At the July meeting of our Trades Union Council we noted and discussed the announcement made by Wes Streeting, on 28th June, that Healthwatch England and Local Healthwatch bodies were to be abolished.
This move appears to link with the publication of the “Dash” “Review of patient safety across the health and care landscape”, which recommended that the government should “bring together the work of Local Healthwatch, and the engagement functions of integrated care boards (ICBs) and providers, to ensure patient and wider community input into the planning and design of services”, and that “the statutory functions of Local Healthwatch relating to social care (a very small proportion of the work of Local Healthwatch) should be transferred to local authorities”.
We feel, however, that the Review made a structural error in treating Local Healthwatch more as part of the internal structures of the NHS, rather than as channel for the community representation of public responses.
In one sense, this is not surprising, given that the establishment of Healthwatch, and its position as part of the Care Quality Commission, was one of several steps away from representation of local public views . Community Health Councils (CHC) were established in 1974 and abolished in 2003 to be replaced by Public and Patient Involvement Forums run by the Commission for Patient and Public Involvement in Health. They were replaced in their turn in April 2008 by Local Involvement Networks and then by Local Healthwatch.
A 2020 study in “Health Expectations”, “Enabling ‘citizen voice’ in the English health and social care system: A national survey of the organizational structures, relationships and impacts of local Healthwatch in England”, commented: “Originally conceived as a ‘consumer champion in health and care’, local Healthwatch are now ostensibly a major partner through which local government monitor the quality—and support the design—of health and social care”.
But the “Dash Review” made no call for public evidence on the question of how to place greater emphasis on local representation, and merely saw Healthwatch as an example of structural duplication.
In the past we had our local disagreements with the Community Health Council – especially over PFI and the “throughput” expectations tied into the RBH scheme. But it was more clearly separate from the NHS, and more clearly able to articulate a public response to developments. It had to be consulted on major changes in health care and could appeal directly to the Secretary of State.
Our Local Healthwatch does good work with initiatives such its surveys and “enter and view” reports, but it does not appear to have the same potential for impact in respect of local decision making – at a point where this itself has moved further away itself from public accountability.
The 2015 “People’s Inquiry into London’s NHS” recommended that we could “breathe life into the organisations that are supposed to represent local patients and communities (by) giving Healthwatch bodies the statutory powers that were previously held by Community Health Councils”, suggesting that “Local Healthwatch bodies (should be) separated from the Care Quality Commission (CQC) and modelled on the old CHCs. They should link up with local community organisations, pensioners groups and other community organisations, and be given the statutory powers to inspect hospital and community services, to object to changes which lack public acceptance and to force a decision on contested changes from the Secretary of State”.
Transferring the responsibilities of Local Healthwatch bodies to NHS Integrated Care Boards (ICBs) and local authorities screams “marking your own homework”. As the “Patients Association” comments: “The Dash review’s recommendation to bring together the work of Local Healthwatch, and the engagement functions of integrated Care Boards (ICBs) and providers and move the strategic functions of Healthwatch England into the Department of Health and Social Care will leave many patients without arm’s length advocacy. When patients need to give feedback about their local NHS services, many won’t trust advocates who report to the same NHS structures. As these reforms move forward, the Department will need to work closely with patients to build trust in the new system and ensure it genuinely serves their needs”.
Local Healthwatch bodies represents an accessible and trusted local network that should not simply be put to one side. We would prefer to see the government build on it by giving it a structure that once again envisages the direct involvement of local civic society organisations, and strengthens its right to engage with health policy and decision making, alongside a clear and uniform channel of funding independent from any other NHS or local government body.
We have written to our local MPs to put across this point of view. It was interesting to note that even members of our “local” ICB voiced some concern about Wes Streeting’s decision at their meeting on 24th July – though this event was itself evidence of the need for the public to be better able to exercise more influence over NHS decision making. Across several items there were fugal variations on the themes of public “engagement”, “co-production”, and the like – except when it came to the point of them being asked to commit to something specific!
