In an attempt to focus more on local issues future articles will from now be posted here .

I have to follow up the May 9^th meeting of Richmond’s PCT’s board – partly because my contribution under “Public Question Time” was inadequate, due to the distraction caused by an unhappy typing error in the agenda papers on the new London SHA.  These papers are a constant and remarkable demonstration of the public and local accountability of the NHS, and of our PCT in particular: too few gives them the attention they deserve. Sadly for once I held them in too high a regard.  

1. Enough has been written about the reprehensible confusion within the NHS on its statutory duty to consult on “Commissioning a Patient-Led NHS” (Ca PLNHS) on both its launch and its development.   That this confusion should continue after nine months of hammering at all levels – as confirmed in the minutes D2 table at the May 9^th meeting – has to be noted with concern and regret (although it may have been due to the absence of Modernising Director, Paul Mitchell).   

No decision has been taken on the transfer of community health services for people with a learning disability. Protests should not have been necessary to secure the PCT’s agreement that consultations were necessary and until they were put in hand the so-called decisions amounted to no more than proposals.  

2. A further and perhaps more serious confusion has to be noted in the May 9^th agenda papers.  In its report, Fi, on Corporate Governance Framework, presented by the Chief Executive, paragraph 5.2 refers to Ca PLNHS as a “directive”. 

2.1 In her December 8th letter however to the Royal College of Nursing the Health Secretary writes that “we do not have a policy or timetable for PCTs to divest themselves of provision”, and specifically of a “context of no central directive”. 

2.2 Where does this PC directive stem from?  In his March 28^th letter to the SHA Chief Executive my MP Dr. Vincent Cable writes of “the important issue of where in the chain of decision-making, from Ministerial desk to PCT, particular decisions are being taken and whether they are being exposed to the democratic local scrutiny”.  Can you – or the SHA – please elucidate? 

3. A strong protest has to be made, not at but through the PCT, over the continued insularity of the NHS.  In attachment D on “PCT Fitness for Purpose Assessment Programme”, one of the six “assessment tools is entitled ‘External Relations’???. 

3.1 The title “Partnership Relations” would have been far more appropriate, and less alien, not least because of the statutory partnership between the PCT and the Council.  Our PCT is as much a Richmond agency as it is an agency of the NHS and should be so regarded.  

3.2 No mention is made of the voluntary sector and its representative role of patient and carers as one of the “key relationships” – nor indeed in Minute D2 quoted above.   Yet it is a relationship of increasing importance with the ongoing transfer of health services away from hospital into the community. 

3.3 Both Section 11 of the 2001 Act and the Compact agreement – which you personally got our PCT to endorse at my request – endows such representatives with powers, matched by corresponding responsibilities.  They help to make the Richmond community a reality and should be encouraged.  Yet the NHS does the reverse. 

3.3.1. The PCT would be hard put to it to find the last time it made mention of the Compact. The voluntary sector contribution – both direct and through Joint Commissioning Boards, and with the Council’s two Scrutiny Committees and its MPs – has to be considered as important and central as that of the “Public and Patients Involvement Forum” (PPIF), in the strategical and tactical improvement of health and social care services. A closer alliance, supported by the statutory sector, should be an urgent priority between the PPIF and the voluntary sector through the CVS and/or the Voluntary Sector Community Group.  

3.3.2 At the consultation on a single SHA, the SHA’s Strategic Director undertook to confirm that the Compact would continue to apply to the new SHA.   Her reply is still awaited – as is an SHA reply on the distinction between eligibility and entitlement for NHS services.  

3.4 The report by the South West London Mental Health Trust on its “Spring Regeneration Programme” was tabled as an addendum to the agenda papers.  No doubt this major development will be put out to formal consultation in due course of time.  But before this takes place, it would be helpful for the voluntary sector – MIND, Age Concern etc., not to say the CORLD KSO – to be kept advised of progress so that they can build up a more informed position when it does.  Understandably for the moment the report is lacking in any local community input.  

3.4.1 It is to be hoped that some of the considerations that I have touched on above will apply.  From a brief reading however two paragraphs caught my attention: 4.37 on the changes from January 2004 to March 2006, “a reduction in the inpatient service for people with learning disabilities as a result of a strengthened community service”: 4.29 on older people, “In some of the boroughs, the transfer of continuing care service from NHS to local authority provision will also reduce the trust inpatient provision over time”. 

