Your views are important......

Join the national debate on patient and public involvement and its influence on the NHS.  How can the NHS become more responsive to the population it serves?

   

The NHS Alliance – the independent voice bringing together everyone in primary health care - is looking for diverse views around the UK  from patients, carers, NHS board members, GPs, nurses and other health professionals and of course members of the public whose taxes pay for our most important public service.  The debate will continue with regional meetings and the Alliance will bring your ideas together at the end of the debate.

To stimulate your thinking Download Whose NHS is it anyway - a discussion paper prepared by the NHS Alliance.  What do you think about its six questions on NHS accountability set out below, and the practical suggestions for patient and public involvement in the NHS “with teeth”.  

1. Is there enough local accountability in the NHS?

2. What would be gained by greater accountability? What might be lost?

3. Are elections the best way to deliver greater accountability?

4. What role should local authorities play, if any, in promoting local NHS accountability?

5. What kind of accountability is needed and is it different for those who commission services and those who provide services?

6. How can the inevitable tensions be managed?

The new NHS Constitution says “The NHS belongs to the people”. Help us find out what that really means by saying what you think it really means to be one of the owners of the NHS. Click on the "Comments" link now.

 

Comments

[Dr Syed Abidi]

NHS must belong to its stakeholders:the patients.The accountability must start fom up to downward. The elections are not the best way of accountability as it may get wrong people elected for wrong job.The NHS managers must be selected through a transparent receruitment process..

[John Barlow]

I believe that elected PCT Boards would go a long way to improving accountability. Bucks PCT has failed in its statutory duty to "balance its books" and has amassed some £64M worth of debt over the last few years. The typical response to this, and critiscism from the Audit Commission,is that the Board has agreed an action plan! Year after year the same mismanagement of public money. The local Overview & Scrutiny Committee (Health)has raised questions about the implications of this situation in terms of service reductions but, as we know, the only power that such committees have is to refer matters to the Minister of State who normally responds with "... its for local decisions".

In other words the public have no say in the management of the huge sums that are administered by PCTs. Yes NEDs are appointed but they are not accountable to anyone. Yes some PCTs allow the public 10 minutes at the begining of Board meetings to ask a few questions ~ but there is no accountability. The public cannot change anything and even when there is overwhelming evidence of the direction that the local population wish the PCT to go their views are noted and then ignored.

An entirely unsatisfactory development could be that PCTs become answereable to Overview & Scrutiny Committees. Even this would be better than the current situation. At least elected members would direct the PCT. However for the best democratic result each PCT Board should be directly elected.

[Geraint Day]

Democratic accountability is essential to help improve the National Health Service. The moves made in England over NHS foundation trusts should be extended to other bodies such as Primary Care Trusts, including election of their boards of directors (by direct election, from within stakeholder groupings).

Assertions that 'democracy does not work' can on the one hand be seen as special pleading to maintain the hugely unaccountable appointment process, and on the other hand deny the fact that making democracy work requires leadership WITHIN an organisation, as the better co-operatives and mutuals around the planet know from very long experience. It has to be built up and cannot happen from scratch. That does indeed mean possible pressure from existing members but also a need for governors and directors to realise that it is in the interests of the organisation for there to be a vibrant engagement by members and other stakeholders, so that capable people will actually want to stand for election or get involved in other ways. (Offering training to potential candidates is one way of helping equip people for such committee and board roles; like having a concern for employee wellbeing, that should actually be an investment that will improve the organisation).

There are also very probably too many local bodies that purport to act on behalf of patients. "Which one should I approach?" can be the resulting confusion, by individuals seeking help or advice. Incorporating at least some user groups into the democratic structures could surely be a way of streamlining matters. For example, in some co-operatives and mutuals there may be specific interest groups. In healthcare the analogy might be people with particular conditions, with interests in volunteering, etc.

It is not efficient to appoint local government councillors to the boards of NHS bodies. For one thing local government has enough problems of its own, without diluting the effort needed to rectify those; councillors should attend to those before trying to immerse themselves in other bodies, particularly those as large and complex as the NHS. For another it is a waste of resources to have NHS bodies summoned to appear before local council scrutiny committees. It requires much investment of management time. When local government largely has no control over NHS bodies it is also bordering on a perpetuating a culture of meetings just for the sake of it. If, for instance, the board of Tesco were required to appear before the board of J Sainsbury (or vice versa) twice a year it might make for interesting meetings, but as one has no control over the activities of the other, why do it, and why institutionalise it as part of what can often become a sort of institutionalised partnership ritual, with little or nothing to demonstrate by way of outcome or actual improvements in healthcare?

