Last update 19th. November 2004
It is not surprising that this Review has been carried out so soon after the formation of the Commission, given the whole way the primary legislation, and the abolition of CHCs was set up in the first place, although I believe that most aspects of the Government's reforms to Patient and Public Involvement which were needed to replace the work of CHCs - the creation of the PALs and ICAS services, the strengthening of the HealthCare Commission and probably the scrutiny role of Local Government (although they have permissive duties rather than obligatory ones) - are working well.
However, in the light of my experience on the Birmingham and Solihull Mental Health Trust to which I was appointed in the last quarter of 2003 I think the role of the Forums and the Commission does need re-examining. I have been most dissatisfied and unhappy about many aspects of both the Commission and the Forum Support Organisation (FSO), and this has led me to think more deeply about the whole concept and purpose of the Forums and the Commission.
In theory the Forum is responsible for its accounts, but we do not have a separate identifiable budget since this is concealed in the contract between the Commission and the FSO (which we were told is confidential between those 2 bodies), so we can neither be accountable for any money spent on our behalf, nor plan a budget. This led to the nonsense that accounts for the Forum had to be prepared and signed off by the Chair of the Forum at the end of the last financial year, on what was a blank sheet of paper and the unnecessary bureaucracy required to submit an annual report at the end of that year when the Forum had only been meeting since February. I agree that as public bodies Forums must publicly account for their activity - but they should have real information and control over their budgets. A derisory £500 "pin money" has now been allocated to each Forum plus the possibility of more by application - a classic way of diverting limited energy to proving the case for more money.
The Forum has much more limited rights compared with the CHC. The most significant of these is that we do not have rights of consultation about changes in service plans (that right has gone to OSC) and our rights to information are governed by the 20 working day rule. I believe these restrictions have affected this Forum's ability to represent the interests of users with respect to the Tall Trees service. It is of course right that the Forum should be concerned about how the Trust has consulted with its own users about this issue, but it appears to me the Trust have been reluctant to share information with our Forum about their plans and we have certainly not seen a coherent document which sets these out, together with options. Could it be that the Trust has realised they neither have to consult us and they can in effect shelter behind the 20-day rule? Although members of Management staff have spoken at meetings about proposed plans, in all the paperwork I have accumulated on the issue there is not one from the Trust. I know the Forum has to move beyond this situation with the Trust and build up a more positive relationship, but my point here is a more fundamental one about the Forum being hampered by a lack of statutory rights.
Forums can only build a positive relationship with Trusts if they are truly independent of them - the limited rights do not help establish that. The fact too that we are "named" after the Trust whose activities we are monitoring also seems a token of our attachment to the Trust rather than a statement of our independence from them. I know this means in theory the coverage of Forums can former a denser network in this way that the geographically based CHCs could do, but this has led to practical problems (see below).
Independence should also be reflected in the appointments system. I am unhappy about the Commission's tenuous grip on the concept of independence and conflicts of interest. I would not accept membership of the South Birmingham PCT Forum because I am involved in the Trust's own User Involvement programme and didn't want there to be a conflict of interest - the Commission however saw no problem. In relation to the Mental Health Trust Forum the Commission appointed a member of the Trust's own User Voice Panel - not in itself problematic, but the person in question was actively involved with the management of User Voice with Trust managers, and our Forum was unanimously agreed that we could not be sure there would not be a conflict of interest in these circumstances. In the end the appointee stood down. The Commission would not concede that we had a legitimate concern, merely quoting that they had interpreted the Regulations correctly.
At the same time the Commission and the Forum Support Organisation began to establish relations with the Trust before the Forum had its first meeting, and then were subsequently not open to the Forum about these. This has led to great difficulties for the Forum in establishing good working relations with the Trust. Yet on the other hand the Commission appears to be limiting our independent role. There are several members who are current patients of the Trust. The Commission now seem to be suggesting that these Forum members cannot liase with other users in their role as Forum members, but only as another user - this deprives the Forum of a valuable link with users in discussing with them legitimate Forum business and concerns.
One of the main roles of the Forum is to monitor how the Trust involves users. The Trust quite rightly has its own strategy and programme for involving users, while a key driver for Clinical Governance is the involvement of users (patients/ carers and the public). I wholeheartedly welcome this "sea change" in the NHS to a "patient-centred" service. But it has already led in some Trusts/ Forums to a duplication of activity, and it does seem to me it would be far better to let the Trusts get on and do it, building up relationships not least with their local geographic and client communities (for example in Birmingham by working with b: cen and BVSC). I think this work of the Trust could be financed by them but should be managed at arm's length from them so that users have confidence in it, and monitored by the Healthcare Commission (CHAI). The budgets of the Forum and the Commission for Patient and Public involvement in health could then be used to support much more substantial programmes of user involvement rather than unnecessary duplication.
