NHS Reform and Health Care
Professions Bill - Lords' Briefing
This briefing sets out the background
to the patient and public involvement clauses of the NHS Reform and Health
Care Professions Bill, considers the state of the Bill as it enters the Lords,
and commends a number of amendments which would improve the Bill whilst remaining
consistent with the framework set out by the government.
For the past 27 years Community Health
Councils (CHCs) have been the most democratic and accountable part of the
NHS. CHCs perform various functions on behalf of their local communities.
- Providing help and support to NHS complainants.
- Acting as a convenient one-stop-shop for the local
community, providing help and advice on a range of NHS related issues.
- Acting as a powerful voice for community concerns about
local health issues.
- Monitoring and scrutinising the work of the local NHS.
CHCs have a substantial record of accomplishment
within the NHS. Recent high profile successes have included playing a key
role in helping to expose events at Alder Hey; providing help and support
to the relatives of Harold Shipman's victims and highlighting the lengthy
waits faced in the nations A&E departments through the 'Casualty Watch'
surveys. In short CHCs have have been at the forefront of ensuring that the
patientís voice is heard and their complaints listened to.
The NHS Reform and Health Care Professions
Bill currently before Parliament proposes the abolition of CHCs and their
replacement by a range of new bodies. The Bill's proposals on patient and
public involvement have provoked widespread controversy. Concern about the
proposed changes was reflected by a substantial backbench Labour rebellion
during the Commons' stage of the Bill.
David Hinchliffe, Labour Chair of the
Health Select Committee and the Liberal Democrat Health Team tabled an amendment
to the Bill which would have ensured that there continued to be a community-led,
independent NHS Watchdog at local health economy level called a "Patientsí
Council". The amendment was supported by a range of organisations including
the Association of Community Health Councils for England and Wales (ACHCEW),
the National Pensioners' Convention, Action for Victims of Medical Accidents
(AVMA), Age Concern, the Consumersí Association and the Patients Association.
The rebellion by Labour MPs, including 4 former Ministers and the support
of the Conservative Party resulted in the government's majority being reduced
to only 74.
The NHS Reform and Health Care Professions
Bill as it enters the Lords
Despite several welcome government amendments
to the Bill, ACHCEW believes that the Bill remains fundamentally flawed. The
key concerns are:
- The Bill replaces a system of proven efficacy that
is easily understood and accessed by the public with a highly complex and
confusing structure. Many patients have complex problems involving a number
of different services. Where a patient journey spans a number of different
Trusts, the individual patient could be faced with the prospect of approaching
a confusing array of new bodies for advice and support: Patient Advice and
Liaison Services (PALS), Patientsí Forums, and Independent Complaints Advocacy
Services (ICAS). In addition the fragmentation of the monitoring function
will mean that it is no longer possible for one body to monitor or track
the whole of a patient's experience. CHCs have been responsible for playing
a sustained advocacy role over prolonged periods of time for local groups
with ongoing concerns about their local health service, for example, Alder
Hey parents, users of mental health services, and homeless groups. It is
difficult to see where such support could be accessed under the new structures.
- The proposed separation and fragmentation of scrutiny,
monitoring and complaints work - between Overview and Scrutiny Committees,
the Independent Complaints Advocacy Service the Patient Advice and Liaison
Service and Patients' Forums - is likely to considerably diminish the extent
to which these areas of work mutually inform one another. The danger is
that the broader patterns that emerge from complaints work will never come
- Individual Patientsí Forums will only have a remit
for considering their own Trustís services, with no formal way of coming
together to provide an informed overview of local health issues from the
patient and public perspective.
- Lack of a one-stop-shop. CHCs provide help and advice
to members of the public across a range of areas. They are a convenient,
community based, frequently high street presence, that is able to address
concerns such as: 'what are my rights in the NHS?', 'I've been removed from
my GPs list is their something I can do about it?', 'I believe I may have
been the victim of malpractice, can you help? There is no adequate replacement
for this function in the Bill.
- At present the work of a core group of expert staff
in each CHC is overseen by local community representatives, drawn from the
voluntary sector, the local authority and interested members of the public.
The new Trust based Patients' Forums will have no staff of their own. They
would have to rely on help from staff of the separate Commission for Patient
and Public Involvement in Health. This would create a significant organisational
barrier between lay representatives and the staff whose job it is to support
them and mean that the Commission staff had no formal lines of accountability
and connection with local communities.
