Abstract
The patient involvement in focus here is tightly interwoven with the introduction of NHS Foundation Trust Hospitals in 2004. This chapter will analyse key arguments such as higher local accountability and patient orientation, which would be achieved through a greater latitude of the local management as well as other contributing factors for the enactment of patient involvement. A high individual dedication to the topic by the two main drivers also played in, as in the Netherlands. In contrast to the Netherlands, however, the bill was highly debated and criticised not only by the opposition parties but also by many leading Labour MPs, the government party at the time, the vote by the House of Lords to amend the bill ignored.
Regarding their implementation, Foundation Trust Hospitals performed fairly well. However, they experienced difficulties owing to unclear definitions, repeatedly changed requirements, and what seems too formal and too superficial quality criteria set by the supervisory authority.
1 a person who governs; esp., 1) a person appointed to govern a dependency, province, town, fort, etc.; 2) the elected head of any state of the U.S.; 3) any of the group of persons who direct an organization or institution: the board of governors of a hospital; 4) Chiefly Brit. the person in charge of an organization or institution, as a prison; 2 a mechanical device for automatically controlling the speed of an engine or motor as by regulating the intake of fuel, steam, etc.; 3 Brit., Informal a person having authority; esp., one’s father or employer: as a term of address, somewhat old-fashioned
1 [uncountable] i. (in/with something) the act of taking part in something; US involvement in European wars [synonym: participation]; 2 [uncountable, countable] i. (in/with something) the act of giving a lot of time and attention to something you care about; her growing involvement with contemporary music; 3 [countable, uncountable] i. (with somebody) a romantic or sexual relationship with somebody that you are not married to;He spoke openly about his involvement with the singer.
1 a person who governs; esp., 1) a person appointed to govern a dependency, province, town, fort, etc.; 2) the elected head of any state of the U.S.; 3) any of the group of persons who direct an organization or institution: the board of governors of a hospital; 4) 
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Notes
- 1.
www.yourdictionary.com/governor; accessed on 12 February 2017.
- 2.
http://www.oxfordadvancedlearnersdictionary.com/dictionary/involvement; accessed on 12 February 2017.
- 3.
Despite an intensive follow-up, most of the 19 MPs contacted repeatedly in writing and additionally on the phone refused to participate in the study with a few not responding at all. Reasons given for not being willing to take part in the study were manifold. The most common were lack of time, the author not being a member of their constituency, and lack of interest in health care policy—even expressed by high-ranking former chairmen of important health care committees.
- 4.
This attitude appears to have been partly taken over into the NHS as Julian Tudor Hart noted (cited in: Hogg (1999, p. 38)): ‘Doctors traditionally recognized two kinds of patient. Paying patients, like other customers, were always right and therefore had to be humoured. Non-paying, public service patients, were supposed to earn their right to care by having serious or at least interesting diseases, and to be grateful for getting any care at all; beggars can’t be choosers’.
Great Britain based its welfare policy much longer on the ‘poor law’, even though the distinction between ‘deserving’ and ‘undeserving poor’ was watered down. While the idea to establish a national health system, consequently, was in line with the tradition of public provision of poor relief and, thus, came up very early, social insurances attracted in particular liberal forces. Consequently, the National Insurance Act of 1911 included a compulsory health insurance for employees. As family members were not covered, the friendly societies as well as the municipal hospitals providing health care services for the poor continued to play an important role in the fragmented health care system (Boyle 2011, p. 25; Ogu 1981, pp. 315–316, 337–339, 351–353).
- 5.
Originating in the old Norse word umboð for ‘mandate’ or ‘authorisation’, the term ombudsman used to name someone who is authorised to speak on behalf of someone in court in early 18th century’s Sweden (Fallberg & MacKenny 2003, pp. 344-345). It developed into a term for an office which is to advocate citizens in any kind of complaint procedure against state bureaucracy in the modern welfare state at an as inofficial and local level as possible.
- 6.
Interestingly, the Department of Health (2005) not only views the means of involvement in the sense of this book as PPI but subsumes even services and bodies to level criticism and issue complaints as a form of involvement. In 2005 the Department of Health summarised the existing ways of involvement as follows:
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‘Patient Advice and Liaison Service (PALS) —NHS provision of accessible support, advice and information to patients and carers
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Overview and Scrutiny Committees (OSCs)—local authority councillors have the powers to review and scrutinise the planning, provision and operation of the health service and to make recommendations for improvement
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section 11 of the ‘Health and Social Care 2001a’, which places a duty on the NHS to consult and involve patients and the public in the planning and development of health services and in making decisions affecting the way those services operate
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patient forums [also called: Patient and Public Involvement Forum (PPIF)] – independent bodies made up of volunteers and set up to monitor the quality of the NHS from the patient perspective; PPIFs do not exist at FTs [Foundation Trust Hospitals]
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complaints investigations by the NHS, with the Health Care Commission managing the independent review stage of the complaints procedure
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Independent Complaints Advocacy Service (ICAS) —the provision of independent support to patients wishing to complain about the NHS
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NHS Foundation Trust Boards.” (Department of Health 2005, pp. 11–12)
In this context, Milewa, Harrison, Ahmad & Tovey 2002 point at the very broad meaning in which the term ‘public involvement’ is used in the first place. While ‘healthcare manager might thus think of “involvement” in terms of consulting citizens about plans that have already been prepared’ advocacy organisations might rather think of being included in the very planning process itself (Milewa et al. 2002, pp. 49–50). By this vagueness the term suits many purposes and becomes pretty meaningless.
