Concrete action

Public consultation in inner-city East London has not had a happy history in recent years.

There have been instances when it appeared to follow a decision, rather than precede it - the consultation over whether to close Bart's when Virginia Bottomley was health secretary being one example. And there is some cynicism from an audience that feels it may have been over-consulted, but not very well.

So when the local health services joining together to form the new primary care trust for Hackney and the City of London began to consider the form of public involvement exercise they would conduct, it was clear a half-hearted approach just wouldn't wash.

Consultation has to work hard to reach people in this part of the capital.Hackney is one of the most deprived boroughs in the country and population turnover is rapid. There are many short-term residents and recent arrivals, including asylum seekers, with all the consequent difficulties about accessing local healthcare services.

Census information is virtually useless - not just because the 1991 census is out of date and pre-dates the conflicts that have triggered new waves of immigration, but because the national census fails adequately to record communities such as the Orthodox Jewish, Kurdish and Turkish ones in Hackney. Despite having their own distinct needs, the census simply records them as white Europeans.

As with any inner-London borough, boundaries are porous, meaning that residents may relate to adjacent boroughs more strongly than to the rest of Hackney, with the result that many have crossed borough boundaries to register with GPs.

City and Hackney Community Services trust and the primary care group recognised that the consultation preceding the establishment of the PCT offered a valuable - and possibly one-off - opportunity to reconnect with local communities.

The two organisations worked with City and Hackney community health council and voluntary sector organisations to produce a consultation that would be up to the task. Both formal consultation meetings - one in the City of London and one at Sutton House in the heart of Hackney - were poorly attended.

But a series of meetings with about 50 local community and healthcare organisations also took place. PCG and trust staff met these groups on their own premises at a time convenient to them. The health authority was persuaded to allow a less structured approach to the consultation. Simple, graphics-based presentations with supporting overheads were created as aids rather than templates.

Staff were able to vary their style to suit the audience. In some cases there was no formal presentation at all: staff visiting a residential care home for older people split up and talked to residents individually or in small groups.

Important, too, was the decision to use clinicians and staff working at quite a grassroots level to take part. Each presentation team included one staff member from the PCG and one from the community trust, one relatively senior and one operational staff member and a third person to record and feed back results.We took care to be frank about the scope of the consultation on the PCT itself - to emphasise that the new structure was almost certain to come about. In this way we hoped to minimise cynicism. The primary focus of the exercise was to identify issues concerning residents and frontline staff - in effect to audit attitudes to primary and community healthcare.

Some issues emerged that might not have been aired - for example, one Asian women's group voiced concern at the response one of them received when asking her GP about the adverse side-effects of medication.

A more predictable issue was the pressure on chiropody services in City and Hackney. Several groups expressed dissatisfaction with the waiting times for appointments for this and other services.

Many complimentary things were said about the standard of primary and community healthcare services.Health visitors are highly valued. Despite the growth nationally of a complaints culture, our residents really do understand they are part of a bigger healthcare picture. They do not expect luxuries or cosmetic fripperies. But several common themes and anxieties emerged, including the need for better information on accessing services and a higher standard of customer care.

Much feedback centred on access to GP services and the quality of service patients receive from their GPs.On the whole people had great confidence in GPs' clinical competence but were sometimes dissatisfied with the quality of customer care. Some believed that the more articulate a patient, the better the quality of their treatment was likely to be.

There was a desire for more of a patient focus in the provision of services, with patients being seen at the appointed time, a greater choice of ethnic foods in hospital, and more public health work. Suggestions included keep-fit classes and closer work with the local authority, to reach housebound or isolated residents and to improve housing conditions.

Access to GP lists can be difficult in Hackney.

Several lists are full and closed to new patients.

Greater co-ordination between practices can only improve the situation. Also, patients feel reluctant to complain to their GPs direct, fearing they may be dropped from a list, and unable to get on to another - because they are full, or because there may be a secret 'blacklist' in operation. This feedback will be important to the early priorities of the new PCT. A transparently fair and impartial complaints procedure is needed, and patients would prefer not to have to complain to their GP in person.

Also, groups which might previously have been the main priorities - such as our Vietnamese, Kurdish and Turkish communities - may find it difficult to accept the need to reprioritise our budgets towards, for example, more recent examples such as Spanish, Portuguese, Swahili or Albanian speakers.

There was dissatisfaction with the quality of GP premises.We were able to reassure residents of progress in this area. Direct feedback to immediate concerns was well received.More general fears about the future of the NHS were not so easy to assuage. People in Hackney value the NHS, but fear it will not remain free.

The effect of the organisational change concerned staff, who are a key audience; understandable personal anxieties exist about bringing two organisations together and the impact on jobs. At least one group said that it was difficult to be enthusiastic about yet another change. There was concern, too, about the exact nature of staff representation on the PCT board.

Staff participating in the consultation exercise, many of whom live in Hackney, have benefited from building closer working relationships with future colleagues from the PCG or the trust. It has helped begin to chip away the atmosphere of uncertainty about the future and helped those who took part to focus on the positive benefits of the PCT. For many, the experience of presenting to large audiences of patients and residents was a worthwhile and developmental experience.

We hope we have established a good basis for wider and more meaningful contact. A community participation steering group, already up and running, will continue the task.

The links forged during the consultation exercise have enabled us to identify potential candidates for non-executive directorships, who will be representative by ethnicity and gender. This consultation will be used as a model for how the PCT handles consultation in future.

City and Hackney is prepared to be held to account and we hope our communities will, in return, recognise they must be prepared to speak their mind but also to listen and understand the pressures on our decision-making and resources. There are sometimes difficult choices to be made but we will work with local people to come to the best possible decisions.

Key points

Community trust and PCG staff met more than 50 local organisations to prepare the ground for the launch of the primary care trust.

This approach seemed more appropriate to the area than a traditional consultation exercise.

Concerns from residents included difficulty in getting on to a GP's list, poor premises and shortage of chiropody services.