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A NEW PUBLIC INVOLVEMENT STRUCTURE FOR NHSSCOTLAND
A REFOCUSED HEALTH COUNCIL STRUCTURE
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. Patient Focus and Public Involvement proposes replacing the existing 15 Scottish health councils with a new national body - the Scottish Health Council - which will also have a local presence. For the purposes of this paper we assume that this will, as at present, involve a local office in each NHS Board area. However, in considering its structure, the new organisation will wish to note that a number of those consulted in the pre-consultation, particularly in rural areas, thought that there should be more than one local office.
Functions
21. The pre-consultation noted a degree of resistance to what was perceived as a narrowing of the functions from those of existing health councils, and a dilution of their role as watchdog of the NHS in general. It is therefore important to state that
all existing core activities carried out by local health councils
8 will continue to be provided. They will not, however, necessarily be delivered in the same way, and some will be delivered not by the refocused Scottish Health Council itself but through other routes, supported by more incisive Health Council powers (see Annex 3).
22. The proposed refocused health council structure should, as
Patient Focus and Public Involvement proposed, have three main functions: the assessment function, the development function and the individual patient and
carer feedback function.
23. The three functions are distinct, but there are good arguments for combining them within one body. In a field where there is little established wisdom and where methods are still developing, the assessment function should be informed by the best expertise available. Conversely, the assessment function will provide a comprehensive overview of current activity in the health service within Scotland, which will feed into the development function. Finally, awareness of the experience of individual patients will help keep the other functions grounded in reality.
24. These functions are essentially similar over the whole of Scotland, so a national body - with a local presence - would be more appropriate and effective than many separate local bodies. Working on a national scale will boost professionalism and expertise, and create and maintain a clear sense of focus on the roles and responsibilities of the Scottish Health Council.
to play a central role in the annual accountability review process, by ensuring that NHS Boards are discharging their duties in relation to
monitoring the patient experience and to patient and public involvement.
25. There is a strong case for an independent body to assess, through the NHS accountability review process, whether the views of patients and the public are indeed sought and acted upon. The Scottish Health Council would be the body to carry out this assessment. It would receive, from NHS Boards and their constituent organisations, information and other materials, such as consultation proposals, annual and other reports as they may require. This information would be used to produce an informed and expert independent assessment of the NHS Board's involvement activities and their impact on the service itself. The Scottish Health Council would also oversee the way in which the NHS carried out public consultations to ensure that they were carried out properly. Where the Scottish Health Council considered that a consultation had not been carried out adequately, Ministers could require the NHS Board to carry out the consultation again.
26. To achieve credibility and balance in relation to strong health provider interests, the Scottish Health Council will need to be seen as independent
, and have strong professional resources. It will be expected to use other sources of advice and information, and must have regular direct contact with individual service users, community groups and voluntary organisations to inform this. Its annual assessment report will form part of the NHS accountability review process and also inform the review function of NHS Quality Improvement Scotland.
27. The pre-consultation exercise found that, for many, the assessment role meant 'monitoring' that the public involvement process had made an impact on services as well as ensuring that appropriate public involvement mechanisms were in place. For some, this implied that some monitoring of service delivery should be allowed for and that the health councils' powers to visit health premises should not be lost. There were concerns about the demarcation between the proposed new structure and the current work of NHS Quality Improvement Scotland. It is agreed that it is important not to duplicate the work of others and to have the Scottish Health Council's work firmly bedded in the reality of patient experience. Proposals on the relationship between the Scottish Health Council and NHS Quality Improvement Scotland are made later in the paper in paragraphs 62 and 63.
to provide a critical mass of expertise and experience, available to organisations representing the interests of service users and the public throughout Scotland, to help develop and spread good practice in public involvement in the NHS.
28. Experience suggests that patient and public involvement will not be effective unless patients, carers, members of the public, and organisations representing their interests, are supported to develop the knowledge, skills and confidence they require to engage constructively in the process. NHS Boards will be expected to be proactive in delivering this support and in involving communities and organisations in the planning and review of their services. The White Paper
Partnership for Care also proposes setting up Public Partnership Forums at Local Health Care Co-operative level.
