Citizens, Consumers and the NHS

Christine Hogg’s Citizens, Consumers and the NHS: capturing voices (Palgrave MacMillan, November 2008; 224p; £19.99  ) provides a thorough narrative of where the Community Health Councils (CHCs) came from  in 1974, what they achieved over 30 years and why they passed from the patient and public involvement (PPI) scene in England in 2003 after a rancorous final chapter following their surprise abolition almost as an afterthought in the NHS Plan of 2000.

Woven through this narrative  is an analysis of citizenship and social rights versus consumerism and user choice as drivers of often competing, conflicting and even contradictory initiatives in the PPI world from the mid ‘70s until now.  As Christine Hogg makes clear, the one cannot be properly appreciated without an understanding of the other, so in essence this is two books in one.  You will not be disappointed if you pursue either or both strands as the history and theory are inextricable.

An overriding conclusion from the book is that 30 years of  fragmented policy, political expediency and false starts in PPI have taken a fatal toll on organisational memory. That is perhaps the greatest collateral damage from the death of the CHC movement and the miserable interlude from its creation in 2003 to its extermination in 2008 of the Commission  for Patient and Public involvement in Health and its ill-fated Patients Forums.  After only one year in operation it is too early to tell if the Local Involvement Networks (LINks), the main element in the still-fragmented replacement system to everything that went before in England,  will succeed in spite of their vague governance and accountability arrangements and a seeming lack of interest from the Department of Health.  But as the author makes clear, without understanding the mistakes, missed opportunities but also notable successes of the past 30 years, we shall all have to live through –  or perhaps be dragged through –  them again. 

Conspiracists might conclude that all governments wish to divert user knowledge, energy and the attention of user-led organisations away from the levers of power. That retrospective is sloppy and simplistic, though consumed in large quantities.  The truth  about why the CHCs were not reformed but abolished in England and the motivations of the major players at the time and subsequently is a tangled skein, but a vital story emerges from the unpicking in this book.  Rather like democracy in Weimar Germany, CHCs  did not fail on any objective criteria so much as because their potential was never seriously understood, valued, developed or – most importantly – reformed to meet evolving circumstances.  By 2000 the NHS Plan’s diktat simply ordered their demise in England to everyone’s surprise (though in Wales they have evolved and prospered in what is becoming quite a different healthcare environment).  Perhaps Wales therefore provides the counterfactual historical model to the  English experience of CHCs:  “what would it have been like if…..”. 

The story of PPI over the last 30 years as Christine Hogg explains “has much to celebrate and much to mourn.  Though the world has changed enormously since 1974,  the issues that policy makers tried to address in setting up CHCs are still current and seem to have advanced little.”  What patient – not forgetting carers –  and public involvement is actually for (in other words, the ends of the policy) is still the hardest question to answer and the one most easily avoided and obscured as the debate about the means to encourage and sustain participation thunders on generating more heat than light and often exhausting the participants. It will be interesting to see if the NHS Constitution is but the most recent example of avoiding the real issue of ownership and control of our most important public service.

As one of the “usual suspects”, I am delighted to be among this book’s collective dedicatees – it is good company to be in.  Would I recommend this book to others?  Without reservation, particularly to Chairs of LINks and their members for whom Christine Hogg has provided a reliable anchor in history and theory for the otherwise uncharted journey they have begun.  For LINks and their Host bodies,  Citizens, Consumers and the NHS should help them understand the issues and efforts of the past which are with us still so they don’t waste time discovering them anew and wondering what to do next.

There are many people with first hand knowledge of the CHC experience and its closing chapter in particular.  This is an open invitation for them to comment from their experience and give their views on what followed.

Comments

  1. Andrew Craig says

    More voices can be heard saying “come back CHCs all is forgiven”. Nigel Hawkes, health editor of The Times and estimable health journalist, writing in the BMJ on 27th May is the latest. Commenting on the lack of scrutiny over the Baby Peter and Mid Staffs Hospital scandals, he laments the lack of modernised CHCs with powers to stick their noses into inconvenient places and concludes: “I used to think it slightly sad that people with nothing better to do would endure public meetings in draughty halls listening to other people making decisions about their local hospital. They were, I thought, the NHS equivalent of Sid and Doris Bonkers, the sole supporters of Private Eye’s cod football team, Neasden FC, and its ashen-faced manager, Ron Knee. I take it all back. I was wrong. I never expected to feel any nostalgia for CHCs, but I do. Every change in patient and public representation since then has been a change for the worse. And by now, even Sid and Doris are beginning to lose heart.” Read the full piece at BMJ 2009;338:b2023

    Are Messrs. Cameron and Lansley listening I wonder?

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