There will always be tensions. To pretend otherwise or that they can be 'managed' [out of existence?] would be a denial of that reality.

[www.facebook.com/profile.php?id=904590460]

Democracy and accountability are not the same thing. Foundation trusts have democratic elections, but the people elected have no capacity to hold the organisation to account.

[Gerda Loosemore-Reppen]

Any service provider should regularly seek feedback from service reoipients as part of the quality circle and use the feedback to improve the services. There is no reason why any health service provider should be treated differently.
COmmissioners should consult and discuss commissioning priorities and outcomes with those representing the catchment population and other stakeholders on a rolling basis, so that views can be acted upon. LINKs and other stakeholder organisations such as voluntary organisations can be useful conduits for condition specific views to be fed into service mapping and prioritisation.
There is also the level of democratic accountability - enabling the population to change the leaders of organisations if they are dissatisfied. This does not currently happen with the NHS. Thought should be given how the democratic deficit can be remedied - not by putting local councillors on boards, but perhaps by a total change in the configuration of health and social care services. They depend so much on each other that a merger might be the best way forward. A separate locally elected governing board would then decide on priorities and delivery of services. Rationing is inevitable, but it should be through a more transparent process than at present and not just be left to doctors or government appointees.
.

[Daphne Havercroft]

The culture of the NHS has to change radically for PPI to be truly effective. Too many Patient and Public representatives who hold Local NHS organisations responsible and accountable for their services by asking questions, challenging and requesting evidence to support proposed changes are ignored or receive answers to questions they haven't asked and made to feel that they are the enemy and/or treated like naughty children.

On the other hand, too many Patient and Public representatives are too deferential to clinicians and NHS managers and (wrongly) feel that they can't make a difference. They can.

The NHS pays lip service to PPI and needs to do a lot of work with patient and public representatives to make it a success. A good start would be for local NHS organisations to LISTEN to patient and public views about what PPI means rather than trying to impose their own interpretation of PPI on local people.

In theory, LINks should be able to improve local NHS accountability, but they are swamped with work.

[Charles OKell]

In my view....

1. Is there enough local accountability in the NHS?

Theoretically yes; however Council Scrutiny is often poorly informed or too politically biased to be of benefit to the system and the LINk system was scuppered by a total lack of national support and "off-shelf" governance/training.

It would seem that, currently, both systems are lacking credibility, this is due to a lack of clarity in the specific role they carry out and knowledge of role by both the members and statutory staff.

2. What would be gained by greater accountability? What might be lost?

Gained - more responsibility taken for decisions taken, leading to greater thirst for informing those decisions through involvement, research and, hopefully, making work as a Commissioner a profession, with professional training/qualifications [like in the building trade]

Lost - trust that the professionals in the NHS system know what they are doing and know what is best for the patients.
Lost - autonomy of the organisation's internal accountability systems.

3. Are elections the best way to deliver greater accountability?

Elections are an established system of accountability within a democrasy - however, due to the low profile of such systems as LINks and the ambiguity over membership, elections can be skewed towards popular support rather than actual acheivement.

Profile raising of activities and acheivements of those in the business of holding people to account, be they Council members or LINks, or staff at the audit commission...

4. What role should local authorities play, if any, in promoting local NHS accountability?

Being aware of, and understanding, the Council role of Scrutiny would be beneficial, also promoting the activities of and value of involvement would be of help to the accountability system.

Councils can also help in changing culture - encouraging the coummity [through education and profile raising] to get involved, have a say and share their experiences with those responsible for purchasing and delivering services.

Their is a serious conflict regarding Council Scrutiny and Social Care service delivery to my mind; however if Councils are not to be involved in holding public services to account - what is the point of having elected members?

5. What kind of accountability is needed and is it different for those who commission services and those who provide services?

Of course there is a difference...

Providing Services; accountability needs to be about quality of service

Commissioning Services; accountability needs to be about the appropriateness of the services provided and the cost to the public purse

Both Commissioners and the Public can hold the Services to account; the Public and the Regulators need to hold the COmmissioners to account.

