff
  • need for strong union representation (patient advocacy groups not aware of most staffing issues)
  • concerns about skill mix – who is doing the nursing/are some nursing functions neglected – feeding, washing by relatives (cf Africa)

CLINICAL GOVERNANCE – VALUING COMPLAINTS

  • role of honest criticism from bottom-up / whistleblowing to alert management to problems. Legacy from `internal market’ philosophy includes clamp on honesty – managers (particularly Chief Executive) still too focused on `bottom line’.
  • legacy of consultant top-down culture – but sea change being driven by clinical governance agenda.
  • staff and public should be able to agree reports upwards.  Accountability leads to democracy.  Currently there is disincentive to take messages upwards; fear of making complaints.  Need culture of learning from mistakes, not hiding them
  • need to address inequalities in care – what happens if effective and ineffective trusts are merged (danger of levelling down). Potential dangers on morale of red/yellow/green status. Emphasis needs to be on putting weaknesses right. Welcome for role of Commission for Health Improvement, providing critical support not punitive OFSTED-style reports.

ACCOUNTABILITY – SPOTLIGHT FROM OUTSIDE

  • Importance of audit – currently too many bodies come up with standards; need simplification – one central auditing mechanism (this would take some stress off staff, and increase democratic accountability)
  • Tools for auditing mental health care in the community lie within Health of the Nation outcomes.
  • role of CRE : Human Rights Act, Freedom of Information – potential legal framework for patients
  • what will be the impact of evidence-based culture?  What patients want, or what they need?  Where is the public input?
  • what is the responsibility of the public to be `accountable’ – ie will the means to pay for what is needed, through taxation, or agree what is to be cut

COMMUNICATIONS

  • importance of quality of care, and understanding role of communication with patients/public – and at all levels
  • Keep patients well informed
  • advocacy for (very ill) patients – power of attorney for care providers
  • communication with immigrant communities – role of CRE in monitoring interpretation + technical know-how

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