29. The pre-consultation identified general support for NHS Boards having primary responsibility for public involvement, though comments were made about the importance of underlining that this duty to involve the public extends throughout the NHS, at Trust, Local Health Care Co-operative, practice and clinic level as well as Board level. The pre-consultation saw this as bringing with it a requirement to provide
ongoing support for patient and public interests. This would included support for those who wish to engage constructively with their NHS Board and other statutory provider bodies about present and future services.
30. We do not propose to prescribe the exact structure and mechanisms for this function as these will need to vary to reflect local circumstances, and in particular to avoid duplication with existing arrangements. It will be for each NHS Board to decide what is most appropriate, to negotiate this with a wide range of local organisations, and agree it with the Scottish Health Council.
31. Comments from NHS staff also confirmed a need to develop good practice in involvement
within NHS Boards and provider bodies throughout Scotland.
32. The Scottish Health Council will also work with service user organisations at a local level to identify what their development needs are and with the NHS Board to identify where the appropriate support can be found.
33. At a national level, the Scottish Health Council will provide support, expertise and experience to organisations representing the interests of service users, carers and the public throughout Scotland, to help them develop and spread good practice in involvement. They will also develop and disseminate, through its national structure, skills and good practice in quality assuring the patient focus and public involvement process. This will require its small central staff team to have a mix of relevant backgrounds. The central staff team would:
identify and disseminate good practice
provide training
encourage and support innovation, through consultancy work
undertake and disseminate research with NHSScotland, patients, communities and voluntary organisations.
34. The Scottish Health Council should also draw together evidence from across Scotland to be able to bring matters that are of concern on a broader regional or national scale to the attention of the NHS or to the Scottish Executive.
to ensure that individual patients and carers who have views about their health services that they wish to express have the opportunity and, where necessary, the support to do so.
35. The NHS must ensure that individual patients and carers who have views about their care have the opportunity and, where necessary, the support to be heard. This would also apply to patients and carers who wish to make a complaint and, for whatever reason, have not found a way of doing so that they have found satisfactory. It would not, however, be confined to supporting formal complaints (see paragraphs 39 - 44).
36. Many users have views about the services they have experienced that they would like to make known, but even where these are critical they do not want to invest them with the status of a "complaint", with all that this implies. If services are to be improved for patients it is vital that such views are captured, fed back constructively, and acted upon. (See also the consultation paper outlining proposals for a new NHS Complaints Procedure
9)
37. It is the responsibility of the NHS Boards, Trusts, Local Health Care Co-operatives and
Family Health Services to make sure that the views of people who use their services are actively sought and that it is as easy as possible for people to give them. As the
Building Strong Foundations Toolkit
10 illustrates there are many ways of providing feedback, from comments cards to patient liaison officers to surveys. Many of these forms of feedback can and should be set up and operated by the appropriate NHS provider body. However, this is not enough. There should in addition always be easy access to an
independent body or mechanism that can not only pass on the patients' or carers' views, but also support him or her through the process. In terms of feedback, the independent body will be the Scottish Health Council.
38. To fulfil its individual feedback role, the Scottish Health Council will require to proactively raise issues of public concern, for example issues where there is no representative patient or carer groups, for example accident and emergency services. It will require NHS Boards, Trusts and
primary care services to explore the views of patients and the public about any issues in question, and support individuals and community groups who wish to express their views.
Complaints
39. The pre-consultation exercise noted concern in relation to complaints and whether the Scottish Health Council role would extend to representing patients' views. These exposed a concern that an emphasis on working with, and building the capacity of local organisations might develop which would see the individual left out.
40. There were mixed views in the pre-consultation exercise on the extent to which the local offices of the Scottish Health Council should be involved in complaints and how far that involvement should go. It was thought it would be very easy for the organisation to become overwhelmed with complaints and become a reactive organisation instead of gathering views and taking a proactive role in improving services.
41. It is proposed that it should become a clear requirement on NHS Boards to ensure that suitable
independent advice and support facilities are set up, at arm's length, to enable patients, carers and the public to get support in preparing and pursuing a complaint. This may be done in a variety of ways, for example, by commissioning a voluntary body or
advocacy organisation. Ideally, this would be done in conjunction with the local authority or authorities in the NHS Board area. This would have the advantage that there would be one source of help for people with queries or views about issues crossing organisational boundaries, such as various community care issues.