6. How can the inevitable tensions be managed?

Given appropriate protocol, training, an acceptance that this will go wrong [human nature] and an open attitude to scrutiny and accountability, tensions can be managed.

The issue is management of conflict and everyone through the system knowing who they are accountible to, why and how - ensuring that no-one acts in any interest other than for the wider public good.

Bottom line - accountability from the public perspective is in its infancy and there is definately development to do throughout the system; this means that LINks need to be given a longer term of finance than is presently in place, in order to give the system the best chance to help deliver the common goal - Better Services

[David Gee]

As Chair of the local LINk I am constantly frustrated at attitude of PCT Board. Whilst we are welcome on various committees, any attempt to influence services at a strategic level at Board meetings is dismissed by Board Chair.

[Brian Fisher]

Thanks everyone for your contributions. I see a sense of frustration in the posts here about lack of PCT responsiveness. Also a feeling that democratic involvement may help.

What sticks and carrots are therer to make PCTs more responsive?
CQC - what would they need to do?
Invoke the law - Section 242?
Training?
Democracy?

So far as democracy is concerned - what do people think about:
- maybe no-one would vote
- what are the risks of the organisation being swamped by, say, the BNP?
- maybe single-issue people would come to dominate

Any thoughts about these issues?

Brian Fisher

[Hilary Rowell]

There isn’t enough accountability in the local NHS, but there is a huge amount that can be achieved without changes to existing structures. The most urgent need is for PCTs to grasp the challenge of informing and engaging with individuals and local communities – starting with ‘giving an account’ (to use the King’s Fund ladder) of their activities and performance in ways that are meaningful and accessible.

PCTs, as the local headquarters of the NHS, need to take responsibility for sharing information about the quality and availability of healthcare locally, local challenges and needs, how and why they make decisions – and seeking feedback and input on all these. Most PCTs have started to grasp the challenge of social marketing as a means of influencing health behaviours, founded on a greater understanding of local demographics and needs. They now need to take this a step further towards more holistic engagement strategies drawing people in not only to shape their own health but to shape local healthcare too.

PCTs have yet to fully grasp the potential of digital channels to reach out to their local populations and engage them not only with their own healthcare but with the challenges of planning healthcare for the whole community. Imagine being able to find out what services are available locally, how good they are (including what other people say about them), how your locality compares to others in terms of health needs and healthcare performance, what your NHS is doing about it - all at the click of a button. While digital channels will not reach everyone, they offer effective and more importantly cost-effective means of drawing people into new kinds of relationships with the NHS, relationships they are used to having in nearly every other aspect of life. That leaves more resources available for more concentrated efforts to reach the so-called hard to reach.

Moves in this direction will start to shift perceptions of what you rightly call the illogical postcode lottery towards planned and evidence-based differences between localities. Structural changes to governance would be very likely to be disruptive and counter-productive without having first addressed this challenge of ‘giving an account’ and then 'taking into account'. Elections risk being tokenistic and prone to activist participation - understanding and responding to the whole community, in all its diversity, is the first nut to crack.

[Andy warren]

The most important part of Public and Patient Engagement / Involvement is that you have to start as low down as possible, i.e. at the Patient Participation Groups associated with GP Practices. Most of the public are only interested at this level. If there is the support then the next level is at Practice Based Commissioning (PBC)cluster level. The public are still affecting what they are interested in - The Local Picture.
The progress to PCT level is a distant target as they are NOT interested in what the Public think as it will adversly affect there "Spin " machine that only generates good images and supports the current none involvement, despite Section 242 1B and WCC Competency 3. This is demonstrated by the wave of PCT's that have submerged their existing PPE/I activities into the Communications (Spin) group.

Future developments of PBC must include all aspects of PPE/I

LINks will never work as it is aimed at the PCT level, and increasingly national involvement.

Demoncacy will only be achieved at PCT and SHA level if:
A) All NEDS are appointed by the PBC groups within a PCT
B) Chair and Chief Executive annual reviews include input from the PPE/I groups at PBC level.