4. Finance:  The report on “Progress on Annual Accounts and 2006/07 Budget” has to be both noted and applauded, confirming that the exceptional performance of the department continues.  A verbal comment at the board was however a serious disappointment.  Apparently there has been no reduction in the 11% overhang, the level of expenditure assessed by Whitehall to be in excess of what might be appropriate for Richmond’s PCT. Could the voluntary sector be advised of any change in this percentage figure?  

4.1 In this context a comparison between health expenditure in London and in Scotland would be helpful, and might be raised by Richmond’s MPs.  The longstanding practice under which Scotland receives some 17% more public revenue than England should be questioned.   

5. Another issue that Vincent Cable raised at my request in his March 28^th letter to the SHA was the excessive load placed upon the PCTs “scarce management resources in playing a lead role in six of the eleven work streams involved in NHS modernisation”.  Cannot a virtue be made of this necessity?  Should not our PCT be enabled to speak with a far stronger voice with the higher echelon of the NHS in support of Richmond’s local health services, as seen by the PCT, if not in a wider local context?  Is not this a fair price for the PCT to exact at Richmond’s request in exchange for this diversion?? away from local service improvement?  Further, does not this SHA dependence on our PCT confirm the total nonsense of the NHS downgrading the PCTs’ star status. 

5.1 An example – and hopefully a precedent – of this more robust upward voice from our PCT was set in the Chief Executive’s May 9^th report.  Having been “very disappointed” with the SHA’s response over the PCT “Standards for Health” relating to the administration of the “GP performance list” the PCT was determined to have the final word – and so it stands with the full approval of the board.    

The SHA must take heed of unanimous decisions such as this which have the full support of the Council’s Director of Social Services and of those members of the voluntary sector present.  This was an administration issue, unlike the political issue of the PCT’s coterminous boundaries, where the voluntary sector strengthened the Council’s cross-party approach, taken up by its Scrutiny Committee and our two MPs. 

5.2 Vincent Cable’s arguments have been strengthened by the May 9^th agenda attachment D.  Modernising Director Paul Mitchell and Senior Finance Manager, Sheila Bull are being detached full-time for the eight week “Fitness for Purpose Programme”, covering finance and governance and the PCT’s strategic commissioning capability. 

Further, in this context was the news, as noteworthy as any May 9^th agenda item, of Dr Graham Lewis’s Chairmanship of the London National Primary Development Team – not to say the loan of Ian Maxwell as Kingston PCT’s interim Finance Director.??   

Yes the NHS has to get its house in order and yes, our PCT has to play its part – but not, please, to the exclusion of the community’s involvement, even if it has to be at the expense of postponing some service improvement. 
 

Finally at 78, I grow old, so may I register not only my formal thanks to the board but also my personal thanks to you – for your constant good cheer and positive outlook, for your understanding of the issues confronting Richmond’s PCT, and for your leadership of an exceptionally able board, exemplified by its Chief Executive Joan Mager. 

With my best wishes. 

Yours sincerely, 
 
 
 
 
 
 

Francis King 

c.c.  Dr Vincent Cable, MP

      Susan Kramer MP

      South West London SHA

      Richmond Council

      Richmond’s Voluntary Sector Community Group and its CVS 

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Dear Sir 

“Democracy versus Control Freakery” was the headline of a recent letter of April 7^th in which I followed up Councillor Geoffrey Samuels protest on education.  Such control freakery equally applies in the field of health and social care – a fact that has been demonstrated daily on TV and in the national press.   

Local examples are perhaps harder to find, but the Council Guide, sent to every council tax payer, contains a typical “Performance Indicator” on Social Services and “client assessment”.  The quoted figure of 90% looks commendable and reassuring, but it is in fact deceptive, almost to the point of being dishonest. 

Now GPs, the most constant and trusted of care providers, are saddling themselves with the same order of bureaucratic freakery.  Compare their record, for instance with that of Cambridge social workers who spend only 16% of their time on face-to-face contact with their clients.  GPs have received exorbitant increases – up some 30% since 2004 and now over £100,000 per year – while undertaking less patient care.  Are they not in danger of selling their Hippocratic souls for a mess of potage?  Cannot they be persuaded otherwise? 

