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By Graham Clews ...
By Graham Clews

New arrangements for patient and public involvement will rely on a three-way relationship between local authorities, new 'local involvement networks' (LINks) and the NHS.

The Department of Health today published proposals for LINks to replace patient forums. There will be one for each local authority with social service responsibilities.

The LINks will be tasked to gather, analyse and sift information from local patients before making recommendations to commissioners, providers, and local authority overview and scrutiny committees.

A Stronger Local Voice, the DoH report on the proposals, promises a model contract for LINks, and says funds will be given to local authorities to 'consult with local organisations such as voluntary and community groups or social enterprises to identify the most appropriate arrangements' for hosting them.

Extra responsibilities will be introduced for local NHS bodies and OSCs to ensure they co-operate with LINks. One of LINks' few explicit powers will be the right to refer matters to OSCs and get an 'appropriate response'. OSCs currently have the right to be consulted on major service changes.

DoH director for patients and the public Harry Cayton, who chaired the consultation on improving the patient voice, described this as a 'right of audience', but accepted that new bodies will have fewer official 'powers' than patient forums.

'They were statutory bodies and part of the problem has been that they were unable to adapt to a changing NHS,' he said.

Mr Cayton said the emphasis of the new-look patient involvement model was on transparency and flexibility. If the new system was effective, that in itself would attract patients to LINks, he said.

'We would not deny that we are trusting that local groups will learn to do this well,' he added.

The proposals suggest LINks develop close working relationships with OSCs, and envisage some LINks members acting as advisers on OSC reviews.

The commissioning framework, expected to be published today (see page 7) was expected to set out more explicit rules on how the NHS should carry out consultations and involve local people in decision-making, and to use their concerns as a trigger to introduce new entrants to the market.

The DoH report says commissioners will have to publish regular reports of how their plans have altered following public consultation, and explaining why they have not adopted suggestions from representative organisations.


Exclusive by Mary-Louise Harding

Primary care trusts should consider options as radical as giving NHS facilities to the private sector in order to encourage new providers into the market, a recent draft of the government's commissioning framework has said.

The document, seen by HSJ, sets out a range of 'levers' PCTs could use to stimulate new providers to enter the market in circumstances where 'a model of commissioning based on free entry, tariff payment and patient choice may not secure the service change we seek'.

The suggested levers designed to 'reduce the risk for providers and make [providing NHS services] more attractive to new entrants' include:

'Reduce the capital investment required from the provider' by offering 'existing PCT facilities to potential providers' or, where none are available, offer 'to provide the capital investment to provide the facilities' on behalf of the provider.

'Facilitate access to capital funds': PCTs could underwrite both NHS Bank and commercial loans by giving activity assurances.

'Pay a supplement to tariff' to 'cover the set-up or development costs faced by the provider in some scenarios'.

'Provide guarantees within the contract' - provider risk could be reduced by 'providing minimum income guarantees.'

It was unclear whether such controversial measures would make the final draft, given the recent outcry from unions after the DoH placed a contract notice calling for bids to run 'PCT management services' in the Official Journal of the European Union, including the running of clinical services.

The DoH later said the advertisement was an error, and a redrafted version is expected to be published.


DOH press release follows.

Patients will have more power and say over how their local health services are organised and run as part of wider NHS reforms including an updated commissioning framework, the Department of Health says.

Local people will have more involvement in shaping services via input into a 'PCT prospectus' and they will be able to trigger a review of services if they feel they do not meet local needs, according to the new commissioning framework. An annex provides more details, including a host of incentives which could be introduced to encourage new entrants into the market.

Press release from the Department of Health follows.

New commissioning framework designed to deliver better health outcomes and secure best value for money

Health secretary Patricia Hewitt today unveiled plans to give patients more power and more say over how their local health services are organised and run. Under the plans Primary Care Trusts (PCTs) will for the first time be required to formally respond to public petitions if more than one per cent of the local community are unhappy with a particular health service.

As part of the reforms to put patient preferences at the heart of the decision making process, Patricia Hewitt also announced new arrangements for organised patient involvement. These changes will build upon the existing 'patient forums' by establishing new Local Involvement Networks (LINks) designed to have more clout to influence services both in hospitals and in community settings.

The plans are central to new guidance to the NHS about how services should be commissioned (or purchased) by PCTs. 'Commissioning' is the process by which the local NHS analyses what health services patients need intheir area and then secures these services through contracts with healthcare providers.

The new guidance - Health Reform in England: Update and Commissioning Framework sets out how PCTs will work with local clinicians to:

* improve the health and well-being being and reduce health inequalities;

* secure access to a comprehensive range of services;

* improve the quality, effectiveness and efficiency of services;

* increase choice for patients and ensure greater responsiveness to people's needs; and

* achieve best value for the resources allocated to them.

In delivering each of these objectives, PCTs will be required to involve patients in how services are organised. In addition, PCTs will be expected to publish prospectuses that set out an assessment of the local needs and the quality of current services, patient satisfaction levels and plans for future investment.

Patricia Hewitt said:

'I am determined to give patients and the public a bigger say in their local health services. People increasingly want to become active partners in their own health care and we need to create a system where people are no longer passive recipients of NHS and social care services but are able to shape them to suit their needs.'

The Government is also issuing a tender advertisement to procure specialist support services to help PCTs improve their commissioning functions. This tender process will lead to a national 'framework'

contract which PCTs will be able to use to get specialist help to support their commissioning - removing the need for expensive and time-consuming local tenders. For example, PCTs may choose to seek help in actuarial skills for population assessment, data analysis or opinion surveys. The procurement simply means that if any PCTs decide to seek this kind of support they will have a menu of companies with expertise in these specialist areas to choose from.


