News analysis: Signs of the times - will people power deliver accountability?

An obligation on PCTs to respond to community views - and protests - about NHS services is one of the most significant aspects of the new commissioning framework. But how might this work in practice? Daloni Carlisle petitions stakeholders for their views

Hidden away in an appendix to the annex of the Commissioning Framework for the English NHS is a proposal that could, depending on your view, become either a thorn in your primary care trust's side or a thoroughly modern boost to local democracy and empowerment.

'Triggering community action', as appendix E is snappily entitled, envisages mechanisms that would make PCTs respond to petitions from the public and/or service users. It is not a new idea, but one that has been given a good spit and polish by New Labour.

This most recent outing for petitions as a force for change seems to be attributable to Paul Corrigan, visiting professor of public policy at London Metropolitan University and special adviser to Number 10. His January report for the Social Market Foundation outlines how he thought primary care should change to meet patient needs.

In short, he said that for 50 years the NHS has expected the public to like it or lump it. That has to change and now it is time for public pressure to shape a patient-led NHS, using petitions as their lever. They might, he dared to suggest, demand alternative services from independent providers.

Devolve power

Nor is primary care the only area where New Labour is pushing the idea. Also in January, David Miliband, then communities and local government secretary, outlined his thinking to the New Local Government Network on how to devolve power and increase local democracy.

He saw petitions as one means by which people could force issues on to their council's agenda. 'Let's debate how to give citizens the right to force consideration of the quality of rubbish collection or the regeneration of an area of the development of play facilities for children,' he said.

Institute for Public Policy Research research fellow Joe Farrington-Douglas draws a parallel between the ideas of Professor Corrigan and Mr Miliband, but says: 'The health reform agenda is more driven by marketisation than by strengthening civil society. There are elements of devolving power [from the centre] to PCTs, but we have seen very little being devolved to the public from PCTs.'

During the spring the idea developed and the white paper Our Health, Our Care, Our Sayintroduced it into policy, saying: 'We will go further in giving people the power to demand changes where community services are unresponsive or resistant to their needs... we will ensure that, where a specified number or proportion of users petition the service provider for improvements, the provider will have to respond, within a specified time, explaining how they will improve the service or why they cannot do so. This will apply to local GP practices as well as other services commissioned or provided by the PCT.'

These bare bones get some flesh on the commissioning framework. Public petitions, it says, could be raised by members of the public and/or users of a service commissioned by a PCT. MPs could also raise petitions. They could cover demands for a new service or dissatisfaction with existing provision although they could not be used to prolong a debate on a proposed service reconfiguration after the end of a consultation.

Mr Farrington-Douglas - like many others - gives the idea a cautious welcome. 'It could give more direct accountability, but it would probably be a relatively minor role among other tools for engaging the public,' he says.

Petitions have well-documented limitations. Mr Farrington-Douglas enumerates a few: 'They tend to serve public needs rather than patient needs,' he says. So, for example, the public may well defend a local community service they never use but patients of the service may in fact be quite happy to see it replaced with something new and better.

They can be taken over by special interest groups or political groups, he adds. 'It's the well educated, middle class people who do things like complain, access councillors and lobby effectively. The hard-to-reach people are not usually included in this type of activity.'

The political aspect is certainly true. The Liberal Democrats run a good line in petitioning for 'your local NHS' with several active and recently active petitions available on-line from 'bring back NHS dentists in Devon' to 'save Abingdon Cottage Hospital in Oxfordshire'.

'Certainly the right to petition is well entrenched,' says Lib Dem MP for Torquay Adrian Saunders. 'But the authority still has to decide which petitions are significant and make decisions about allocating resources. So while this is welcome I can't see it making much difference except at the margins.'

Broad welcome
The large trade unions all use petitions. Unison provides a whole online toolkit on its Keep the NHS Public website. It advises branches how to petition against foundation hospital status and provides model petitions, press releases and publicity items.