42. To provide firm assurance that these arrangements are independent and effective, we propose that, before they are set up or commissioned, they should be subject to the approval of the Scottish Health Council, which should be represented on the commissioning group or committee. The Scottish Health Council would not be involved in actively managing advice and support services, but would have the right to monitor the effectiveness of the independent support and advice facilities to ensure consistent quality standards training and monitoring
11.
43. The way in which this system is set up is not a matter for this document and we do not propose to prescribe a uniform solution for Scotland. It will be for the NHS Board to decide what configuration is most appropriate, to negotiate this with a wide range of local organisations, and agree it with the Scottish Health Council. The final shape of the service will also have to take account of any changes to the complaints system that may flow from the consultation exercise on the complaints procedure currently taking place.
44. There was strong agreement in the pre-consultation exercise that the Scottish Health Council at national level should have a strategic role in relation to complaints, monitoring complaints handling and procedures. We accept this suggestion which we believe sits well with the assessment function of the Scottish Health Council.
Advocacy
45. Some patients and carers may need help of a more intensive kind or over an extended period of time. In these circumstances it may be appropriate to enlist more specialist advocacy support, in contrast to the more generic advice and support service described above. NHS Boards are already required to commission independent advocacy arrangements
12. It is not proposed that the Scottish Health Council should be involved directly in commissioning advocacy services, but its assessment role should extend to being given full information about what advocacy arrangements have been put into place and how they are operating.
46. The Scottish Health Council will, as part of its assessment function, be able to comment on the adequacy and effectiveness of the arrangements for advice and support and for advocacy, as part of the NHS annual accountability review. In carrying out this function for local advocacy services the Scottish Health Council will work closely with the Advocacy Safeguards Agency.
Support for Patient and Public Interests
47
. Patient Focus and Public Involvement suggested that this might be done through the establishment of a health service users forum (see Annex 1) in each NHS Board area. This forum, it also suggested
13, should
"
appoint the non-executive members of the local office of the Scottish Health Council".
48. Those consulted in the pre-consultation exercise remained to be convinced of proposed health service users forums. There were fears that the large number of organisations involved could make the forums too large to be manageable, and that it could be dominated by minority interests or by paid staff within the voluntary sector and not by service users. It had to work with and not duplicate or be superimposed on existing organisations or forums, for example community care forums, and other patient or health forums organised at Local Health Care Co-operative or community level. At the same time there was strong support for good connections with local concerns and issues, and for control to lie at local level. There was a clear interest in the possibility of creating such forums, if the practical difficulties listed above could be addressed. We accept this view on Health Service User Forums and make alternative proposal (see paragraphs 59 and 60) for local Advisory Councils to ensure public representation in the Scottish Health Council's local structure.
49. We also propose that NHS Boards promote and support a network of local patient and public interests that is led by individuals and groups from the community. The Public Partnership Forums, which are to be established at Local Health Care Co-operative level, following the White Paper,
Partnership for Care, will potentially be an important part of such a network.
50. The exact form of each local network would, however, be for the NHS Board to decide in negotiation with a wide range of local organisations and agreed with the Scottish Health Council. In doing so, it should have regard for any parallel arrangements that may be in existence to represent the views of patients, carers and the public to local authorities in its area. Many local authorities are already working to create local service user forums and panels, and using a range of methods to involve their service users. It is important that local areas seek to build on or join forces with these rather than duplicate them, wherever possible.
51. The members of any governance structure established for the network should consist of individuals who are not paid officials of constituent organisations.
52. The network should not be treated as a representative body. It should not be the only body asked for its views on services. Its role should be as a means of communicating with and keeping relevant individuals and organisations informed of developments in the local health care system and of facilitating their involvement as well as providing feedback. The NHS Board should therefore provide the network and its members with access to all necessary information and to an appropriate level of support.
