Feature

Do we still need CHCs?

As plans to devolve health care commissioning to Primary Care Groups gather pace, is there still a role for Community Health Councils? Toby Harris explains why we still need the watchdogs of the NHS

Is time running out for Community Health Councils? Is there still a need for separate statutory bodies to represent the public’s interest in the NHS? And if there is, have CHCs shown themselves up to the job?

The NHS Confederation, representing NHS trusts and health authorities, clearly thinks these are good questions. In a recent consultation document, it pronounces: ‘If CHCs are unable and unwilling to improve their performance then urgent consideration will need to be given to more effective ways of utilising the current resources spent on CHCs.’¹

CHCs were created in 1974 to represent the public’s interest in the NHS. This followed a series of scandals in long-stay NHS care and was preceded by other steps to provide protection for patients, including the creation of the Health Service Ombudsman and the Health Advisory Service. In addition, the creation of area health authorities (AHAs) that year did little to meet calls for more accountability in the NHS and local authorities were smarting over the transfer of community health services to the NHS. CHCs — with half their members appointed by local authorities – went some way to redressing the balance. The other members were elected by voluntary organisations or appointed by the NHS. CHCs were given rights to visit NHS hospitals and to be consulted about substantial changes under consideration by the AHAs.

CHCs’ statutory position has been remarkably stable given the transformation of the NHS since 1974. The abolition of CHCs was floated shortly after the 1979 election, but the threat was fought off; they survived the abolition of AHAs in 1982 and the emergence of powerful general managers. The 1991 reforms were seen as a threat. As purchasers of care, health authorities (HAs) were presented as the ‘champions of the people’, so where did this leave CHCs? If NHS hospitals were to grow and contract in response to the demands of the internal market, how did ‘consultation’ about these substantial changes fit in? But still CHCs survived with their formal powers intact.

More recently, the glow around general managers has faded a little and GPs are seen as the new hope for the NHS. Under the Tories, GP fundholding was increasingly seen as an aspect of the ‘primary care-led NHS’. Labour’s White Paper proposes that commissioning health care should be delegated to Primary Care Groups. It gives CHCs a passing pat on the back but says nothing about how they will relate to PCGs.

More generally, New Labour’s proposals involve passing power to GPs as if they can unambiguously be seen as advocates and proxies for patients and communities. The NHS White Paper for England states: ‘Quality standards, service protocols and agreements should be set by direct discussion between clinicians to ensure primary and secondary services are properly integrated and programmes of care developed to reflect patient needs.’ There are passages referring to public involvement in general terms but at times it reads as if a generation of campaigning for patient empowerment has come to nothing.

While CHCs’ powers seem increasingly inadequate, a number of alternative approaches to public involvement have been gaining favour. The NHS Confederation insists: ‘A key part of any strategy to secure high quality health services is to obtain the views of patients and carers.’ The Confederation lists ‘a considerable number of initiatives’ including ‘focus groups and similar techniques’, ‘patient satisfaction surveys’ and ‘appointment of patient representatives and patient consultative groups’.

NHS trusts and HAs should be praised for these initiatives but they should not be seen out of context. Before Frank Dobson changed the rules, many trust boards met behind closed doors, merely fulfilling the Tories’ statutory requirement to hold an annual general meeting in public. In 1996 the Association of CHCs reported that: ‘Just over half the trusts never invite the CHC to attend board meetings, never give the CHC speaking rights and never send the CHC the agenda and background papers.’ Meanwhile, HAs have sometimes approached their duty to consult about substantial changes with less than wholehearted enthusiasm. The recent report of the London Strategic Review concluded: ‘The statutory requirement to consult seems often to be carried out in a perfunctory manner.’

Trusts and HAs should be judged by their record on public involvement, not just by their fine words. However, organising their own focus groups and questionnaires gives these bodies the power to decide which questions are most relevant to their agendas. Citizens’ juries are called to adjudicate on difficult questions after full briefing on the criteria deemed relevant and the options deemed realistic. Then, unlike CHCs, citizens’ juries are thanked and dismissed. A cynic might suggest these initiatives are in part designed to undermine effective opposition to potentially unpopular changes. They certainly cannot guarantee accountability, which must involve permanent structures and mandatory procedures.

