community health councils

Community health councils - largely unchanged in 25 years - need radical thinking in order to serve the public effectively. Chris Dabbs explains

Can a 1974 model work in the 21st century? Community health councils celebrate their silver anniversary this year. But while a new direction has been posted for CHCs in Wales - as federations linked to local authority areas - the future of English CHCs has never been more open to question.1

CHCs were established in 1974 as a response to psychiatric hospital scandals in the 1960s and the consumerism of the early 1970s. With one CHC for each health authority district, their role was to represent the public interest in the local NHS. They had a duty to keep the operation of the local NHS under review and to offer advice and recommendations. Most were given two staff and 24 members: half nominated by local authorities, a third elected from the voluntary sector and the remaining sixth appointed by the health secretary. Essentially the role and model of CHCs have not changed since their inception.

But radical thinking is required to ensure that the£22m spent on English CHCs is used effectively. A national agenda for change seems at last to be developing. An all-party parliamentary group on CHCs has been established and the Association of CHCs for England and Wales has set up a commission on representing the public interest in the health service, which will report by the end of the year.

There are many individual examples of effective practice. Bristol CHC's Local Voices project promotes the views of local people on health issues to effect real change in services. North Tees CHC has focused on public health issues, inside and outside the NHS, and worked with local people to address these. West Essex CHC has established a strong monitoring function, while Sandwell CHC has successfully developed its role in empowering and involving local people in health issues.

But CHCs collectively need to think how they do their job, and focus on three principles that have been sadly lacking: imagination, effectiveness and their own accountability.2

To date, the government has said little about the future of CHCs in the New NHS. This is despite its emphasis on all the major themes of health strategy across Europe: improving public health, quality and effectiveness, decentralisation to primary care and citizen participation.

CHCs also face challenges to their core role from other directions. Digital technology offers the public swift, direct access to information and advice without the need for an intermediary. Political change, especially devolution and local government reform, will bring more local democratic control over healthcare and more elected politicians to represent citizens' interests, including on NHS matters.

CHCs' effectiveness relies on resources; organisation, particularly the breadth of local networks and quality of relationships with other statutory bodies; leadership, particularly the skills of chief officers and their external relationships; and approach, particularly the quality and range of collective knowledge and expertise.

The variability in these factors, linked to the lack of any clear, common vision for CHCs, has created a set of organisations that vary unacceptably. This applies equally to their role, functions, quality and effectiveness. The best can point to significant change in mainstream health policy due to their work; the worst are ignored, sidelined and affect only marginal issues.

Most CHCs attempt to fulfil too many priorities with tiny resources. They seek to be watchdogs, community voices, facilitators of service user involvement and citizen participation, providers of information and advice, and complaints advocates. Most either seek to develop or are drawn into extending their role into social services and private care. Too large a proportion of resources is spent on management and administration.

CHCs are relatively cost-effective at local level, sometimes providing services at a fraction of the cost of management consultants. But their effectiveness has tended to lie mainly in peripheral issues, and their potential and achievements have been undervalued. They cannot afford to stand still.

Successive governments have failed to focus or harness the potential of CHCs which, for their part, have failed to get their collective act together.

Complaints services vary wildly from one CHC to the next, with no national standards or core service - something for which they often criticise others. And while there are key health developments relating to primary care and local authorities, CHCs lack rights or remit in these areas.

A growing range of statutory and independent organisations is seeking to monitor NHS activity. Information and advice for the public on health and healthcare is expanding rapidly.

So where are the gaps to be filled? Recent publications have offered different ways forward. In 1998, In the Public Interest, published by the Institute for Health Services Management, the NHS Confederation and the NHS Executive described a new role for CHCs. They envisaged them moving away from their 'quasi-democratic' role and instead saw them revitalised - with a wider remit but fewer functions - as professional scrutineers of public sector contributions to health, of the health impact of public policies, and of health services and facilities.3

By contrast, Reflecting the Public Interest outlines a model based on the current statutory functions of CHCs.4 This incorporates a lay board responsible for representing the interests of the public, and a professional staff team - strengthened by secondments from local organisations - to spearhead public involvement and local quality evaluation activities.

At the Crossroads argues that providing direct services to individuals with queries and problems is no longer viable as a main focus or function, given growing competition from helplines, advice agencies, self-help groups, the Internet and other public-access media.5 It suggests instead two possible main focuses: either health and social care provision, or public health improvement. With continuing integration of the NHS and social services, focusing on the NHS alone is meaningless from a lay perspective. There are two possible basic functions: either independent external monitoring and scrutiny, or participation of lay people.

Combined, these reports suggest several possible roles for the future (see box). Which will most benefit the public? Function must come before form, so the main question is not: 'What is the future of CHCs?' Neither their continuation nor abolition should be assumed.

The choice of role is unlikely to be made collectively by CHCs themselves. Rather, this choice must be one for the health secretary and Parliament. If such a decision is avoided, the national picture will continue to range from oases of excellence to deserts of ineffectiveness.

If and when any such decision is made, several principles should be central.

A clear, national strategic vision should be set and supported by national policy.

Autonomous organisations should be established at national level with a common purpose, remit and configuration.

Their rights should apply equally to all agencies in their remit.

A comprehensive accountability framework will be necessary, incorporating a minimum set of statutory duties.

This approach would address the main weaknesses of CHCs and could also build on their strengths - not least their networks, knowledge and lay perspective. Particular effort would need to be spent on recruiting and developing chief officers, promoting networks and partnerships, and encouraging a focus on effectiveness through incentives and sanctions.

There are more similarities than differences between the various current proposals. Any decision to change CHCs significantly or replace them will be controversial. But the worst option would be to allow CHCs to become increasingly anachronistic. There is a bright future for an effective lay contribution to the health agenda. Only a clear decision at government level can resolve the situation - the sooner the better.