Primary care trusts will have more public representatives than primary care groups - but will they necessarily be more representative of the public they serve?
Since April 2000 the number of PCGs has fallen as a direct consequence of the near to medium-term process of becoming PCTs. These new trusts will require lay members to fulfil the role of chair, with others taking on the duties of non-executive board members.
But research has raised doubts as to whether lay members are representative of their communities, and has questioned their effectiveness in challenging the medical profession's dominance of PCGs and local health groups.
1If these concerns are justified, it is questionable whether the shift to PCT status will change the situation, even if lay members on PCTs will not be the only 'public' representatives on the board, as they currently are in PCGs.
Concerns about the social make-up of lay membership and their ability, or desire, to challenge medical dominance, led to a study at Hertfordshire University. This research looked at the social characteristics and role of the lay membership in PCGs in England and LHGs in Wales.
The 265 lay members who responded matched the overall lay membership population of 503 in terms of regional breakdown and population size of the PCG or LHG on which they sat. The respondents were distributed across the nine geographical health regions and five population size ranges.
Some 52.1 per cent of respondents were women and 84 per cent were over 45 years old. In contrast, only one lay member was aged 18-24 years and just five were in the 25-34 age group (see charts).
Only 3.9 per cent, or 10, of the respondents described themselves as belonging to an ethnic minority group; these included Black British, Black Bengali, Black Caribbean, African Caribbean, Indian, Ugandan Indian and Kashmiri.
Just over 60 per cent (163) of the sample said they were in paid employment: 38 per cent (101) said they were not. Of the former, 40.5 per cent (66) worked more than 30 hours a week and 25.2 per cent (41) worked part-time (less than 30 hours). Of the remaining lay members in paid employment, 27.6 per cent (45) of respondents were 'selfemployed without employees' and 6 per cent (11) were 'self-employed with employees'.
The lay members not in paid work were either retired (30.6 per cent, 81); homemakers (5.3 per cent, 14); permanently sick/disabled (2.6 per cent, seven); or unemployed (0.4 per cent, one).
The largest number of respondents represented PCGs with a population size of 100,000 to 150,000 (41.8 per cent, 64) and the next largest group represented populations ranging from 70,000 to 100,000 (32.7 per cent, 50). At the extreme ends of the population range 8.5 per cent (13) represented populations of 50,000 to 70,000 and 4.6 per cent (seven) represented populations greater than 200,000.Most respondents believed they were mainly responsible for public involvement on the board. A majority sat on two or three subcommittees, and though 5.3 per cent (14) sat on no sub-committees at all 1.5 per cent (four) sat on six sub-committees or more.
More than 90 per cent of the respondents said they were recognised as full members of the board, but 7.9 per cent said they were not. Three-quarters believed PCGs had improved, or were starting to improve, the provision of primary healthcare, but 18 per cent believed this was not the case. Lay members indicated a sense of isolation and exclusion.
The study's initial findings were that in terms of gender the make-up of the lay membership was representative of the general population. But this did not seem to be the case with regard to age, social background and ethnic origin.
Clearly, most respondents were not in what might be regarded as traditional full-time employment.
The results suggested that only those with flexible employment patterns or significant control over their workload would be able to attend the various PCG board and committee meetings. Threequarters of those in some sort of paid employment held jobs in education, consultancy and the public or voluntary sectors.
The statistics for paid employment imply that a professional position, which affords some control over time or self-employment, is an advantage.
Furthermore, a high proportion of lay members not in paid employment were retired (see chart above). Employment status, therefore, may influence who can apply for lay membership posts, rather than social selection taking place at the interview stage.
Without access to health authority data on unsuccessful applicants, we cannot know if the selection process or the age, race, sex or background of the applicant was an influence on appointment.
The responses from those in paid and unpaid employment suggested that unless the advisory/executive roles can be accommodated outside traditional working hours and/or generous remuneration is awarded, the potential market for lay membership of NHS boards is restricted.
There is some cause for concern over the low proportion of lay members from ethnic minorities.
National figures for the ethnic population of England and Wales (5.9 per cent) imply that there has been under-recruitment of lay members from these groups. The small number of ethnic minority respondents may be indicative of fewer applications for posts. But it also raises the question of how the individual lay members can access disenfranchised groups within a PCG. If they are unable to do so, how can they represent everyone within their area?
The issue of representation is especially relevant if the PCG is large; some PCGs cover populations greater than 200,000. If representation is poor, an important goal of the NHS plan - to bring decisionmaking nearer to the public - may not be attained.
There seemed to be no correlation between the population size of the PCG/LHG and the role adopted by the lay member within the organisation.
A large proportion of respondents believed they were mainly responsible for public involvement on the board, although many said that while it was their main role it still remained a board responsibility.
Although most members were recognised as full members of the board, many felt they were viewed as 'token' or as 'being tolerated rather than respected'.
Some reported boards as being provider-dominated to such an extent that issues were described as being 'too complex' for the lay member to understand.
Overall, lay members remained confident that PCGs would eventually make a difference to the local population's health experience.
In future, PCTs will have a board dominated by lay members, which will spread the burden of representation. But given the PCG experience, there is doubt as to how representative they will be.
This research suggests that particular age groups, ethnic groups and those in certain areas of the economy have been generally excluded from lay membership posts. Without access to data on selection, however, it remains unclear whether this is due to non-application on the part of individuals from these groups, or the result of a biased selection process.
Question and answer: the method
Names and addresses of the lay membership in England and Wales were compiled from the Healthdata website in October 1999.
2In March this year, 502 questionnaires were sent to all lay members in England and Wales. A cover letter explained the research. The number of responses received by the end of April 2000 was 265 (249 English and 16 Welsh lay members). The overall response rate was 52.79 per cent. The questionnaire investigated the demographic characteristics of lay members, and the profile of the primary care goup/primary care trust or local health group on which they served. Lay members were asked about their role and the perceived progress made by their PCG/LHG in the area of primary healthcare.