[Yann LeFeuvre]

1. Is there enough local accountability in the NHS?
The straightforward answer is No, and we can either consider another "fame and blame" shot or perhaps look at it more from an organisation point of view. Starting with budget

-historical budget of the previous 2 years- and roll it forward the following year within voted/agreed targets and work from there. I find it difficult to understand that currently as a base-line Gp the only information is, "we need to cut our Pct budget by £80,000,000 within 5 years". And what, how, from where? No answer, a bit scary as far as I am concerned.

2. What would be gained by greater accountability? What might be lost?

If only one thing, are we providing value-for money services? There are so many stories out there where suspicious has been raised about unnecessary hospital follow-up appointments, splitting hospital contract allowing private companies to be in charge of cleaning and causing extra-deaths. The driven force should be evidenced-based patients centred quality care not only budget driven care. My experience locally is that Pct `s managers are not very good at relaying top-down information: "we need to reduce follow-up hospital appointments." fair enough, which one? and if in the community anybody is producing some work -rapid audit cycle of referrals for top 5 high referrals- and as a result changes one’s practice referral, what next? My experience is, as an example there is a urgent care centre (run by local Gps) created at the front end of our local hospital which has reduced inappropriate referrals by 30/40%, the next thing we have heard, the A/E consultant has created a follow-up clinic and is asking patients to come back to his clinic.

3. Are elections the best way to deliver greater accountability?
If the participation is significant and representative, then yes. If this is another long-winded process then No.

4. What role should local authorities play, if any, in promoting local NHS accountability?
They hold a budget, have a knowledge on costs and contracts; is it in their remit to withhold pro-rata payments if a target has not been delivered? My answer is Yes.

5. What kind of accountability is needed and is it different for those who commission services and those who provide services?
Contract-based (short term, no more than 5 years). No conflict of interest provider/commissioner. Contract based on budget with payment retained if not delivered as initially voted/agreed.

6. How can the inevitable tensions be managed?
The difficulty would probably to keep current Nhs workforce and only allow partial private exercise. Locally, it seems when colleagues are unmotivated; they go private or look to increase private income at the expense of their Nhs work.
As long as this exercise is contract-based, the discussion should have happened. Perhaps the next step for Nhs Alliance / Bma is to look into submitting some form of template of contract shifting resources from Pbc budget which are already used -at least by our Pct- for other non-Pbc means.

[Martin Rathfelder]

I agree. I don't get much feeling of genuine engagement, although there are some interesting things going on. For real engagements the patients need some sense of control - or maybe a share in control. Not many people seem to have that.

The most interesting things seem to be going on in the IT sector - a
place where the NHS still lags years behind.

[Tim Gilling]

Following David and Martin - what seems missing to me is any sense of 'influence'. Most people want to be involved, not many actually get involved and I suspect that this is because people do not think it is worth it as nothing tends to change.

Not many organisations seem to have the culture/capacity to listen, understand and (crucially) change activity and approach.

Linked to this is the difference between 'performance' and 'experience'. By that I mean that the NHS is good at reporting 'performance' e.g. waiting times down, but peoples experience of services can present a very different perspective.

We've seen this most recently at Basildon - 'good' performance reported but obcvious flaws in patient experience.

[Brian Fisher]

The other strand of the work we said we wanted to do as a group (the first being shared decision-making) was to look at and influence issues around accountability and responsiveness – which I take to mean partly:

the culture/capacity to listen, understand and (crucially) change activity and approach.

So, it would be very sensible to take this discussion and see if between us we can develop something concrete and practical that would make it more likely that a Trust or PCT or PBC group would move more clearly in this direction.

What do people think?

[Mark Duman]

Dare I suggest that both strands could be interconnected. Shared decision making gives me the opportunity to influence my healthcare and/ or the people I care for (speaking from personal experience). This occurs primarily at the 'individual' level not at the collective 'user' nor 'citizen' level.

However, once one realises the ability one has to influence their 'invidual' care, their is the potential for them to move up the ladder and become more involved in more collective activities. For example I have been campaigning locally (albeit on a small scale) for better primary mental health services. Prior to my individual involvement, I had no interest in influence the collective agenda. If someone had come to me to ask me to get involved at user or citizen level I would have politely declined.

Equally I would never have considered Foundation Trust (FT) membership until, having received such amazing service during a very traumatic episode easrlier this year, I felt the need to give something back to Central Manchester FT. I recenntly lost the election to become a patient governor but my enhusiasm to contribute is still there.