Under the provision for raising questions with the Board we had written to them as follows:
“The first principle stated in “Working in partnership with people and communities: Statutory guidance” is that NHS organisations should “ensure people and communities have an active role in decision-making and governance”.
“In meeting this, the ICB should “make sure that boards and communities are assured that appropriate involvement with relevant groups has taken place (including those facing the worst health inequalities); and that this has an impact on decisions”.
“There is, in addition, a whole section in the Guidance on “B3. Service reconfiguration and public consultation”. The Guidance here does not mandate public consultation in every circumstance, but it gives an unmistakeable steer in that direction: “Service change proposals can be subject to judicial review or be referred by the local Health Overview Scrutiny Committee (HOSC) to the Secretary of State for Health and Social Care, particularly if they have not been sufficiently involved. In undertaking service change, systems must comply with their legislative duties to engage the public, consult their HOSC where required and have regard to the need to reduce health inequalities, and to have due regard to the Equality Act and the Public Sector Equality Duty. In carrying out these duties, consistent and meaningful involvement from people and communities is fundamental”.
“”The document “Planning, assuring and delivering service change for patients” still appears as “live” guidance on the NHS England website. This says:
“”The range of duties for commissioners and providers covers engagement with the public through to a full public consultation. Public involvement is also often referred to as public engagement.
“”Where substantial development or variation changes are proposed to NHS services, there is a separate requirement to consult the local authority under the Local Authority (Public Health, Health & Wellbeing Boards and Health Scrutiny) Regulations 2013 (“the 2013 Regulations”) made under s.244 NHS Act 2006. This is in addition to the duties on commissioners and providers for involvement and consultation set out above and it is a local authority which can trigger a referral to the Secretary of State and the Independent Reconfiguration Panel………..
“”Both commissioners and providers need to ensure that they have satisfied their statutory duties to involve and consult. In general, where there is commissioner led consultation with the local authority on a substantial service change, full public consultation will also be required”.
“In light of this, how can the ICB justify its failure to hold a public consultation on the decision that all patients from East Lancashire who need vascular inpatient services will, at some time in the future, be expected to go to Royal Preston Hospital? Will the ICB now commit to holding such a consultation, alongside appropriate discussions with the relevant Local Authorities and “Healthwatch” bodies?”
A comment was made that “nothing has been decided yet”. But there was still a complete unwillingness to commit to any public consultation if they do decide that they do want to go ahead.
In the case of the closure of Myerscough College Witton campus it has been brought home to us how, in another field of public service, there has been the gradual erosion of public accountability.
The August 2014 document “College Governance: A Guide” (which we think is still “live”) does, however, say:
“26. Although there is no statutory duty for college governing bodies to consult communities or address their needs, funding bodies are required to satisfy themselves that a college’s public funding meets the needs of local learners and employers and Ofsted inspectors make judgements on how well a college’s provision meets local learning and skills needs. In practice a college’s mission will almost invariably contain a reference to meeting the needs of its communities”
And
“28. Any college that receives funding from the Skills Funding Agency’s Community Learning budget must plan and deliver learning in line with national community learning objectives. The objectives require providers to consult with their local communities and work in partnership with local authorities, Local Enterprise Partnerships and other community stakeholders”.
We have written to Blackburn’s MP, Adnan Hussain, asking him if he can take up these points with the Department for Education – but we have yet to receive any further feedback and Myerscough has now formally announced the closure of the campus.
Our July meeting also finalised our plans for a local Young Workers Survey. We shall be running this from Monday 8th September to Friday 3rd October, and we will report on the feedback and have a discussion around it at a meeting in Blackburn Library’s Hornby Lecture Theatre on the evening of Thursday 23rd October. Save the date! We are pleased to say that we shall be joined at this meeting by Frazer McGuire, Chair of the TUC Young Members Committee.