Examination of Witnesses (Questions 60-80)
MR TOMMY MORGAN, MS PAT CADWALLADER, MR ROBERT HALL, MS JANE JEFFS, MS CAROLYN THEOBALD AND MR CLIVE BARNBY
MONDAY 17 JUNE 2002
60. If you were wanting to extend the work you do, surely it would entail a considerable amount of training for your members. Have you got the capacity to do that or would members have the appetite and opportunity to do it?
(Ms Cadwallader) We do have training already. That is one of the aimsthat the training is consistent and that it would be done the same for the whole of Wales.
61. I am saying if you want to extend the work say into prisons?
(Ms Jeffs) It would require training. We are going to have a large enough job at the moment if we move into primary care. We do quite a lot of that already. It depends on the relationship you build up with the practices in your area and the nursing homes in your area. Generally it is the better ones that are perfectly happy to welcome you in. At the moment we can only go in if we are invited in. We are doing quite a lot about training. One of the reasons we wanted this central body was we wanted the support that we are going to lose when ACTU goes because the training support is provided generally by ACTU and we only have a small sum (£20,000) make to sure we get training in Wales. We have already identified the fact that we need to be much more specific about training in Wales because over the last two years we have started to diverge concerning the rules and regulations in Wales and in England so we have had to do that. We have asked the Assembly if we can have a training officer. It is one of the issues that has been discussed and they have been listening quite favourable to this. It is just a question of how many resources we can have. To start with we need to look at training for going into primary care and private care. Prisons is a particularly interesting one because we do have real concerns there, but I do not think we have got the capacity at the moment to go that much further. We will take things on as and when we can, but that is why we go back to the point that if we were able to have more input into what members we got, we would then be better able to to make sure they are properly representative of the community which is really what we need. It is not so much we want people with qualifications, we want to make absolutely sure those people are really keen to be part of it and that they are going to give it their time and they are not just there because the Red Cross has said, "You going to be the one who has got to do it", or the local authority has said, "We need five members and you five are going." We want to make sure these people are keen to do it. One really committed CHC member is worth three of the ones that are just detailed to do it.
62. Moving on to the provision of informationthe 1996 community health council Regulations place a duty on the health authorities etcetera to provide information to the CHCs; the new schedule 7A in the Bill does not. Do you need it repeated in the Bill?
(Ms Jeffs) Yes, it is one of the most important things. I do not know whether it is just an oversight, but in the old Bill the furnishing of the information to councils by health authorities followed the consultation and it is not in there, and I think it is particularly important that we ask that we have health authorities, primary care trusts and care trusts, in other words the English organisations in there, because Carolyn and all the officers working along the eastern borders of Wales and all of us who have tertiary and specialist services delivered in England still need those rights to come to us. We are concerned that if we do not put them in here we will not be included when they say they will furnish information on primary care to the Patients' Forums or whatever organisations replace CHCs in England. We think this is a major oversight and we would really like your support.
(Mr Hall) I would like to support those points. If you look at anything in the NHS, whether it is Wales, England, Scotland or Northern Ireland, they talk about effective information on health inequalities and everything else. The Health Centre for Wales is going to be a centre for information so if we cannot access information we cannot make valued judgments, so that is a most important thing that has been omitted from this particular Bill.
63. Just to bring in a later question, do you think that should be extended to English authorities as well as Welsh authorities?
(Mr Hall) Yes.
(Ms Cadwallader) Yes.
(Mr Hall) Definitely because we have cross-border provision.
Mr Caton: I would like to come back to the issue that we have touched on now of enhanced visit rights. I do so with some hesitation because in a previous existence I was a local authority appointed member on a community health council. I have to admit that although I was an assiduous attender of the evening meetings of the community health council, many of the visits had to be (for the reasons said) in the day, and I was working at that time and did not have a nice job like this
Chairman: You had a proper job!
64.And I was not able to attend those visits. The Explanatory Notes for the Bill refer to these enhanced rights of CHCs to visit premises. You have mentioned that the shift into primary care is clearly an important element. Can you tell us what the difference will be and what you will be able to do and where you will be able to go where you cannot go now?