The key to all this - at least for me - is the word 'relevance'. Make it relevant to me and I'll join in. Relevance starts from the bottom up, not top down. So lets focus on building capacity and capability at the individual level for patients, clinicians and the system and then see what migrates upwards...

[Brian Fisher]

I agree with Mark. I also think that most organisations do actually have lots of patient data. Now that we are gathering data in one place we realise that the PCT has LOADS OF DATA. The trick remains – how do we ensure that the organisation changes in response? In my view, one approach that is increasingly showing relevance and effectiveness is working with change agents on the ground. I call them community development workers, but others call them other things. Nonetheless, the idea is that they are outreach workers, they talk to people and they help them both explain what they want and then work with them to help them negotiate with the organisation about change.

I think that goes some way to meeting David’s concerns about an emphasis on structures rather than people and also Mark’s point about relevance.

[William Jones]

Is there enough local accountability in the NHS?
Could be improved by some Non-Execs being elected by the local community

What would be gained by greater accountability? What might be lost?
Potential for political interference if local politicians are involved, but elected reps should ensure they canvass local opinion to feed into decision making

Are elections the best way to deliver greater accountability?
National NO

Local elections - potentially

What role should local authorities play, if any, in promoting local NHS accountability?
Further develop meaningful joint commissioning & provision. Develop the Health Scrutiny role.

How can the inevitable tensions be managed?
Strong leadership – with CEOs from LAs & PCTs sitting on respective Cabinets & Boards

[Fedelma Winkler]

I wanted to support David Gilbert's views on the need to begin to do some fresh thinking about PPE/I --a fundamental review of what it means to the various stakeholders.

I agree with you on the industrialisation of the process but I would ague that much of that was a necessary by product of ‘consumerisation’. I first produced an article on this written at the behest of the Department in 1986 ‘Beyond the Supermarket’ and published by Chris Ham in Policy and Politics. The Policy of Choice is of course an extension of health consumerism.

The beginnings of the future may lie in the past
Early Campaigns. Any article seeking the way forward needs to look at the past and chart changes in the involvement of ‘patients’ in decision making; the result of campaigns by the newly established organisations of the 60’s and 70’s such as the Campaign for the Welfare of Children in Hospital and the various maternity campaign groups . Many of those early campaigners are still around. They changed the landscape for whole groups of patients as did the advocacy groups in learning disabilities and mental health. When we set up the first advocacy scheme, in the early 80s, we used euphemisms because the word advocacy evoked such strong reactions and alienation.

CHCs. The CHCs were (and I know you don’t always agree with me on this ) important mobilisers, facilitators and developers of health campaigners and user led advocacy and information groups. The proof of this, I would suggest, is found by looking at who opposed CHCs and who supported their demise. I assume you have read Christine Hogg books on these developments.

Chronic Care Focus More recently the user movements main focus has been in the chronic care sector. The style is different, more based on partnership with providers that the earlier adversarial tendencies.

What has changed
Professional Attitudes An audit would show a major shift in attitude within medicine and medical institutions and education over this time period. One of my vivid memories is being vilified during a lecture at a post graduate GP centre because I said patients should be ‘allowed’ to see their notes. The lead protagonist tutor would of course have been embarrassed ever to have held that belief by the time she came to retirement in the late 90s. The attitude has not completely died out but is less prevalent.

This change is accounted by the emphases/demand of the early campaign groups was on changing the nature of the relationship between the clinician and the patient/user. (See Charlotte Williamson’s new book) An international comparison would show the NHS is more cognizant of the patient rights than many European health care systems or despite the legal requirements ahead on much custom and practice in the US.

Gender Shift. A shift in the gender of the leaders of the user movement has occurred in this time. This may or may not account for the ‘industrialisation’ which is more aligned with male culture and customer relations.

Professionalisation of user representation. Maybe even of ‘colonisation’ with the direct employment of patient representatives inside the hierarchy. Again the evidence from the US would suggestion that organisational capture is a likely outcome of direct employment of user representatives. The processes of consumerism are the skills required by the professional user representative not those of campaigning and advocacy.