A Scottish Health Council: local accountability
53. Taking account of the commitment to change set out in
Our National Health and the conclusions and recommendations of the pre-consultation exercise, a governance and accountability structure has to be developed for the proposed new national body and the Scotland-wide structure which will replace the existing 15 local health councils.
54. It is important that the Scottish Health Council, as a national body with a local presence, should be seen to be delivering the national agenda with a degree of local autonomy on the issues they should be addressing and how. This will mean engaging with local communities and being guided by the concerns and views of local people.
55. It is therefore proposed that, while it should be for the local offices of the Scottish Health Council to negotiate with a wide range of local organisations on how most effectively to engage communities in its work, each local office should:
have an advisory council (see paragraphs 59 and 60) drawn from local people, patient and carer groups, community organisations, and other groups (such as Community Care Forums, Social Inclusion Partnerships, patient councils or forums);
work with local people and organisations to develop an annual work plan for approval by the Scottish Health Council;
demonstrate in all their work that they have involved and co-operated with a wide range of local health interests; and
work with existing networks and forums.
56. The White Paper,
Partnership for Care, also proposes that there should be Public Partnership Forums at Local Health Care Co-operative level to encourage stronger relations between primary care teams and their local communities. This will offer the opportunity for greater patient and public involvement in the preparation of local health service plans, and will be particularly relevant in developing the links between health care and social services. The Scottish Health Council will work with Local Health Care Co-operatives to support and encourage the development of these Forums. Public Partnership Forums may also offer a source of recruitment for membership of Scottish Health Council's local Advisory Councils.
57. Whatever solution is adopted locally, any organisation with a demonstrable health interest, which is open to and controlled by individual members of the public, should be entitled to be involved in this range of local and community activities. However, there would be a potential conflict of interest if any individual or organisation whose main or substantial activities are the
provision of health or community care services were included and these organisations should not be involved.
58. Boards should make arrangements so that members of the public can be kept informed of, and take part in all appropriate local public involvement activity.
Local Advisory Councils
59. It is proposed that Scottish Health Council should appoint local Advisory Councils to provide a local presence in each NHS Board area. Membership would be advertised widely to attract interested members of the public. The Advisory Council's role would be to keep the Scottish Health Council structure aware of local issues and concerns and to advise it of local views on the extent and quality of the involvement activities of their local NHS Board, Trusts, LHCCs and Family Health Services. The Scottish Health Council would be free to use other sources of advice and information, and would indeed be expected to do so.
60. The local Council's role would be to ensure that the voices of local patients, carers, patient organisations and communities are heard rather than representing the voices of patients and the public. There are many and varied patient and public interests, and wherever possible it should be patients, carers, patient organisations and communities who should speak directly to the NHS without the necessity of an intermediary, or representative.
A Scottish Health Council: national accountability
61. In considering options for this, the goal is to ensure that the new organisation is, and can be seen to be, independent of local NHS Boards and the Scottish Executive. It should also be an integral part of the development of the
clinical governance and quality agenda, ensuring that it responds to patients and public needs. This includes ensuring that NHS organisations take a proactive and positive approach to engaging directly with the people they serve and demonstrating that they have listened to, understood and acted upon their views.
62. The pre-consultation noted issues about a need for clarity between the proposed new structure and the work of NHS Quality Improvement Scotland. The Clinical Standards Board, now a constituent part of NHS Quality Improvement Scotland, recognised the central importance of patient focus and public involvement in the delivery of continuing service improvement with the development of generic clinical governance standards.
63. The work of NHS Quality Improvement Scotland will be entirely independent of Government and NHSScotland and it will have a new power to 'intervene itself, for example, in response to public concern'
14. It is important that the views and needs of patients and the public are placed at the heart of this agenda. The Scottish Health Council will therefore be established as part of NHS Quality Improvement Scotland. It would be a body with its own distinct identity, but operating within NHS Quality Improvement Scotland and contributing directly to the operation of NHS Quality Improvement Scotland's new powers. The details of this relationship require to be agreed, but the Scottish Health Council's chairperson would be a member of the board of NHS Quality Improvement Scotland.
Legislation
64. As the
Patient Focus and Public Involvement framework states, subject to the outcome of this consultation process, further consideration will be given to any issues concerning
legislation.
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