(Ms Cadwallader) In private nursing homes at the moment we go in by invitation. In my particular patch it is fine but we have to announce our visits. There is only one home which says come in any timethey have got nothing to hide obviously. If we had the right to go into private homes and into primary care GPs' surgeries or dental practices, all the primary things, which at the moment we cannot do without invitation, we can see what is happening there.
65. How do you interpret this enhanced right of CHCs to visit? Do you have a picture of what you are going to be able to do when this Bill is on the statute books?
(Ms Jeffs) Up until now it has been secondary care where we have had the right to do that. In primary care we are increasingly having more out-patient clinics in primary care. They are talking about GP specialist services. There are a number of not just clinics but there are issues around finding out how services are delivered. At the moment if you were trying to negotiate with a GPs' practice to do a patient questionnaire or something like that, you do it by negotiation. It would be helpful if we had enhanced statutory rights to do this. Then it would not be so difficult always to be negotiating these rights. Also we tend to get the rights to go to places which are good. We do not get the rights to go into the ones that we have concerns about. If we had a statutory right we could still handle it fairly sensitively but they could not say no and, therefore, we would be in a stronger position. We have things like orthopaedic clinics which happen in GPs' surgeries where there are never any preparations made for people to sit so you cannot sit down if you have had a new hip. Those are the kind of places where we want to be able to do that and GPs are commissioning beds from private nursing homes as well. Wherever a patient is going where they receive NHS care, whether in-patient or out-patient, it would help us if we had the statutory right to be able to go in there to see if it was okay or to do some work in ascertaining what the patients' experiences were.
66. Presumably you have talked to officials behind the scenes. Do you expect to have those rights?
(Ms Jeffs) That is what we are hoping for.
67. Are there any areas, if we can leave aside private care homes for a minute, because I know Dr Francis wants to talk about that, or are there any other premises you feel you should be able to get into where it looks like even the new Bill is not going to let you get into?
(Ms Jeffs) We have had quite a difficulty finding out exactly what all these things refer to and that is because we are a very small Association. There are literally only three members. ACTU is the one that gives us our legal services. We have a service level agreement and we have been trying to get the services of the legal officer up there to give us a bit more information about it. She has been very busy. You can imagine how much work they have been doing there. We were hoping we would have a bit more time. We have got until 5 July for talking to the Assembly about the Regulations. We have not had that much time to prepare for today, sending you our written submission as we did. We are going to have a meeting of all the CHCs in Mid Wales on Wednesday where we will start to go into more depth, but we have not really had as much time as we would have liked to have done to be clear about exactly what rights this Bill gives us, but we are going to be looking at those.
(Mr Hall) It needs clarification, for example, where we make unannounced visits. Some trusts accept that; other trusts do not accept it. If it is in statute then we can refer back to the legislation and say this entitles us to carry on the unannounced visit. It is important, as has already been highlighted. If they know you are coming they can tidy everything up ready. They should not be concerned about what time we come. If they are providing the right services it should not be a problem but it is, unfortunately, on many occasions.
(Ms Theobald) Reading through the regulatory impact assessment that comes along with the Bill it specifically seems to be talking about primary care and private nursing homes, but there is another area that is increasingly important and that is the links between social care provision. That was particularly the case with the closure of long stay hospitals for people with mental illness or learning disabilities where a lot of people have moved into community living schemes which are partnership ventures with health but the homes are very often managed and run by social services. Some of us in the past have negotiated that we can follow the patients from the NHS hospital into that new setting and that has been done fairly successfully, but we know that there are other areas of Wales where that request has not been allowed. So that might be one area that perhaps needs to be made more explicit perhaps in the Regulations that come along with it rather than into the Act itself because that is very important. As more and more there is joint working with health and social care, the management of that facility is going to vary. The management will move out of the health setting into the social care setting even though there is still a strong health input into it.
68. Good afternoon. If we could come back to the private care homes. You refer to uncertainty, which we share as well, on how far paragraph 3 of the new schedule 7A allows for CHC inspection of private care homes. What exactly do you need?