Nationally, Unison was not prepared to pre-empt its response to the questions posed by the DoH in appendix E and so broadly welcomed the idea of public petitions. 'We would use any and all tools at our disposal,' says a spokesperson.

Locally, Geoff Reason, Unison's head of health in the eastern region, is more forthcoming. 'We have had any number of public petitions in Suffolk about closures of community services but no-one has taken any action or any notice,' he says. Although in future PCTs might have to take notice, until the requirement to respond to local petitions comes with cash attached they will not be in a position to take any more action than today, he believes.

'I think it is rather hypocritical of the government to say people are in control when we know very clearly that they are not,' he says.

The aspect of special interest groups hijacking a PCT agenda is one that worries Nicola Russell, director of the Multiple Sclerosis Trust. An audit of take up of National Institute for Health and Clinical Excellence guidelines on MS services published last week by the MS Trust and the Royal College of Physicians shows why.

Despite the guidelines being issued in November 2003, they have barely made an impact on commissioners, says Ms Russell. 'People are getting a very, very poor service. Not only that, but even where PCTs are commissioning services they do not have mechanisms to check and monitor what is being delivered.'

Compare this to the lightning speed with which PCTs have had to move on the breast cancer drug Herceptin, which was given a rapid appraisal by NICE and introduced by PCTs post haste.

Ms Russell says: 'The MS Trust has been really quite exercised that the unlicensed drug Herceptin warranted an intervention from the secretary of state when people with MS are not getting access to a licensed drug.'

This is likely to be repeated on a local stage where a petition to save the local MS nurse will be up against campaigns for local cancer services, each competing for PCT and media attention. As Ms Russell puts it: 'We do not have the same appeal or media-friendly face. People do not die of MS and, let's face it, with breast cancer you are talking about young women who might die.'

PCTs will be expected to address these political and pressure-group issues. The commissioning framework sets out a series of principles for designing mechanisms for public petitioning. They should, for example, encourage genuine, not trivial or vexatious, petitioners. Mechanisms would need to balance the needs of different groups in the population and priorities and be consistent with the aims and values of the NHS and the roles of PCTs.

Thorough and rigorous

Any public petition mechanism would need to be properly resourced to ensure a thorough and rigorous approach. PCTs would have discretion about how to respond but be expected to set out their mechanisms publicly. There would need to be arbitration when the petitioner appealed against the PCT's decision.

Experience in all of this is at hand. The Scottish Parliament has been hearing petitions for seven years and has a public petition committee to advise petitioners, hear their cases, take evidence and make recommendations for action by the parliament.

That committee is convened by Michael McMahon, MSP for Hamilton North and Bellshill. Part of the job is to help petitioners frame their demands in a way that allows the Scottish Parliament to respond. So, for example, he says: 'We cannot demand a health board overturn its decision to close a service. We can demand that it demonstrate it followed proper procedure. We have seen a couple of decisions overturned on that basis.'

With experience of 1,000 petitions and an academic review now commissioned, Mr McMahon feels that, properly handled, the process can result in real gains for local democracy and engagement. 'Even if people do not get the outcome they wanted, many of them feel that they have engaged in the democratic process.' He is happy to share his experience with any PCT that cares to call him.

The DoH has promised to consult on specific mechanisms later this year, but in the meantime has asked for views - not least about what thresholds should trigger a response. Despite an early press release saying this would be set at 1 per cent of a local population, the framework poses a question. What would be the right threshold? Should it be 1 per cent of a local population or 10 per cent of the users of a service?

PCTs and national organisations contacted by HSJ were by and large unwilling to comment, saying they did not want to pre-empt their formal response. None saw the idea in the positive terms described by Mr McMahon; a couple of PCTs felt that petitions would be a line of last resort - an admission of failure to engage by other means.

NHS Confederation deputy director of policy Jo Webber sums up the nervousness many feel. 'We need an answer to some of these questions. The threshold of the number of signatures is going to be very important.'