Triggering Community Action: Public Petitions
This is a response from the Moore Adamson Craig Partnership LLP to the consultation on "Triggering Community Action" in Appendix E of Health Reform in England: Update and Commissioning Framework (Annex) issued in July 2006.
This consultation stems from the Government's commitment to introduce "public petitions" made in Our Health Our Care Our Say, (January 2006) para 7.21 which occurs in the chapter "Ensuring our reforms put people in control" It said:
"We will go further in giving people the power to demand changes where community services are unresponsive or resistant to their needs. As well as the independent user surveys referred to earlier, 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."
The Commissioning Framework states that further work is required to develop specific mechanisms and thresholds for public petitions which will be subject to consultation later this year. It is important, however, that this work is informed by the views of patients, the public, providers, staff, and partner organisations.
As a specialist consultancy in user engagement, the Moore Adamson Craig Partnership LLP has taken this opportunity to give its views on the following questions in the consultation document.
Should petitions should cover only community and primary care services (including jointly commissioned services and primary care), or the whole of PCT-commissioned activity including acute services and (through the co-ordinating PCT) specialised services?
All services commissioned by a PCT, including from Foundation Trusts, should be subject to community action triggers and subject to the same safeguards and checks to prevent misuse of this facility. In addition, as Our Health, Our Care, Our Say stated, this should include services provided by primary care contractors.
Who can petition?
Public petitioning rights are part of openness in public services and accessability for all. It is a logical extension of participation by service users and the public, enabling more people to make an effective contribution and be listened to. From this it follows that anyone should be able to petition who is directly affected by a commissioning decision of a PCT, whether or not that person is a current patient. This should reflect the definition of who can make a complaint under the NHS complaints procedure in England.
There should be safeguards to ensure that petitioning is not abused for vested or commercial interests.
How the voices of children and the vulnerable, disadvantaged and excluded members of society can be heard?
This needs to be considered as separate questions.
- Children – involving children in petitioning should reflect the best practice of the Children's Commissioner for England
- Excluded/under accessing groups – involving these individuals, including people from social and linguistic minorities or other disadvantaged groups, in the petitioning process should encompass advocates, spokespeople and representative organisations, as well as public representatives such as MPs and local councillors
The threshold number of signatories to require a formal response from the PCT. What level of threshold should induce a review, for example a response from 1% of the public served by a PCT or 10% of the users of a service?
The threshold should be "either/or" depending on the scale of the affected group and the significance of a particular aspect of care in terms of risks incurred or resources consumed. For example, many people in a given area will be users of community nursing servcies, therapies or sexual health services and therefore 1% of the population served by a PCT would be acceptable to trigger action in one of these service areas. With reconfigured PCTs averaging 300,000 in population size, that would be a petition with 3,000 names.
In contrast, many fewer people will be affected by a relatively rare disorder like Motor Neurone Disease. In a PCT serving 300,000 people, there will be some 21 people with a diagnosis of MND and about 6 new cases diagnosed each year (according to incidence and prevalence figures in the relevant NSF). This is a small number of course, but the implications for a PCT of not commissioning and managing care well for people with complex deteriorating neurological conditions are serious. Not following the care pathway identified in the NSF for Long Term Neurological Conditions, for example, impacts not only on the experience of patients and carers but also on service quality and costs where there are inappropriate admissions and weak case management.
It would be logical, therefore, for a petition representing 10% of a much smaller but clearly defined patient group, such as people with MND and their carers, to be enough to trigger a formal response from the commissioning PCT. This proportionality is justified because of the magnitude and complexity of resources which their care represents.
What should the process be for PCTs to respond to petitions?
Petitions should be received, read and formally acknowledged at PCT Board meetings held in public. The PCT's formal response should become part of the public records of the PCT Board.
E-petitions should be allowed. The process used by the Scottish Parliament for handling public petitions, including e-petitions, is recommended as is the learning that body has accrued from several years experience in this area.
In England, e-petitioning has been successfully undertaken by Royal Borough Kingston upon Thames Council and Bristol City Council. See the report on e-petitioning from Napier University's International Teledemocrary Centre.
The PCT website should have a pro forma for initiating petitions.The website should list those petitions which have been received, how they are being processed and what responses have been made.
Which measures should be used to ensure a fair and robust process in all cases, but especially when the service to be reviewed is provided by the PCT and independence needs to be demonstrated?
Where the PCT is both commissioner and provider (through directly employed or contracted staff) there is an inherent conflict of interest. The same processes should be used in these instances as apply in petitioning English local authorities where the authority is both commissioner and service provider.
We note that the suggestion has been made that "Community Foundation Trusts" are a possible way forward to address this issue of conflict of interest between commissioning decisions and directly provided services. We support this suggestion.
What are the rights of challenge to the PCT's decision?