The cost of these increases in Richmond must have totalled in excess of £500,000, with the average for each of the country’s 300 PCTs estimated at some £1 million.  Our PCT successfully balanced its budget, but to do so it had to cut back expenditure on learning disability and mental health services and both by more than £500,000 a piece in 2005/6 (quite apart from loaning some £1 million, and foregoing this expenditure, to the NHS and its hospitals). 

In my April 7^th letter I drew attention to the fact that GPs are now offered in their contracts 40p a patient for agreeing a written plan with their PCTs.  Plans are desirable, but they need to be freely negotiated with Whitehall input confined to the genuinely agreed minimum – or consequences to their patients will be dire. 

It is up to individual GPs or their practices to decide.  But to do so collectively – at a total loss to their pockets of some £70,000 from which the PCT would benefit – would have far greater impact than any protest from Councillor Samuels, or indeed from the full Council in its present over-regulated state, that shows all the signs of being either brainwashed or dumb-struck.   

Is this too much for a parent-carer, who has served the learning disability client-group fully and freely these past 22 years, to ask? 

Yours sincerely  

FRANCIS KING

The Editor, Richmond and Twickenham Times  

Dear Sir

May I follow up my recent letter on “democracy versus control freakery”, and draw your readers’ attention to the Council Guide, sent to every council tax payer in our Borough.  Excellent in many ways, informative and well designed, it nonetheless contains one remarkable sentence on social services – “% people receiving a statement of their needs and how they will be met: 92.4% (for 2003/4): 96% (2004/5 target): 89.38% (2003/4 London Borough Average)”.  What facts do these figures convey, apart from a warm glow in the hearts and minds of voters? 

A clue can be provided in a report on “PAF Indicators” submitted to the March 8^th Social Care Scrutiny Committee of the Council, where Indicator D39 sets out a similar sentence, with percentages given for the first 3 quarters of 2005/6, and with the comment “Excellent result, though unlikely we will achieve 100%”. 

If this is not a total nonsense, could Councillors, and not their over-stretched officers, please explain what helpful facts these sentences are intended to convey? 

All whose care needs are more severe than moderate are entitled, by statute, to an assessment of their needs.  Those of us in the voluntary sector, serving the learning disability client-group and others – and particularly those in transition from childhood to adulthood – know that an assessment and a full statement can only be an aspiration not a legal entitlement.  The best is the enemy of the good.  The law is being brought into contempt, yet the rule of law came first, before democracy, in our history. 

As for the description D39, it speaks of endless other indicators, some useful, other of doubtful merit, but most a thorough waste of time, particularly when reported on quarterly.  Could officers please advise the Council, and the voluntary sector, which they consider which?  Their first duty lies with the Council, and not with national inspectorates. 

It is a typical example of “control freakery” which, heaven help us, GP’s, those most trusted providers of care, have been persuaded to take aboard from April 1^st. 

No councillor deserves any medals for this lamentable state of affairs, neither the Tories and their Cabinet, meekly acquiescing along with other Councils, in Government-imposed processes, nor the Lib-Dems, who have the time, in opposition and as scrutineers, to be more constructively critical.  Credit however has to be given to Jack Straw, who as Home Secretary, and with the support of Tony Blair, initiated the Compact agreements that apply throughout the country between the voluntary sector and the statutory sector, its councils and its primary care trusts.  All Compacts contain this crucial sentence – “the voluntary sector is an essential element in a democratic society”. 

Yours sincerely 
 
 
 

FRANCIS KING

The Editor, Richmond and Twickenham Times

Dear Sir 

This year it is “drastic policy confusion and ………. initiativeitis” – a typical comment on the NHS in last week’s national press.  Last year it was “a staggering lack of central guidance”, in a report on continuing NHS-care, commissioned by Strategic Health Authorities. 

If the NHS is to continue to be free at the point of use – in which “we believe in most of all”, as the BMA Chairman, James Johnson, puts it – then the public and patients have to accept that limited resources from the taxpayer means and requires a limitation on the services provided by the NHS.  So should the Secretary of State at whose desk the buck stops. 

