Published: 07/06/2002, Volume II2, No. 5808 Page 18

For the best part of a year, I have been poised to rewrite a chapter in the College of Health's resource book on training and support for user representatives in the NHS. The chapter was about how the NHS is organised and where patient and public involvement fits in. At the end, we suggested user reps ask themselves three questions:

Am I clear about where my committee/self-help group fits in with the bigger NHS picture?

Am I clear about how I could get my voice heard more?

What opportunities are there for users to be involved at a local, regional or national level?

On reflection, perhaps 'poised' is the wrong word. Sitting on a rollercoaster might be more apt.

The future of patient and public involvement is far from clear as has been apparent in the current stormy passage of the Health Service Reform Bill through both Houses of Parliament.

Much of the problem stems from the surprise last-minute decision to abolish community health councils in the NHS plan.

It might have been sensible to consider the cost implications to the NHS first. One minute, it looked as if we might end up with patients' councils at local level.

The government had seemed to agree this would be a good idea during the passage of the Health and Social Care Bill (now an Act) through the House of Commons before the election last year. This time round, it was a House of Lords opposition amendment that proposed patients' councils and the idea didn't go down so well. Addressing last-minute government amendments in the Commons, then junior health minister Hazel Blears said patients' councils were 'flawed organisations... they would involve the introduction of 150 new bodies, adding an entirely new layer to the system of patient and public involvement'.

She said 'the other fundamental reason why we oppose patients' councils is that they would involve a system where a body purports to speak on behalf of the public'. The system the government had tried to establish 'enables the public to speak for themselves' and it was crucial to have a system 'not about an exclusive delegate democracy, but about liberating local people so they can speak for themselves'.

What we do have are local authority overview and scrutiny committees, which would by one account need£22m a year to fulfil their function if this were made a duty rather than a power.

Add the independent complaints advocacy function that the government intends to give to the primary care trust patients' forums at an estimated cost of£13m, and the cost way exceeds the budget for CHCs.

PCT patients' forums will now also take on the functions previously envisaged for local offices of the Commission for Patient and Public Involvement in Health, a new national body welcomed by the voluntary sector. This, said the minister, would represent 'a position on patient and public involvement that is as good as it gets... a robust, independent and vigorous system of patient and public involvement'.

Giving a lead role to PCT patients' forums makes sense. In the College of Health's response to the discussion document Involving Patients and the Public in Healthcare, we suggest PCT patient advisory liaison services should take the lead in coordinating the activities of PALS in NHS hospital, mental health, community and other trusts. This was because PCTs would be taking over the role of the former health authorities, not just in commissioning health services, but also in relations with local authority social services, community and voluntary organisations. Since PCTs would set the standards on which service agreements with trusts are based, PCT patients' forums would be in a position to tell forums inspecting other trusts what standards to measure against.

But CPPIH will have a big job recruiting 7,500-11,250 members of the public and patients, to include disadvantaged and marginalised groups, to the 625 PCT and acute trust patients' forums. If the 'local' level CPPIH staff are based in PCT patients' forums alone, it will bring a logistical nightmare since there will be more acute trust patients' forums with no staff of their own.

The transitional advisory board charged with advising the government on how to take patient and public involvement forward will have its work cut out to make sense of all this. I hope the government will listen. l Marianne Rigge is director of the College of Health.