In effect, this situation would constitute a complaint. Petitioners seeking to challenge a PCT's decision in response to their petition should have the right to refer disputed matters first to the relevant Health Overview and Scrutiny Committee and, if resolution cannot be achieved, to the Parliamentary and Health Service Ombudsman for England. The Ombudsman would make criteria governing this and her ruling should be final.
Who will arbitrate if the response of the PCT is challenged?
This should be a matter for determination by the Parliamentary and Health Service Ombudsman for England whose ruling should be final
The following example from a M-A-C associate consultant in Switzerland illustrates some of the implications for petitioning and voting electronically which may be relevant to how PCTs might handle such developments in the future. Note that issues get on the ballot by virtue of citizens' petitions challenging the actions of of the local Council.
Direct Democracy the Swiss way
Angela Haden our Swiss Associate Consultant is an advocate of the Swiss approach to these matters and sent us the paperwork accompanying issues to be voted on at both cantonal and federal level in the elections of 24 September this year. We take a look at the cantonal initiatives since this all happens at a more local level.
At this level there were 7 issues that citizens of the Canton of Geneva were asked to vote on. Issue 1 was about the rights of tenants – Issue 2 was the reply from the cantonal Council. Issue 3 was to deal with the situation if both topics were supported by the voters – ie a sort of dead heat – and asked the question – in this case, which of the two would they prefer to see enacted?
Topic 4 was about primary school education – the monitoring and evaluation of childrens' progress throughout the six years of primary education. The proposers wanted to maintain the more traditional approach to the way that children were appraised and judged ready to move up a year.The Council opposed this and put forward its own ideas for legislative change in this area in Issue 5. Issue 6 – and you may be expecting this – deals with the voters voting for both. (The citizens' motion won by the way and there was a 55% turnout)
These first two issues were put on the agenda by citizen groups challenging the Council's intentions. The primary school issue gathered over 28,000 signatures in support – very much more than the 7000 needed to trigger a referendum and the 10,000 needed to propose a new law*. Issue 7 is one that the Council put up itself to bring an aspect of the constitution up to date and in line with modern circumstances.
However what the Swiss process shows us is that direct democracy has to be very well organised in – well - a Swiss way.
Each topic being contested is treated in exactly the same way – the proposal by the group asking for the vote, their arguments for their position and ending with a recommendation, then the arguments of the Council are stated in the same formant ending with their recommendation to vote yes or no. In the case of issue 6 (what happens if there is a deadheat over the primary school debate), the Council did not indicate a preference either way between one and the other.
These recommendations are then summarised on two pages - no, yes, counterproposal and a straight line for the 'no-preference' option. The language on the government side seems very clear, objective and calm – the citizen texts are more emotive as fits the two issues that they were concerned with in September – tenants rights and their childrens' education. But they have equal amounts of words to make their cases in the same format. After this discussion, comes some very interesting data which answers the question 'what does everyone else think?'
These pages note the recommendations of all those politicians and community groups for all 3 principal issues – Oui, Non , --- . We know what the Liberal Party thinks. We have the views of the Greens. The other groups range from the public service unions through the Mouvement Populaire des Familles MPF (the People's Family Movement ?) and landlord and tenant Associations to single issue groups (to guess from its title) 'Don't Destroy Our Schools' (Ne Cassons Pas L'école) or less emotively perhaps the Committee for Quality Schools/ Schooling (Comité pour une école de qualité). Websites are listed as well. The views of a total of 61 cantonal organisations are listed against the 42 listed as having an interest in the federal issues raised in the same elections.
So we see that this is not a process to be embarked on lightly or casually. The PCT procedures are going to have to be equally well-organised, totally robust with a level of transparency that meets the Swiss standards. The current processes of consultation challenge many PCTs and the recent Derbyshire decision has increased their concern. The competencies needed to design the petition process – even if it is on a scale that is much smaller than a cantonal election in Geneva - are the same as those deployed in Switzerland. They will involve expense, management time and the use of considerable writing and editorial skills. These are rare skills on either side – community or PCT. Finally there needs to be a diverse and established range of organisations to represent the range of citizen views.
An E-aside – Making a lot of voting, lots easier
Geneva has implemented an eVoting system which is considered to be an example of good practice by the EU. The tender for the system was issued back in 2001 and has been used now for some years. One primary consideration is the convenience of voters. The Swiss citizen can expect to vote about 4 times a year. 95% of the votes are cast by post and the e-system is an extension of that. Some 65% of Swiss are connected to the Internet. There is still some debate around the means of checking how the system works exactly – all Swiss citizens have a right to check how an election has been conducted. The Geneva website says that the source code is available to citizens.
* The population of the canton of Geneva is around 440,000.
Dr Andrew Craig (October 2006)