(Ms Cadwallader) The statutory powers to be able to go in and look at everything in the home to see the people and particularly how that public money is being spent, and to see that they are getting what they should be getting and that their quality of life is what it should be. As I said before, you go on a scheduled visit and everything looks fine but you are not getting a true picture. You should be able to go there. In my experience I have only got one private home which says come in any time at all, which I have done and everything has been fine, but you should be able go into any home not just when they are expecting you because it is human nature, apart from anything else, to get everything looking good. I have done it myself with my own job. Somebody is coming round so you make sure everywhere looks neat and tidy. It is far more important when it is people's lives that they should be getting the good care all the time and not just when you go on a scheduled visit. All the equipment and everything should be there in good repair and the staff should have the correct things for dealing with the patients or the residents.
69. The implication is that you believe there is a difference between the public and the private sector generally?
(Ms Cadwallader) Yes, the public sector you can go in any time, they have got to be open. I am not saying it is so in all cases but I have had experience of it and it disturbs me.
(Mr Morgan) You can only go into the private sector when NHS patients are involved, you cannot go in if they are not?
(Ms Jeffs) You can only go there if that has been specified in the contract, so that the same inspection rights exist for everyone. There are two other things that we really are very keen on with regard to private homes. One of the things that concerns us is if you talk to the Nursing and Midwifery Council about the number of conduct hearings they have, 90 per cent of those hearings relate to people working in private or residential nursing homes. That concerns us because we feel maybe those are the areas where patients need protection. The other thing is the access to information about what those services are. Pat has talked about supplies but there are also lots of issues around how much the physiotherapists are involved and how much exercise people are getting. You find that when they should be being walked, nobody is making that effort to make sure these people are kept up and about, and you do not know anything about the level of the drugs that are being administered. There are lots of things we have concerns about that emerge from information we get through our members and through our members' contacts and then we are frustrated because we cannot go in and do anything about it. All we can do at the moment is tell the health authorities about it. At the end of March the health authorities will go and we will need to give this information to TIE (?) and to the Care Inspectorate. We do not see ourselves duplicating that work, but we do think there is a specific need for lay people to be doing that and we see it as complementing the work they do. However good the Care Inspectorate inspections will be, I do not think it will substitute people from the community who get the information from other people living in the community and relatives of the people, those whose nearest and dearest are actually in those homes. That is how we use the information to inform us when we need to go in.
70. My concern was about duplication. I understand that health care and personal care almost come together and are occasionally very difficult to distinguish. There are social services information units that do go around and inspect care homes and they are not light inspections. They are inspections done in depth and however much a gloss is put on those establishments because the inspection units are there for a considerable amount of time, it is very difficult to draw a veil over bad practice. It just seems to me that if you have got two organisations both inspecting the same organisations, you could have problems of duplication and in fact you could confuse issues rather than clarify them.
(Ms Jeffs) Sometimes I definitely am looking at the issue of complementing it rather than duplicating it. In Dyfed Powys, for example, they had great difficulty in enlisting lay people to help with those inspections so they asked us if we would provide the lay members. We also did that with primary care. Dyfed Powys Health Authority would ask the CHC to provide the lay person to go round. I appreciate that the inspections they do are very thorough. We do not ask things like what is the temperature of the fridge, which somebody needs to be doing but, equally well, they would not notice from a purely lay perspective the furnishings in the room and how that would suit somebody who was in there permanently. There are things that we see that the professional people do not see. There are things that they see that we do not. We have talked about the difficulties of how we are going to be able to inspect them. I do not think we would be inspecting every home every year. I do not expect for a moment to be able to achieve that. What we would like is to be able to complement what they are doing and we will see the homes according to a schedule that we devise that will work with our members, but it is an opportunity to go to places such as Pat has described when somebody comes up and says there is a problem there. A lot of people will not make complaints about people that are being cared for. We know something is wrong but they will not make an official complaint because they are quite convinced if they do then the person that is in the home will then suffer. So we have to do it in different ways. We have to use the information that we have got anonymously. We have to go in then and check what they are saying is true and that is how we use our information. If we had the legal right to do that, even if we do not exercise it every single six months, it would be advantageous to the patient.
(Mr Hall) Another point as far as that is concerned is you will make the homes realise that another organisation was going to look at it from a lay perspective and not so much from a professional point of view. In Gwent, most of the social services inspectorates, exactly as Jane has already highlighted, have CHC members on there already because it is a joint visit. We found it very beneficial. We also have a process of visiting them on behalf of the CHCs and we look at things in a different way. That has also benefited patients.
(Ms Cadwallader) Can I also say for social service visits that they know in advance that social services are going for the social service visits.
