Review

Sleeping with the enemy?

Partners in Purchasing? The role of the CHC in commissioning health services
Nikki Joule
Greater London Association of Community Health Councils, 1993

Although this examination of the involvement of community health councils (CHCs) in the purchasing/commissioning process specifically focuses on the Thames regions, many dilemmas which Nikki Joule identifies are familiar in Yorkshire (where I am chair of a CHC) and, I suspect, throughout the country. How to maintain a healthy working relationship with someone whose motives and motivation may be at odds with one’s own? How to maintain independence and integrity while responding to a rhetoric of collaboration and partnership? When does an understanding of the constraints facing health authorities (HAs) become a collusion?

HAs have newly overlapping functions which can serve to confuse and weaken the traditional roles of CHCs as watchdogs of health services and champions of local people. Assessing the quality of services provided is now a task with which commissioners are explicitly charged — yet it is essential that an independent organisation still considers these issues on behalf of health service users. Making visits to clinics and hospitals has always been a valid part of CHC monitoring work, as well as an opportunity to meet and talk directly with users. Half of those questioned in this report said that they now made joint visits, with their local HAs. This certainly compromises the independent status of the CHC, and must, arguably, lead to a bias in understanding.

HAs currently face a difficult range of issues around ‘priority setting’ or ‘rationing’. In the past, an important CHC role has been to draw attention to areas of unmet need. Increasingly, we are being asked to take part in the decision making process — and be damned if we do and damned if we don’t. As HA commissioners put it in this report: ‘they can’t complain if they’ve declined to be involved’! And even while CHCs may feel clear that they are only facilitating public involvement, or participating in the discussion stages, local people are unlikely to share this perception.

The report reinforces the growing awareness in Yorkshire of the necessity to establish clear working structures. First, we need to address coherently the demarcation between formal and informal networks with commissioners; second, we need to build stronger and more authentic relationships, in new and diverse ways, with the local population. It is becoming increasingly urgent to resource CHCs appropriately so that they can take on new responsibilities effectively and maintain established functions without compromising integrity. Such resources should be made available directly through the NHS management executive, not channelled via DHAs.

The recommendations and pointers to good practice in the report will surprise few CHCs; they may, however, provoke some commissioners into reconsidering the expectations they hold of their relationship with their local watchdog.