-
- 7.
The upcoming of PPI needs to be seen in the context of an emerging civil rights movement in the 1960s. A first ‘Patient Participation Group’ was founded in Berinsfield, South Oxford in 1972 as a voluntary instrument to involve patients in a more extensive way than before (Tritter, Koivusalo, Ollila & Dorfman 2010, p. 98), which later on served as a model for the so-called Community Health Councils (CHCs) established in 1974 on a national basis (Baggott 2004, pp. 306 et seq.; Baur, Heimer & Wieseler 2003, p. 72; Boyle 2011, p. 62; Dabbs 2000; European Observatory on Health Care Systems 1999, p. 22; Hogg 2008, pp. 21 et seq.; Klein 1979, p. 75; Klein & Lewis 1976; Milewa et al. 2002, p. 40; Mullen, Murray-Sykes & Kearns 1984; Staender 2007, p. 37; The Stationery Office 1973; Tritter et al. 2010, p. 99). The main reason on the isle was that experiencing the aftermath of the Second World War Britain, which ended the rationing of essential food first in 1954, was struck by a severe economic crisis for long, and had struggled for sufficient living and housing standards for decades. Amongst other things, this led to high infant and maternal mortality rates until well into the 1970s, which can be perceived as a much stronger driver than the situation in mental care in the other three countries (Barnes, Harrison, Mort, Shardlow & Wistow 1999, pp. 12–15, 42, 45; Hogg 1999, interview 25; cf. also Beresford and Holden 2000, interview 20), which often was the starting point for patient involvement.
- 8.
The advantage of PCTs over PCGs was that usually they formed larger entities, they incorporated primary and social/ community care and held a larger budget, commissioning a major part of services. Given the broader approach certain financial freedoms were linked to this type of commissioning. PCTs were abolished with the ‘Health and Social Care Act 2012’ in 2012 (Department of Health 2012). Their tasks were allocated to the newly established ‘Clinical Commissioning Groups’ (CCG), ‘Commissioning Support Units’ (CSU), and the municipalities.
- 9.
This included a closer monitoring of patients’ assessment of the services providers, publishing an annual report on it (Department of Health 2000, p. 93), including patients as one third of the members of the ‘Modernisation Board’, patients representation on the ‘Independent Reconfiguration Panel’ as well as the ‘Commission for Health Improvement’ (Department of Health 2000, pp. 94–95; Department of Health 2001b, p. 19), and a stronger coordination of PPI activities by the ‘Commission for Patient and Public Involvement in Health’ (CPPIH) (Hogg 2008, pp. 125, 131 et seq.).
- 10.
Sometimes even called ‘Foundation Schools’ or ‘School Trusts’ . In 2010 a new discussion on ‘Foundation Schools’, modelled after Foundation Trust Hospitals emerged, but did not lead to enactment.
- 11.
Looking at the usage of the different names it seems that in later time there has been a shift away from the first mentioned to the latter two (cf. also Ipsos MORI 2008, p. 15).
One reason for this might be the following experience: ‘If you use the word “board”, they think of themselves like a board of directors, which is what they’re not. So you’ve got to be very careful to make sure that there is a distinction between the role of Governors and the role of the board of directors in running the organisation’. Chair, Foundation Trust (Ipsos MORI 2008, p. 15)
- 12.
When asked what MPs would lose if support for Foundation Trust hospitals were denied, Alan Milburn, the then Secretary of State for Health (Labour; October 1999 – June 2003) replied: ‘They would lose the whole Bill’. (House of Commons 2003a).
- 13.
‘Even if agreement cannot be reached on those two points [regarding FTs; the author], I confirm that the Opposition will be happy to let the rest of the Bill, apart from part 1 [on FTs; the author], go straight into law’. Tim Yeo, member of the House of Commons for South Suffolk (Conservatives), 19 November 2003 (House of Commons 2003a).
- 14.
Voting is on each section of a bill.
- 15.
This assumption is supported by the interviews: ‘That is one of your questions: that was one of the great people pushing it. And the Secretary of State at the time was Alan Milburn. And I think it is quite important that our first Secretary of State after 1997 was Frank Dobson, who is very much of the old style, and I am sure he resisted these kind of things, which explains why Alan Milburn, who was one of Tony Blair’s sort of people, he was brought in the sort of: Do it! And a lot of it has got to do with Tony Blair, feeling that he was getting a lot of hassle when he was going around Europe and people were telling him that European nations were much better in providing health care. And he was going around, saying, “We have got the best health service in the world!” Which in some ways it is, but it is not. You cannot make statements like that. And he was getting a lot of hassle there, so there is evidence that he wanted to improve the NHS. And he did by putting lots of more money into it, not necessarily by improving productivity’. (interview 19).