71. How many volunteers and what is the budget of CHCs throughout Wales?
(Ms Jeffs) It varies hugely. We go from about £40,000, it might be £50,000 now in Merionedd. That is one chief officer (he has only recently in the last year become full time) a part time assistant and that is all he has. Then he has got 16 or 20 CHC members. So it is very small. If you go to Cardiff I think they get about £90,000. It is one full-time chief officer with one full-time assistant. The Assembly has paid for Cardiff to have a complaints advocate this year, but it is still a pilot scheme that was running prior to this.
72. What is the global figure for Wales?
(Ms Jeffs) £1.8 million is spent on CHCs and we have somewhere in the region of 50 employees and some of those are part time. We have somewhere in the region of 400 members. They vary.
73. In three years' time the health budget for Wales is going to be something like £5.8 billion. I know the £1.8 million will be enhanced but do you think a budget of £1.8 million for 50 full-time employees and perhaps 1,000 volunteers is enough to help monitor that budget?
(Ms Jeffs) No, I do not.
74. I did not think you would.
(Ms Jeffs) You would expect me to say that, would you not?
75. Do you think what is proposed in this Bill will
(Ms Cadwallader) It is a little light on the visiting one.
(Ms Theobald) However willing the members, they need staff support to be able to really discharge their duties well and that is what we really are very light on. Because we are a bigger CHC and formed from the merger of two, we have still only got four full-time core staff plus our complaints advocate to support 36 formal members and a number of co-opted members spread between three counties. I would not say it is becoming impossible but we are very close to capacity and it would be very difficult to take on any more duties. To do anything new we have got to let something else drop basically at the moment. The proposals in here for the additional help on the complaints advocacy is very much welcome, but certainly on the admin support I think we need more, I have to say.
(Ms Cadwallader) That is echoed across all the CHCs.
(Ms Theobald) I was talking globally.
(Ms Jeffs) ACTU has 15 members of staff for England and Wales. The Association has a chief officer, an admin assistant and a research officer. In order to provide the support, we do feel sometimes very overladen and when people ask us questions about things like the public facilitationsand I see the Secretary of State for Wales is expecting as wellwe are very keen to provide that public involvement facilitation because that is our bread and butter and that is what we do, but it is very difficult to do that with the amount of staff we have. We constantly feel, and I know the staff feel constantly under pressure and trying to make sure you have all information like today is quite difficult, so I would definitely say that it would be beneficial if we had slightly more funding. It is total of £660,000 that the Assembly is proposing and I do think that is a bit light.
Chairman: Can I curtail this now. Money is very, very interesting to those who are likely to get it. We do need to move on. We are over-running already. Miss Morgan?
76. You raise the issue of how a CHC can refer on an inadequate consultation and you suggest it should go to the Minister. I think the RCN has criticised that and thinks it could go to some sort of independent body because the Minister herself may have initiated the closure or change. Could you give us your views on that.
(Ms Jeffs) In England I gather there is going to be an independent reconfiguration panel or a referral panel. One of the problems with that goes back to what I said earlier. NHS in Wales is diverging quite a lot from the NHS in England and the first thing we were concerned about was would they have sufficient knowledge of the NHS in Wales, and without having a Welsh member I am not sure that they would be able to do that. The second thing is that that might delay things. The third thing we thought about was if you had a similar body in Wales, again you start to duplicate things. At the present moment our role is to refer an unsatisfactory or inadequate consultation straight to the Minister. I appreciate what you are saying but it is done very publicly here in Wales, is it not? I suppose we are pinning our faith on the fact that it would be so public. I see your point and I take your point. At the moment I am more concerned that going to a not yet worked out independently reconfiguration panel in England might be not so satisfactory. We are willing to be convinced if that is what you think.
(Mr Hall) It is a different issue in Wales. We are quite happy with the Minister at the present time.
(Ms Jeffs) At the present time I suppose we are.
Julie Morgan: It does not have to be like England.
77. The AWCHC is going to be placed on a statutory footing and you welcome that in your notes. The Explanatory Notes refer to "increased responsibility and powers" and £70,000-worth of staffing. What increased responsibility and powers do you seek or expect? Do you think that advocacy staff or other CHC staff should be employed centrally or at least assessed and appraised centrally by the AWCHC?