Not Changed
Management recalcitrance. What has not changed is the attitude of the management to user representation in decision making. This has been made worse by the involvement of the private sector. Commercial confidentially can be used to legitimise non consultation. (eg Camden last month only going to consultation when forced to by the threat of legal action on change of service)

Management chooses to equate consumer satisfaction surveys and inspection regimes with PPI/E. Essential but not sufficient.

Primary Care. There is a debate to be had as to the degree that primary care has or has not been subjected to the same user pressures as say mental health.

Statutory Powers. The lack of a statutory institutional structure to organise, mobilise and challenge decision making, which was part of CHCs remit , is now missing.

Where the future may be found
Past Success. Examination of process of successful change in the past , –the steps how, where, when, who. Celebrate what has improved and use that as the base to work out next steps .

Cost Involvement is costly so cost benefit of any proposals need to be part of the debate.

Robust discussion How one holds decision makers to account is not just an issue for health services but a societal one, for shareholders in the city, stakeholders in education etc. For next steps in democratisation we need to begin by looking at who is demanding greater democracy and whose interests are served or could be served by it, what are the consequences of lack of accountability. There needs to be a cross reference to other debates in the public sphere, A description of what ‘it’ would look would be a good place to start and then let that shape the action plan.

[Martin Rathfelder]

Good stuff from both David and Fedelma. I am not sure that the words
used quite capture the problem. As far as LINKs are concerned, I think
the problem is that they are excessively constrained and underpowered.
There isn't much which I would recognise as campaigning. The paid staff
are timid because they are on 3 year contracts and most have neither
experience nor confidence. The way Links are set up excludes people with
real political skills. One of the things that made the good CHCs work
was that young politicians cut thier teeth on them. H Blears being the
most notable example.

Part of the problem is that campaigning has changed. Most of the
interesting stuff is on the web. Most patient groups have not got their
heads round this. The average age is very high and the level of
technical competence and enthusiasm low. Both local and national
newspapers are in decline, probably terminal decline.

[Georgina Craig]

The NHS Alliance’s discussion paper defines PPI as a holistic, collective process by which the local population inputs into health service commissioning and prioritisation of resource allocation.
This is in contrast to NHS policy on ‘choice’ at an individual human level, which engages individuals in their care and ensures they get what they need and want from the health system. Whilst individual choice is clearly part of PPI, by bringing decisions at the individual level into the mix within this consultation, we feel it may dilute its primary focus. So we have chosen to focus solely on the fundamental challenge posed and at the strategic level.
What is successful PPI and how would we recognise it if we met it on the street?
In many ways, we still do not know the answer to this question, and that is the challenge. We have yet to find truly effective ways of engaging the public collectively and involving them in health care.
In order to answer this question, we also need to think about what the outcome of effective PPI looks like. If we do not know where we are going to, we cannot effectively plan our journey.
From analysing the discussion paper, a number of likely outcomes of effective PPI emerge:
• Health resources are prioritised and allocated in line with community and public health needs
• Patients and the public’s views inform commissioning and service planning
• Patient and the public perceive health services as a great experience and personal to them
• NHS commissioners are held to account for the quality (as perceived by the public) of services commissioned
• NHS providers are held to account for the quality (as perceived by the public) of services provided.
Why do we need PPI?
The NHS is a managed market. It is dominated by monopoly commissioners and providers. If it were a free market, then its customers would vote with their feet if they did not like the service and go elsewhere for their health care. Then there would be no need for PPI as to flourish, the system would put the needs of its customers first. A free market within health care is unsustainable as people have to use local NHS services; and there is no business case for providers to create excess capacity.
PPI can therefore be seen as a way of ensuring that providers and commissioners focus on the needs of the ‘customer’ in the same way as they would if they faced fierce competition.
It can also be a way redressing the power balance between the NHS monopoly and its customers (the public and patients).
The NHS Alliance discussion document proposes that this balance is redressed through local accountability.
What does local accountability mean?
The discussion paper proposes two different methods of achieving accountability:
• Accountability through democracy and locally elected leaders
• Accountability through a louder, more powerful patient voice
There are other ways:
• Government believes choice and competition creates accountability. Because the NHS and other public services like education remain an imperfect markets dominated by incumbent monopoly providers, the degree to which people have real choice and competition can lever change as it does in the free market remains debatable. In light of financial constraints, competition and choice are becoming increasingly unsustainable.
• The mutual model of public services engages the local population as ‘shareholders’ in the system (The John Lewis Model).
• Co-production is the concept of people becoming part of the delivery system of public services and working alongside professionals (New Economic Foundation, 2009).
We think there is still some debate to be had about local accountability means. In the context of this response, we defines local accountability as the role PPI plays in delivering the outcomes described above.
Responses to questions
• Is there enough local accountability in the NHS?
On the basis that local accountability means effective PPI, the answer to this question is no. Health resources are not always prioritised and allocated in line with community and public health needs. Patients and the public’s views do not sit at the centre of commissioning and service planning processes. Patients and the public do not consistently perceive health services as a great experience that is personal to them. NHS commissioners are not held to account by local people for the quality of services commissioned. NHS providers are not held to account by local people for the quality of services provided.