CHCs are bound to face some criticism from NHS bodies since it is CHCs’ role to keep their activities under review. Some managers and professionals will find that uncomfortable. By contrast, the London Strategic Review were ‘greatly struck by the high degree of expertise and understanding that many...groups, particularly Community Health Councils (CHCs), exhibited with respect to both local issues and the wider debate’.

Another report, this time from the Association of CHCs, gives over 200 examples of improvements in services to patients due to the hard and varied work of CHCs.² These include:

• Southport & Formby CHC ‘were very concerned that the travellers using an official, council run site in the district were unable to access primary care...Our report to the health authority has resulted in health visitor hours being allocated to the site on a regular basis...The GPs have also agreed to visit the site on a regular basis’.
• Dewsbury District CHC: ‘Two widows contacted the CHC to complain that their husbands had died unnecessarily due to two different hospitals failing to prevent the development of diabetes following steroid treatment for brain tumours...As a result, Dewsbury District Hospital has instituted routine urine testing for all patients on steroids, so any increase in blood sugar levels will be picked up immediately.’
• Salford CHC: ‘A range of suggestions from Salford CHC was previously included as local Patient’s Charter standards in the contracts of Salford and Trafford health authority... the CHC was asked to develop a common annex for all contracts held by the health authority and local GP fundholding practices with providers. This has now been produced...and has been accepted by all the local NHS trusts.’

CHCs play three main roles: advising individuals; identifying the health care needs and aspirations of their community; and holding NHS bodies to account. CHC staff provide information to members of the public and support around 20,000 complainants every year as they struggle for explanations from NHS professionals and managers. CHCs have produced more than 2,000 publications, including 730 reports during 1992-96, typically based on surveys of patients or local residents or assessments of local services.

They also network with voluntary organisations, as well as drawing on their own complaints work, to identify important concerns. In addition, CHCs hold the local health service to account by visiting hospitals and (with agreement) primary care settings, and by responding to consultation documents and demanding information from local NHS bodies. Some mechanism for local accountability is surely desirable for a vital and high-profile public service providing local services independent of local authority control.

It would be possible to divorce the three functions of advising individuals, identifying needs and holding the NHS to account. CHCs are not the only bodies doing these things. But the efficiency of CHCs derives largely from the ways in which understanding gained from one activity helps inform other work. CHCs formulate problems which emerge, often fragmentedly, from a whole range of activities around the health services.

But of course there is room for improvement — CHCs should be better, some of them a lot better. There are issues around powers, resources, quality assurance and accountability.

• CHCs need new powers to play a full role in the NHS envisaged in the White Paper, especially in relation to Primary Care Groups and GPs generally. The guidance on consultation procedures is long overdue for revision. Also, CHCs have developed their complaints work without being under an explicit statutory duty to assist complainants.
• At present, the 207 CHCs jointly get less than 0.1 per cent of the NHS budget. Typically each CHC has the equivalent of two or three full-time members of staff.
• National standards for CHCs must be precisely defined and a performance appraisal system finalised and established. Collectively, CHCs must establish mechanisms for driving up the quality of the worst CHCs or these mechanisms will be imposed by the Department of Health.
• CHCs must be accountable to the populations they serve and show themselves to be in day-to-day touch with local people as well as with the collective views of voluntary organisations and local authorities.

In opposition, New Labour talked of transforming CHCs into ‘Local Health Advocates, with a new and extended role...their enhanced functions will encompass the monitoring of every aspect of health: hospitals, GP surgeries, community health services and community care services including those organised by local authorities’.

There is no sign of this yet. The NHS White Paper concerns shifting power to GPs, not to patients or communities. New Labour has inherited a strong emphasis on the rights and responsibilities of individuals and a relative lack of interest in supporting collective rights. It is widely seen as intolerant of dissent and strongly committed to public relations and news management. Socially, the New Labour élite is close to the NHS management class.

CHCs have a proud record and an important role to play in future, but they need the courage to consider changes if they are to survive the latest set of NHS reforms.