(Mr Morgan) Can I answer the first part of the question and Carolyn or Jane can answer the second part. The Bill will give us in Wales a similar body to ACTU that covers England and Wales at the moment. We need a central voice and support in terms of training, research, PR, IT and legal services. The detail of the whole structure and the responsibilities and possible powers such a body will have will emerge from the Regulations. This is another reason why we would like to input into these discussions and we are meeting together as a Council on Wednesday of this week to discuss all the proposals in the Bill and particularly issues around what kind of a central body we need, and we need to feed this into the Regulations, as I asked earlier on.
(Mr Barnby) The complaints advocates are employed centrally by one body and what would be important is that they do have linkages into local CHCs, so I think it would be impractical for them to be located centrally and I think they would need to be out posted. What is key is that they do have linkages into individual CHCs. For example, I am a member of the Trusts Complaints Panel. I think it would be important for there to be quite a good working relationship between myself on the one hand and the complaints advocate if it were somebody not employed by my own CHC but some central body. That would probably be the key thing. Perhaps it is worth adding, of course, that all CHC staff in Wales have been employed by one body anyway because CHCs are not corporate bodies, so we have formally been employed by a health authority. The key thing is that we do have those local linkages.
78. I think it was Mr Morgan who gave a list of responsibilities. Is £70,000 in staffing costs enough to achieve all those responsibilities?
(Ms Jeffs) They are talking about £10,000 for extra rent and accommodation and £70,000 for extra staff. It really depends what we end up with. We have had long discussions about who should employ CHC staff after the health authorities go in order to present an independent body and one of the things we said was could we not be employed by the National Assembly rather than a mainstream NHS organisation. That may be quite difficult but in terms of as far as the staff are concerned it would be unfair if their terms and conditions changed radically from what they had at the moment. ACTU, as I understand it, have a service level agreement to provide the employment of staff and one would assume that is how that would happen whichever organisation and the Association says that they will leave that to the Society of CHC staff to work out where they would be most appropriately employed, but as far as actually directing the staff centrally, I think what Clive has said is that the complaints advocates obviously have to be who located locally. We have always done it but if there were a complaints advocate they would be managed by that local CHC and one of the things we would like to do with the Association is to ensure that there is the same sort of training across Wales to make sure we had the same kind of good practice and to make sure the services were consistent. That is what we are looking for. I do not think individual and autonomous CHCs want to be performance managed as such because that impinges against their autonomy. There are questions that really need to be looked into in much more detail. This Bill reproduces what we had with ACTU. I think that is sufficient for the Bill. What comes out as to what the central body should be, as the Chairman says, really needs to be debated at some length and needs to be looked at with the Assembly with regard to the Regulations.
79. Touching on comments you made about the performance of individual CHCs, if the CHC was seen to be failing or getting into some sort of bother, how could the Association of Welsh Community Health Councils be held responsible unless it had been empowered in some way?
(Ms Jeffs) That is it. We would like to be a supportive body. That is what CHCs would like to see. If you look at the clinical effectiveness units that we hadit has got a different name now in the Assemblythat is the way we would like to do it. If one particular CHC was struggling to meet all the things it was supposed to do then the Association would like to be able to send somebody up there to look at the processes and say, "This is how they do it elsewhere and maybe you could adopt that." We see it as a quality assurance scheme but a supportive one because that would fit in better with the concept of individual and autonomous CHCs because the concern they have is that if the Association became a body that had control of CHCs, if they came across something they did not like and it was different to the rest of the CHCs then somebody might be saying you cannot say that. Local communities must have that ability to be independent and reflect the views of their communities. But as for the performance management of the work, I see no reason why that cannot could be done in a supportive way.
80. I think that is all the questions that we have got at the moment except to say, as I said to the last witnesses, if there is something that you do not think is in the draft Bill that you would like to see in a Bill then do not forever hold your peace, have a go now or, better still, if it turns out that you have further deliberationsbecause I realise there is a very short timescale you have had to get the views of all your member associationsand if, in the fullness of time, those come through, although our deadline has been passed formally, please feel free to send them in. There is still a chance of getting them in our report and it would be a shame to miss it if there was something important you wanted in the Bill. Thank you very much for coming.
(Mr Morgan) Thank you, Chairman.