• What would be gained by greater accountability? What might be lost?
On the basis that greater accountability means more effective PPI, the gains would be:
o Health resources are prioritised and allocated in line with community and public health needs (not political imperatives)
o Patients and the public’s experiences and preferences take centre stage across all aspects of commissioning and service planning
o Patient and the public feedback shows they consistently experience great NHS services that feel personal to them
o NHS commissioners are held to account through existing mechanisms and can show local people’s views (and ongoing feedback) have informed commissioning
o NHS providers are held to account through existing mechanisms and can show their customers’ views (and ongoing feedback) have informed service delivery
o User experience is a key component of quality assessment and provider and commissioner funding depends on it.
When PPI is working effectively, these things would be lost:
o Patient organisations and LINKs that lack high quality advocacy and stakeholder research having default voice and influence
o Politicians legitimacy to ‘speak for patients’
o Professionals legitimacy to act as surrogate patient advocates
o Professionals exercising power over the system on patients behalf
o The voice that shouts the loudest inputting subjective (couched in personal bias) assessments of what the public thinks and wants
o Complacent commissioner and providers who pay lip service to patient service experience.
• Are elections the best way to deliver greater accountability?
No. What is needed are more sophisticated ways of engaging patients, describing their experiences of NHS services and how those experiences can be improved. We need tools to quantify what people say, collectively, they want from services. We need an evidence based approach to PPI.
New techniques for doing this, drawing on social marketing, social network marketing, sociology, psychology, communications, advocacy and community development need to be developed that redefine what PPI means and looks like. This will also create the engagement tools to deliver it.
• What role should local authorities play, if any, in promoting local NHS accountability?
OSCs appear to work. They have helped address the local democratic deficit. Their role should continue and if necessary, they should have more resource to scrutinise key health service developments more carefully.
LAs should continue to be partners in public health service strategy development and are clearly key to delivery of health improvement. More resource should be provided for facilitating joined up working at the front line of care; boundaries between LAs and PCTs should be aligned.
If a point comes when NHS organisations and local authorities merge, that should be seen as a corporate governance issue; not a patient engagement one.
• What kind of accountability is needed and is it different for those who commission services and those who provide services?
See above. It is the same for both providers and commissioners. It is essential that it is the same. Accountability to the patient and service users and delivering a great experience of high quality care must be the goals that unite the whole system.
• How can the inevitable tensions be managed?
The main tensions will come from those who are uncomfortable about losing their powerbase. In this case, politicians, professionals and those who represent patients based on subjective experience rather than empirical evidence.
The key will be empowering all these groups with the tools and insights they need to develop a meaningful understanding of collective service experience and patient/user preferences and priorities so they can continue to act as advocates – albeit from a more informed stand point. This is a change management and communication exercise.
These changes will also need to be part of a wider cultural and organisational change management programme that sees patient (customer focus) become the driving force at the centre of NHS culture and all NHS activity.
Staff engagement will be absolutely key to successful delivery, as will a rich picture and understanding how patients experience NHS care in the context of their lives.

[Brian Fisher]

Thanks to everyone for contributing to this discussion. We are debating, among other things, about how best to carry out the practicalities of PPI. Georgina is offering lessons from marketing and David has said that our current approaches are too managerially and technically based.

My own interest is in community development - outreach to people to help them both define their own agendas and then to assist in getting the changes made. The evidence is good that, by bringing people together with a view to gaining more control over their area and environment, all sorts of benefits flow: better health protection, better PPI and reduced health inequalities.

What do people think about that?

Brian Fisher

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