Published: 24/02/2005, Volume II5, No. 5944 Page 18 19
Appointed to run the Commission for Patient and Public Involvement in Health following the announcement of its abolition - just five months after its official launch - chief executive Steve Lowden is concentrating on leaving a legacy from which PPI forums can grow
A trip through the darker corridors of patient and public involvement can be a disconcerting experience.
Browsing the numerous websites you soon come across the telltale signs: long unsubstantiated defences against long unsubstantiated complaints, and an intense dislike of people who actually work for trusts - anyone turning up to a meeting with a written agenda is denounced as 'Kafkaesque'.
So it must be tough running the Commission for Patient and Public Involvement in Health - an organisation that sometimes seems to be treated with as much disdain by the people it supports as it is by its detractors.
When chief executive Laura McMurtrie was replaced by her deputy Steve Lowden in November, following last summer's announcement of CPPIH's abolition just five months after its official launch, it seemed he had inherited a pretty thankless task - flogger-in-chief of a dead horse.
But February finds him in chipper mood, hot from 80 minutes with a 'very interested' health minister Rosie Winterton. 'There is a real job to do and It is clear that forums are making a difference.' The subject of his meeting with the minister was the consultation on what form the PPI system will take after the commission disappears in August 2006. CPPIH has had 4,300 responses.
As parliamentary action is needed actually to abolish CPPIH, legislation will have to be put together over the next few months.
'What's going to replace us is not clear but I have been told today that it will be part of some kind of modernisation bill. Forums are safe, but a lot of the detail has to be worked out. The Department of Health will need to be clear on legislation by the summer.' The reason for the abolition is still open to debate. Junior health minister Lord Warner criticised operating costs when announcing it, but fellow minister Melanie Johnson stressed the issue was not performance.
Does Mr Lowden accept that mistakes were made? 'It was a political decision - I do not think anything would have made a difference. Community health councils had been around for 28 years; we had six months - during which time we were under this political microscope. CHCs took 28 years to bed down - they were not great at the beginning and they were not all great at the end.' He seems to believe that any new, large, central organisation would have been abolished in light of the government's aim to reduce spending on quangos - a position strengthened by the other major victim of the review of arm's-length bodies, the NHSU. But both also suffered from the deadly combination of high-profile, large budgets and lack of vocal friends.
The chief indictment was high running costs in the first year. Mr Lowden points to the challenge of setting up forum support organisations drawn from the notfor-profit sector. But did that decision give critics a vital early weapon? 'We were adventurous in setting up that system - it was courageous to use the not-for-profit sector. We could have just reinvented the wheel and downscaled CHCs.'
He points out that 80 per cent of the commission's budget is now spent on the frontline - and adds pointedly: 'We spend centrally to the level that the DoH wants to be at in 2008 - our central costs are pretty damn low.' The commission learned from its mistakes too, he says. 'When we started off we didn't know how much money running a forum was going to cost.' He admits that travel expenses for members were too low to begin with - a small matter that created damaging resentments. And there is now a development fund of£1m for which forums can bid.
'The CPPIH originally asked for [an annual budget of]£64m, which would have been comparable with CHCs - we got£33m. As we have gone on We have realised we can free up more money for the front line.
We have 25 per cent fewer staff than the DoH budgeted for.' Mr Lowden accepts that hearts and minds were lost locally, and this is reflected in reading the forum responses to the consultation.
Although Mr Lowden says his staff get rounds of applause at local meetings, there are not a lot of regrets expressed in writing about CPPIH's demise.
The likely result of the consultation is a small institute of PPI promoting good practice, a bigger role for the Appointments Commission in selecting forum members and some form of regional network for the forums themselves.
On the first body Mr Lowden says: 'It can't be a dusty academic institution stuck in the back of some university cupboard writing papers that no-one reads. It needs to benchmark best practice.' It is unclear whether it will performance manage forums - but if not them, who? Mr Lowden suggests it might fall to the centre, but that is unlikely to go down well with independently minded (in other words, all) members.
'But what do we mean by performance manage anyway? We are talking about volunteers who freely give their time and can walk away. Management has to be about light touch and peer review.' Independence is also a strong theme of the responses. But there is a danger of self-perpetuating cliques that no-one is watching. Mr Lowden again believes that this is best tackled by setting the right tone centrally. 'We have common standards. You have got to have a framework, an expectation of what forums are there to achieve. You want common decency to prevail.' One key debate is whether the system can support 572 forums, in terms of funding and finding bodies to fill them. There are more than 5,000 members nationally - but about 80 forums are currently under the statutory minimum of seven. Mr Lowden says the advantage of covering all trusts is the voice it gives to mental health and ambulance services.
But he adds: 'Funding for forums will fall to£30m next financial year and is projected to go down to£28m in 2006-07. It might be that basing them on primary care trust boundaries would have a great deal of merit.
'However, I have also heard talk of moving to a local government model where you would have 150.
The jury is out.' Apart from anything else, the new contracts for forum support organisations will need to be awarded in the autumn, 'which can't happen until you know how many forums you have got'.
Most complex is the issue of foundation trust boards of governors.
These are elected local people intended to play a representative, patient-focused role - just like PPI forums. Surely there is a clash.
But Mr Lowden has an oddly different view of governors. 'As far as I know. they are looking for people with a lot of business acumen. Foundations are going to need a whizzy board. They tend to focus a lot on strategic direction, whereas a PPI forum is more concerned with what a service is like today.' That might be true of a foundation's non-executives - but surely not of its governors, who have different governance roles.
Forums tend to perform well on diversity: about 10 per cent of members come from a black or minority ethnic background and about 25 per cent have a disability.
They tend to be older, but that is true of most voluntary services, as Mr Lowden points out. CCPIH puts a lot of effort into recruiting younger members - it is debatable whether forums themselves feel minded to seek out callow youth.
And is not it valid for the age spread of forum members to reflect not the local population but likely users of NHS services - that is, older people? 'I wouldn't take that view.
There is something good about someone coming along who is not familiar with the service. They can see it with fresh eyes.' So back to that poisoned chalice.
It must have been difficult leading an organisation that had just received its abolition date. 'We recruited some extremely professional staff experienced in this arena and when it was announced we were going to be abolished It is inevitable you begin to doubt your own self-worth. People now have realised It is not personal. We have an opportunity of leaving a legacy and ensuring the lessons are not lost.'