The Forums too are supposed to have a role in building links with their local communities (geographic and client) and here they face several problems. One is that the specialist Trusts provide services for patients over a very wide area- the Birmingham Children's hospital for example - so that building up links with communities over this wide catchment area is extremely difficult to do. I suppose the theory is that PCT Forums will liase with specialist Trusts to develop this broader geographic spread, but they need resources of people to do this effectively. And now voluntary members have to be spread over a larger number of Forums (compared with CHCs). The latest Commission commitment is to increase the size of all Forums to 15 (whereas CHCs had at least 20 -24). Because of the need to reflect the catchments area especially for the specialist Trusts these Forum members often have considerable travelling distances to attend Forum meetings.
Another significant problem for the Forum in building community links is the way in which the 100% appointment system (completely controlled by the Commission who do not have any contact with the local community about appointments) operates. On the one hand, in the interests of reflecting cultural diversity in the local population this may lead to people being appointed who have no first hand experience of the services offered by the Trust they are monitoring. This appears to be the case with the BCH forum which has only 6 members, soon to be seven, only three of which have any knowledge of the service they are involved with and only one has any personal experience. Thankfully this is not the case on the Mental Health Forum which has several patients/ users as members.
On the other hand it means that the Forum has no natural links with its local community (since all members are appointed on an individual "members of the pubic" basis). But there are a multiplicity of local community organisations and community development initiatives which the NHS does need to tap into if it is to genuinely involve the public. Again this seems to me to be a good reason why the Trusts should do this themselves rather than introduce another artificial agency to build another set of networks.
Some aspects of these issues may just reflect the ineptitude of current staff at the Commission, but some are inherent in deficiencies in the legislation (the appointments system for example). The Commission claims it is providing a strong and independent voice at national level (since in effect it is replacing ACHCEW) but I haven't see any evidence of this - it seems to me much more the case the Commission is a quango of Government and not as independent as ACHCEW was, since that grew from the CHCs (and not vice versa as is the case with the Commission which has created the Forums).
There is also the problem that the Commission and the Forums are isolated from all the other elements of modernising the NHS to make it patient centred, particularly the Health Care Commission.
It may be that this problem of isolation would not be so acute if the Forums were adequately funded, but my impression is that the jam (in terms of resources) has been spread far too thin and that far too much is being expected of the voluntary members. This brings me on to the issue of the Forum Support Organisation. Its deficiencies are as follows: -
Each Forum does not have a local accessible point of contact for members of the public or patients as CHCs did. Our Forum Support Organisation is not based in Birmingham and services several other Forums. The Commission has set up an electronic information system (Knowledge Management system - KMS) but this is not accessible to everyone and is not a substitute for an accessibly located office.
The Forums do not have a dedicated officer for each Forum who is responsible for carrying forward the work of the forum in between meetings or who can offer advice to Forum members about the way they should proceed. In the view of a BCH Forum member their first Support Officer seemed to lack expertise about what should be done, in fact she seemed to be following her own agenda. She has now left but their present support seems out of her depth. Of course there is a fine line between offering advice and guidance, and manipulation. Here I can only comment that the NHS has lost a great deal of experience and expertise in the pool of former CHC chief officers. Because of the limited support from FSOs, a great deal of work is falling on the voluntary members. In the case of our forum the user members have willingly accepted this burden, seeing the Forum as a way to improve the voice of the user in the Health Service, but it has put a great strain on them as they are having to take forward action (contacting members of the Trust, seeking out information etc) entirely under their own steam. This task is very difficult in the case of some forums where the lack of support from the FSO has left them at a disadvantage.
The support needed for these tasks has been completely underestimated. It also means that Forum resources are very thin when it comes to maintaining effective links with the other bodies to which CHC functions have been "devolved' - for example maintaining contact with the OSC of the Local Authority - this kind of day to day liaison which is so important in building up good relations would have been largely the responsibility of the CHC chief officer.
I therefore hope there will be full consultation about the Review of Arms length Bodies and that some of these fundamental issues will be addressed.
Janet Upward July 2004
61 Valentine Rd
Birmingham B14 7AJ
+44 (0)121 689 2597