Feature

What role now for CHCs?

Where do community health councils go from here? Fedelma Winkler, organiser for the Greater London Association of CHCs, talks to healthmatters

Accountability is a favourite word of the government, but what does it mean? For consumer watchdog Fedelma Winkler, organiser for the Great London Association of Community Health Councils, it means making sure that the NHS provides a good quality service. It means concentrating on what services we get and how we get them — rather than emphasising various schemes for electing health authority members, important though these are.

’Accountability in the NHS is a hit or miss thing’, says Ms Winkler. The financial side of service provision lacks a system for checking priorities are right and that money is spent appropriately, though some health authority members and some community health councils (CHCs) ‘try very hard to remedy this’. The professional side of care and cure is even less open to inspection and change from outside.

Limited though they are, the abilities of health authorities to hold NHS employees accountable for their actions do not even apply to professionals in the way that they do to financial managers — a problem that is found right across public services, according to Fedelma Winkler.

Accountability requires willingness — something which is in short supply inside the NHS — and CHCs are the ‘only check we have on power’, says Ms Winkler: the only source of expertise outside the health services, and the only free agents able to speak out. They have been very effective in preserving non- acute services, like those for mentally ill or handicapped people, or for the elderly, or family planning and child health facilities. But they have been under-resourced and have lacked the research facilities and technical support needed to do the job properly. On the positive side CHCs have involved an enormous number of people and have drawn on a lot of skills from within their communities.

The problem is that, at the end of the day, it is up to each CHC to decide how much it opens out to its community, and some therefore tend to function as closed organisations. ‘That is why accountability requires a change of philosophy, not structure,’ says Ms Winkler, ‘because the existing structure can be used in an open or in a closed way.’ CHCs could introduce a great deal more accountability into the NHS, if they had the will and the back-up.

’If we are going to get it right on the question of quality, CHCs will need access to more expertise — to inspectorates and their reports, for example — or the right to commission research into service quality.’ she says. ‘Without that expertise CHCs will continue to avoid looking closely at quality, except when public demand forces them to. For example, many CHCs respond to public requests for information about local GPs with no more than the list that is available from the family practitioner committee. They could, and should, do better, if only because the quality of services is so variable that people can not be sure that they will get good care when they need it.’

Originally, CHCs were set up as an experiment — an experiment that has gone on too long for it to evolve into a truly workable system without the introduction of ideas of ‘good practice’ and a set of core tasks. That is not an argument for abolition, as favoured by some people. CHCs are the only means by which community skills can be drawn into directing the NHS, and they have done a lot to promote and protect non-acute care and defend the vulnerable. The nurses, for example, get a lot of support from CHCs, says Ms Winkler, ‘and, in the main, CHC members have not diverted their energies into scanner appeals and the like’. No other pressure group works for such a range of powerless people in the way CHCs do.

So what will happen to accountability? Nobody is sure anymore, she says. But there are three options for CHCs. They can be left unchanged, by abolished, or be revamped.

Abolition is unlikely because CHCs are politically useful for the health service. A recent article in the Economist said that Britain closes hospitals faster than any other Western European country. CHCs are partly responsible for that, because they are central to the tree month consultation period prior to any closure. That three months allows the issue to cool down and keeps the Health Secretary out of the political argument until the last moment, when he can act as final arbiter. Managers who criticise CHC resistance to closure plans are trying to make their own lives easier, but they are not thinking politically.

’Leaving CHCs unchanged is not on’, says Ms Winkler, ‘so their being revamped is the only realistic option;. This may result in their absorption into the health authority machine, as a kind of customer service bureau that does lots of patient-satisfaction surveys. This option, however, has risks for management too. One health authority has told its quality assurance manager, a woman committed to good care, that her standards were too high, says Ms Winkler. The health authority could not afford them. But even if such problems were ironed out, the NHS cannot do without an external catalyst for change. ‘All organisations have problems changing, and we cannot ignore what we know about industrial sociology just because it does not fit into current ideology’, she says.

The better options for CHCs are for them to be strengthened into a counter-bureaucracy or to be made into offshoots of an independent national body with a consumer protection role. It looks unlikely that the government would fund either approach, but the logic of consumerism demands an independent source of information for NHS users, says Ms Winkler. Health authorities may be able to signpost people to the right services, but they cannot be trusted to provide reliable information about quality of care. ‘Would you believe a restaurant guide produced by restaurateurs?’ she asks.

’We can see possibilities for change in management accountability, but making professionals accountable is another matter. When professionals fail to fulfil our trust the complaints procedure does not work well, but there is no mechanism for preventing problems occurring in the first place.’

The medical profession is the most extreme example of the problem of making professionals accountable. Accountability is contained almost entirely within the profession, and the profession has enormous influence on resource allocation, and has great skill in manipulating the media.

Accountability might be made easier if doctors learned to be open, but there is little evidence that they are learning, she says. On the contrary there is a strong feeling within the profession against communicating with local communities, and government proposals to allow hospitals to ‘opt out’ are likely to make that worse, not better. These hospitals will opt out of NHS control, with its real if small community input, into managerial and professional control with commercial interests on the margins. This will appeal to the special health authorities, like Great Ormond Street, which have been particularly resistant to any CHC input.

’The government has got it wrong,’ says Ms Winkler. ‘The NHS does not need any more structural change, it has had too much. Instead we should pay attention to the biggest single issue, the variability in the quality of care.’