Limited remit and independence of the
- The Bill gives Patientsí Forums and the Commission
for Patient and Public Involvement in Health a range of duties but restricts
their remit considerably. As the Bill stands the Commission and Patientsí
Forums' activities would be much more restricted than CHCs and ACHCEW are
at present. They would be acting outside their authority if, for example,
they undertook activities previously undertaken by CHCs such as campaigning
work or engaging in legal proceedings Ė even querying the impact of a Private
Finance Initiative (PFI) could be deemed to be outside of their remit (ultra
- There are also concerns about the independence of the
new Commission for Patient and Public Involvement, in that the Secretary
of State for Health will appoint the Chair, will appoint the first Chief
Executive and will be able to direct the work of the organisation.
- Although local authorities have been given the power
to undertake scrutiny of the NHS they are not obliged to do so. It is therefore,
possible that some areas may be left without any scrutiny at this level
- CHCs have the right to be consulted and to refer any
lack of consultation to the Secretary of State. The Bill does not replicate
this right. CHCs also have the power to refer 'substantial variations' in
local NHS provision to the Secretary of State, when they are unhappy with
decisions made by local NHS managers. This power ensures that the local
community can hold NHS managers to account over unpopular decisions, and
guarantees political accountability for NHS decisions. Although the Parliamentary
Under Secretary of State for Health has said that she wants "the new powers
for overview and scrutiny committees to refer contested reconfigurations
to the Secretary of State to be no less rigorous than those that community
health councils enjoyed", the Bill contains no mechanism to remedy the deficiencies
in the existing legislation to allow that to happen. Without a means of
ensuring that poor consultations or decisions, which have an adverse effect
on patients and local communities, are reconsidered by Ministers, the new
arrangements fall short of those that currently exist.
Cost and administrative efficiency
of the new bodies
- Too often confidence in public bodies is undermined
by the perception of poor administrative and resource efficiency. The potential
cost of the new system has been estimated at 10 times that of CHCs. Some
of this additional cost is attributable to the fragmented and cumbersome
structure of the new proposals. It would make both fiscal and operational
sense to aggregate many of the functions of the proposed new bodies. This
would provide for economies of scale and improved operational efficiency.
- The development of meaningful public involvement is
costly in terms of the time and effort that is required, so it is unlikely
that the proposals will be without cost to the NHS. No indication has yet
been given about the resourcing of the new system in terms of level of staffing,
funding and volunteer requirements.
Proposed improvements to the Bill
ACHCEW remains firmly of the opinion that
the retention and reform of CHCs would be the preferable option. However ACHCEW
has worked hard, in conjunction with politicians of all parties, to develop
a number of amendments that would improve the Bill whilst remaining consistent
with the framework set out by the government. These amendments will focus
on a number of key areas:
- The absence of an independent, community-led, local
NHS Watchdog. It is ACHCEW's contention that the absence of such a body
represents the most serious flaw in the government's proposals. The introduction
of such a body would address many of the concerns about fragmentation, the
lack of a one-stop-shop, the absence of a powerful voice for local communities
and the poor administrative efficiency of the new bodies.
- Ensuring that the proposed new bodies have the powers,
remit and independence necessary to ensuring that they can fulfil their
function of holding the NHS to account on behalf of patients.
- Provide for rights for patient and local authority
bodies to refer failures to consult or contested decisions to Strategic
Health Authorities or to the Secretary of State.
If CHCs were abolished as the Bill proposes it would leave
England as the only part of the UK without a robust network of local NHS Watchdogs.
The Scottish Parliament and the Welsh Assembly have both signalled their intention
to continue with a CHC, or equivalent, model.
Parliament is being asked to abolish a
known quantity, CHCs, without sufficient detail about how the alternative
structures will work in practice. Although it has been suggested that this
detail will be dealt with by future regulations and guidance, we believe that
if patients are to have a robust system of involvement and representation
it must be established by statute. This will ensure that its independence
is not compromised by the threat of changes in regulation and will guarantee
that any future changes in this crucial area of public concern are subject
to parliamentary scrutiny.
The Bill in its current form remains fundamentally
flawed and the subject of much controversy. If amended to reflect the concerns
outlined in this briefing paper, the result would be a much-improved Bill
which could command a broad consensus and the confidence and trust of patients
and the public.