1. 'Commissioning' is the means by which the NHS secures the best value for patients and taxpayers.

Commissioning itself is not new, but stronger Primary Care Trusts

(PCTs) and the acceleration of Practice Based Commissioning (PBC), together with the incentives introduced by the health reform, and a stronger and more systematic approach to patient and public involvement, provides the opportunity for more effective commissioning that will benefit patients, communities and taxpayers alike.

The Commissioning Framework is principally aimed at the commissioning of hospital services. A Framework covering joint commissioning for services for patients with long term conditions, including mental health, and health and well-being will be produced in December.

Effective commissioning makes the best use of allocated resources to achieve the following goals:

* improvements in health and well-being;

* reductions in health inequalities and social exclusion;

* better access to a comprehensive range of services

* Improved quality, effectiveness and efficiency of services;

* increased choice for patients and a better experience of care; and

* improved integration of health and social care.

At the heart of commissioning are the millions of individual decisions of patients and clinicians that lead to the provision of care and the commitment of resources. Behind these clinical decisions lies a range of separate but related processes that collectively make up commissioning. These processes can be thought of as a 'commissioning cycle' as illustrated in the Commissioning Framework (page 6).

PCTs and practices will need to ensure that all the functions within the commissioning cycle are delivered effectively. Key elements they will need to focus on are:

Information to support commissioning

* Better clinical engagement, for example through Practice Based Commissioning (PBC)

> PBC is at the heart of the proposals for more effective

commissioning, engaging Practices in commissioning decisions and service redesign will lead to more effective, responsive services for patients. The Commissioning Framework confirms the role of PBC and clarifies the approach to tendering for services proposed under PBC.

> encourages PCTs to set up local PBC incentive schemes in addition

to the existing national incentives.

* Improved community engagement and stronger voice

> Patients and the local community should be fully involved in the

commissioning process, from the assessment of need, through priorities for service development to feedback on the performance of services on the ground.

* Increased choice for patients

> Patients will have a greater say and choice of the services they

receive. PCTs and their practices will support choice through their commissioning, both to seek the improvements in response to patient views and to develop new services.

* Incentives and contracts for commissioners

> The introduction of Payment by Results and PBC provides new

incentives for commissioners and providers. In this new environment contracts will become more important in managing the services to be delivered and ensuring proper accountability and financial balance.

The Commissioning Framework:

- sets out how commissioners will be able to use open tendering where provision is either unavailable or not to the required standard. Any willing provider will be able to compete in this process. This approach will drive innovation performance and value for money.

- seeks comments on the approach to a national model contract that clearly apportions responsibilities and risks, incentivises performance and supports patient choice and Payment by Results

We are seeking the views of the NHS and other stakeholders on a number of the proposals made in the Framework. In particular we are consulting on:

- The approach to contracting for NHS care

- The approach to community petitions and precisely what the triggers should be, (e.g what the number of signatures on a petition should be to trigger a review by the PCT). This was a commitment made in the Our Health, Our Care, Our Say white paper.

- A Governance and accountability framework for Practice Based Commissioning

2. One of the key outcomes of last year's Your Health, Your Care, Your Say consultation was that people wanted more say over how the NHS is run and what services and care they receive. We made a commitment in the Our Health, Our Care, Our Say white paper to give the public a stronger local voice and now want to see the public and patients playing a bigger part in local decision making and to see more 'citizens' juries' having their say. Further details on the public-initiated petitions can be found in the Commissioning Framework. For further details about the objectives of the new PCT prospectuses, see chapter 9 of the Commissioning Framework.

3. Currently there is a patient forum for every NHS trust (including foundation trusts) and PCTs. They have a range of functions including monitoring and reviewing the health service. We plan to build on the role of patient forums and in their place will create Local Involvement Networks (LINks) which will cover an area rather than be tied to a specific organisation. Section 11 of the Health and Social Care Act 2001 places a duty on NHS trusts and PCTs to make arrangements to involve and consult patients and the public in the planning and development of health services and in how the services operate. The requirements of Section 11 will be made more explicit and a new duty to respond will be placed on commissioners.

4. Both publications are available online;

A stronger local voice: a framework for creating a stronger local voice in the development of health and social care services:

Health Reform in England: Update and Commissioning Framework:

5. Following the publication of the Our Health, Our Care, Our Say White Paper, the Department established an expert panel to conclude the Patient and Public Involvement review. The expert panel chaired by Harry Cayton, National Director for Patients and the Public, and Ed Mayo, Chief Executive of the National Consumer Council, made final recommendations to Ministers in May 2006:

Jane Campbell: Chair of Social Care Institute for Excellence (until 1 April 2006)

Anna Coote: Head of Patient and Public Involvement, Healthcare Commission

Jo Lenaghan: Head of Communications and Patient and Public Involvement, Birmingham and the Black Country SHA

Frances Hasler: Head of User and Public Involvement, Commission for Social Care Inspection

Sue Slipman: Foundation Trust Network Director, NHS Confederation

Jane Martin: Executive Director, Centre for Public Scrutiny

David Pink: Chief Executive, Long Term Medical Conditions Alliance

Maria Reader: Senior Project Officer, Local Government Association

Campbell Robb: Director of Public Policy, National Council for Voluntary Organisations

Richard Wilson: Director, Involve

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