Feature

Independent and informed – for now

Government plans to abolish community health councils offer no coherent alternative, argues Murray Benham

Nearly two years after The NHS Plan announced the abolition of community health councils (CHCs), the future of patient representation in the NHS remains in turmoil. Following a defeat in the House of Lords last March, the government withdrew all the patient representation clauses from its Health and Social Care Bill, leaving CHCs in limbo.

Many hoped that the government would take the opportunity to think again about the abolition of CHCs, a measure that had provoked widespread opposition. But such optimism was to prove ill founded. In November last year the government put before parliament a bill – The NHS Reform and Health Care Professions Bill – that again proposes the abolition of CHCs.

The bill contains some improvements compared with the proposals of the Health and Social Care Bill. The government’s recognition of the need for a national statutory patients’ organisation is particularly welcome.

But there remains a range of serious concerns about the bodies proposed to replace CHCs – not least of which is that there are so many of them. At present, CHCs act as convenient, mostly high-street based, one-stop-shops for the local community. They are able to answer general inquiries from the public; provide independent help and support through the complaints process; and act as a powerful voice for the public in the health service.

Many believe that, under the new system, patients simply will not know where to turn. Where a patient journey spans a number of different trusts, the patient could be faced with the prospect of approaching a confusing array of new bodies for advice and support: Patient Advice and Liaison Services, Patients’ Forums, and the Independent Complaints Advocacy Services (ICAS).

Particularly worrying has been the suggestion that the PALs will take over much of the complaints work conducted by CHCs. This would mean replacing an effective independent source of support with a body based in trusts, employed by trusts and accountable to senior management in trusts.

There is already concern that some patients resort to litigation too quickly. If patients cannot easily find an independent source of advice and support that they trust, this situation is likely to worsen.

But fragmenting the work of CHCs does not only raise problems of accessibility. The fragmentation of the monitoring function will mean it is no longer possible for one body to monitor the whole of a patient’s experience. Each patients’ forum will only monitor the work of its own trust. Such division is unlikely to make sense to patients, who often have problems that span acute care, primary care, community care and even residential care.

There is no single body at local level responsible for drawing together the monitoring work of individual patients’ fora. This will mean there is a real danger, on the one hand, that individual problems will fall through the gaps and, on the other, that problems that are not the fault of individual trusts but the result of problems in the structure of local health services will not be subject to public overview.

In addition, the separation of CHC functions will make it difficult for monitoring, complaints and scrutiny to inform one another. Much of the monitoring and scrutiny carried out by CHCs in the past has, for example, resulted directly from complaints work.

As a consequence of the broad role played by CHCs, their members are exceptionally well informed about their local health care system. In the new structure this is unlikely to be the case. But to be effective, patient representation must be informed.

As the bill stands, the activities of the national commission and patients’ fora will be much more restricted than are those of current CHCs and their national association. For example, they would be acting outside their authority if they undertook activities now undertaken by CHCs such as campaigning work or engaging in legal proceedings, and even querying the impact of a PFI scheme could be outside their remit.

Opposition to the government’s proposals remains widespread and vocal, even from its own benches. Immediately before the report stage of the NHS Reform and Health Care Professions Bill, on 15 January, David Hinchliffe, chair of the commons health committee commented: ‘As they stand, the government’s proposals are simply too fragmented and confusing. Patients need to be clear about who to turn to if they have a problem with the local health service, and they need to be confident they will be able to access independent advice and support when they need it.

‘We also need to ensure that the public retains a powerful voice in the health service at local health economy level. Without an independent, community-led body providing an overview of local service provision there is a real danger that the public’s voice will be weakened.’

An amendment put forward by Mr Hinchliffe to introduce patients’ councils at local level, to address concerns about the loss of a community-led watchdog, drew support from inside and outside parliament. The proposal was supported by a wide range of patient organisations, professional bodies and pensioners’ organisations, among them Age Concern, the Patients Association, the NHS Support Federation and the National Pensioners’ Convention.

In parliament, the amendment gained the support of 26 Labour MPs, including four former ministers. This, accompanied by a large number of abstentions, reduced the government’s majority to only 74.

The bill is currently before the Lords, where it is clear that the proposals will receive a rough ride. CHCs and their supporters are still hopeful the government will pay attention to the force and variety of opposition, and think again. A system of patient representation introduced in the face of such opposition cannot enhance public confidence in new Labour’s management of the NHS.