- 16.
Spain began to transform all public hospitals into public foundations in 1999 (García-Armesto, Abadía-Taira, Durán, Hernández-Quevedo & Bernal-Delgado 2010, p. 48). ‘Spain has presented an interesting experience of innovative hospital management (foundations) since 1997, when relevant legislation was adopted. Public hospitals with foundation status are self-governing units with less external bureaucratic control and emphasis on outcomes’. (Durán et al. 2006, p. xviii).
- 17.
so-called Crown Health Enterprises (Ashton, Mays & Devlin 2005)
- 18.
- 19.
And indeed, there is much to it. In the context of ‘Local Voices’, an initiative for more accountability in the early 1990s, the NHS Management stated that ‘to give people an effective voice in the shaping of health services locally will call for a radically different approach from that employed in the past. In particular, there needs to be a move away from one-off consultations towards ongoing involvement of local people in purchasing activities (NHS Management Executive 1992)’ (cited in Hogg 1999, p. 94).
In that context, however, Paton (2000, p. 13) concludes that ‘[…] the language of consumerism was used to justify an increasing stress upon market. […] Local Voices was more about communication of the inevitable to the public than about participatory purchasing’ (cited in Tritter, Koivusalo, Ollila & Dorfman 2010, p. 102). Concluding from this, we can draw two interesting parallels. One is that this is for the xth time a serious and durable approach on raising accountability by involving locals is announced (cf. amongst others: CHCs, Local Voices, NHS Trusts, Foundation Trusts). The second is that every time well-worded statements including well-sounding buzz-words are employed they remain content-free to some degree, since otherwise no further campaigns only a few years later would be needed. It can, therefore, be assumed that they serve a strategic purpose to secure the support by the public and MPs.
- 20.
A potential additional reason for taking in citizens was brought up by one interviewee, which unfortunately I could not confirm by any other sources so that it should be treated with caution:
‘It has also to be said that it was a strong feeling […] that the unions had too much say in the running of hospitals. […] There was the feeling that this was a force which dragged down innovations and doing things differently and doing things in different ways. Like with most of these things there is probably a bit of truth on either side’. (interview 19)
Giving patients a say was in that sense also a vehicle to curtail the power of a certain actor in the field, in this case the trade unions. Supposing that this actually had been an issue at hand, the outcome, however, is ambiguous: On the one hand, staff do not really lose influence as staff most often forms part of the Governors’ Council. On the other hand, decentralising negotiations to the local level takes somewhat from the union power. It might also be weakened by the increase of managerial competences and by amalgamating staff and other Governors into one council.
- 21.
The question—like its answer—could have been posed in the Netherlands as well—but was not. This has to do with two fundamental factors inherent in the health care system: For one, the state and its subordinate authorities are the actual purchasers—and in many cases providers—of health care. While in this view, it is the task of the authority-like NHS as a whole, it is rather the individual user (or, depending on the view, GP) who asks for primary care services in the Netherlands. Second, the Dutch government view involvement in primary care as sufficient: Individual patient rights secure the possibility to meet GPs on more equal terms and enable patients to take further steps if they are not satisfied. Moreover, beneficiaries can often get involved in their health care insurance’s governance, which is perceived to be a strong ally of patients towards health care providers.
- 22.
Though unrelated, I do not want to withhold the following repoartee: ‘Mr. [Robert] Jackson: The Government are going in the right direction, but there is some poetic justice here, in that the Secretary of State is being attacked in the same terms as the Labour party used to attack us when we were trying to free up the system. On reflection, does he not think that we should take that into account when we conduct our debates on this matter in the House? He is facing exactly the same charges about privatisation and two-tierism as we did. Member of the House of Commons for Wantage (Conservative)
Mr. [Alan] Milburn: Support from the hon. Gentleman is about as welcome as myxomatosis in a rabbit hutch—although I hope that it does not have the same deadly consequences’. 7 May 2003 (House of Commons 2003b).
- 23.
The category is labelled ‘Monitor is requesting further information following multiple breaches of the A&E target and a continuity of services risk rating of 2, before deciding next steps’.
- 24.
‘So I think, again, we talk about strong accountability, but I do not actually think we have this. […] Are they actually looking at the right things? Because you have to ask yourself: Mid Staffordshire they were doing their quarterly reports in, their figures were fine, their governance was fine, and what is actually happening on the ground? […] How can ever a receptionist making clinical decisions on an accident emergency patient. […] Because you have got all these lists of indicators. But it is very easy for a trust to manipulate figures and to say: Right, we have got to reach green on these indicators and this is what we are going to hit it. It is again all about ticking boxes, making sure you are meeting targets but actually not looking what is on the neck’. (interview 17).
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Haarmann, A. (2018). England. In: The Evolution and Everyday Practice of Collective Patient Involvement in Europe. Springer, Cham. https://doi.org/10.1007/978-3-319-64595-7_6
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