Feature

Patient advocacy ‘jewel’ is stolen away

Community health councils are to be replaced by trust-based ‘PALS’ – but Angeline Burke argues that patients need an independent system if their interests are to be protected

After 26 years of supporting complainants and representing patients’ interests, community health councils (CHCs), the only statutory patient-led NHS watchdogs, are to be abolished.

The proposal to abolish CHCs was mentioned fleetingly in the recently published NHS Plan. The full implications of this proposal are only now coming to light.

There is much to be commended in The NHS Plan, a long-term plan of modernisation and reform for the NHS. In particular, its commitment to developing a ‘patient-centred’ NHS is to be welcomed, along with enhancing patient empowerment.

The plan was shaped after consultation with NHS staff, patients and the public. Yet the decision to abolish CHCs was taken without asking the public specifically whether its independent watchdogs should be abolished and, if so, what should replace them.

The official reasons for the proposed abolition are unknown, so there is plenty of scope for speculation. Have the 204 CHCs in England and Wales been too effective?

A broad spectrum of opinion, including MPs from all parties, members of the public, professional bodies and patients’ organisations, have expressed grave concerns about the new structures, questioning whether they will strengthen patients’ involvement in the NHS or, in fact, diminish it. In particular concerns have been raised about the fragmentation of CHC functions, the independence of the new bodies and the absence of statutory rights.

Divide and rule

The NHS Plan fragments some of the work of CHCs across a range of bodies but fails to demonstrate how other important areas of their work will be covered. For example, the abolition of CHCs is sure to end the nationwide casualty watch, an annual snapshot of waiting times in A&E departments.

Critics of the new plans fear that separating scrutiny and monitoring from complaints work on a local level will mean that broader trends or even individual cases of clinical incompetence will go unrecognised.

On a national level, CHCs currently provide a network of independent watchdogs with the ability to raise issues of wider concern to the Department of Health.

The NHS-wide Patient Advocacy and Liaison Service (PALS) being proposed consists of disparate bodies. They lack the capacity to develop an overview which means that no particular body will be responsible for identifying and acting upon patients’ concerns nationally.

CHCs’ independence has been key to their effectiveness. They are able to speak frankly in the interests of patients. If the PALS proposed in The NHS Plan are employed by, and based in, trusts it will be extremely difficult for them to act independently in patients’ interests.

More importantly, patients will not perceive them to be independent. According to the NHS plan, PALS are to ‘steer’ patients or their relatives towards the complaints process ‘where necessary’.

CHCs, by contrast, are able to offer complainants proactive support and advice. A poll conducted by Health Which? (April 2000) found that 84 per cent of those who had contacted a CHC at some point found their advice ‘very’ or ‘fairly’ useful, suggesting a high satisfaction rate. There is a serious question mark over whether trust-based PALS will be able to gain similar levels of public confidence.

Legal clout

CHCs have a number of statutory rights that enable them to carry out their duty of representing the public’s interests in the NHS. These include: the right to require information from health authorities; the right to inspect and report on hospital and other facilities in which NHS patients receive treatment or care; and the right to refer contested plans to the health secretary.

These rights, backed up by the threat of legal action on occasions, have been powerful tools in gaining a fair deal for patients and local communities. The NHS Plan makes no mention of statutory rights for any of the new bodies, yet without them they will be little more than ‘focus groups’, whose suggestions and recommendations can easily be ignored.

Interestingly although CHCs in England and Wales were set up under the same legislation, in Wales there are no plans to abolish CHCs. The Welsh Assembly has opted to consult widely on the issue of patient advocacy and support, including the future remit of CHCs. There is a growing body of opinion in England that advocates such an approach. Change is needed but the current proposals are in danger of throwing away a ‘jewel’ and replacing it with a bauble – a system structurally incapable of genuinely holding the new NHS to account.