The fact has to be faced – and it has been ducked by successive Health Secretaries – that patients have no legal entitlement to NHS services, whether they are in a children’s ward, or for continuing NHS care, or the breast cancer drug herceptin – no matter how truly desperate the cases might be.  Patients are only entitled to receive “best practice” when they are taken into care whether it is in an ambulance, a hospital, in a care home or in the community.  There cannot be an entitlement to new drugs throughout the country the moment they have been licensed by NICE.  Those of us serving the learning disability client group do not need professors of health policy to point this out. 

If equity has to be an important consideration, then so is the need to decide on priorities.  A Saga reader this month had this to say on the threat of an avian flu pandemic – “The elderly should be the last to be vaccinated, having lived our three score years and ten, and with no wish to survive at the expense of our children’s and grand-children’s generation”.  NICE only provides guidance not a legal entitlement – still less for elderly patients willing to forego such vaccinations. 

Funding has to be a critical factor in the tough decisions hospital and primary care trusts have to take, for which they deserve the support of health ministers – and from their partners in the community, both councils and the voluntary sector.  There has been an absence of this support, frankly from all concerned, just as there has been an absence of financial discipline in the messages from Whitehall and its Secretary of State until now, all too late in the day.  Hence the present confusion and disarray – a disservice to the NHS, its patients and all who work in it, and the taxpayer. 

Yours sincerely 
 

FRANCIS KING

Letter to Richmond & Twickenham PCT  Middlesex

Dear Sian Bates, 

I write to thank you for and confirm the assurances you gave, as Chairman of the PCT Board, in response to the question I had raised under “Public Question Time” at its April 11^th meeting. 

1. The question arose over the possible transfer of community health services for  
 people with a learning disability from Kingston PCT to Richmond PCT (or  
 elsewhere), Agenda item G i) Community Based Services, paragraph 43.  You  
 agreed that this was in effect a proposal that would be the subject of  
 consultation (since it concerned a major change in the planning and provision  
 of services) and that it would be coming before the Learning Disability Joint  
 Commissioning Board.  I would be grateful if this assurance could be spelt out  
 in the Minutes of the meeting. 

1.1 The Agenda’s wording directly implied that two decisions had already been  
 taken.  a) to “identify a new Service Provider” for b) “implementation  
 during  2006-7.”  No such decisions can have been made, since that would be  
 contrary to :- 
 
 - the Health & Social Care Act 2001 section 11 and the statutory duty of  
 PCTs to consult. 
 
 - the NHS Chief Executive’s July 28 edict that the “pace of change would  
 be subject to local consideration and consultation.” 

      - the January 24 letter to me from the SHA’s Chief Executive that “all  
 changes of significance from a Ca PLNHS, on in fact any other policy, will  
 continue to be  subject to consultation as a statutory requirement.” 

2. When the consultations take place, issues will be raised such as those I have  
 corresponded with the PCT on since last summer.  An early priority however  
 has to be the need to challenge Kingston PCT to spell out its reasons for  
 seeking this transfer of community health services.  The drive from Whitehall  
 has its importance, but it is an “NHS expectation,” not a directive, as Health  
 Secretary Patricia Hewitt confirmed to the Royal College of Nursing.  In no  
 way should it override what all concerned locally have agreed is the best way  
 forward – a principle that will also apply to Teddington Memorial Hospital.  
 Funds are short, and “if it works don’t mend it.” 
 
3. Your Board formally recorded it’s “surprise” at the CaPL strategy and the  
 suddenness of its appearance on July 28^th.  Now in turn, the voluntary sector  has to express its surprise.  Without your correction your Board could have  
 appeared culpable of a breach of the law and a presumptuous affront to  
 people  with a learning disability and their representatives. 

i)  Sadly, since my main concern is the improvement of LD services, it has also to be noted that the Agenda papers make no mention of Key Strategic Organisations, KSOs, a major structural development of Richmond’s voluntary sector, of its CVS and the Voluntary Sector Community Group – not to say CORLD, the LDKSO formed from MENCAP and Homes For Life Trust, whose joint working with “patients” resulted in the attached page from MENCAP NEWS. 

ii)  The reasons for the failure of NHS agencies over many years to secure the re-provision of Orchard Hill Residents need to be identified and overcome. 

4)   It would also have been an affront to Richmond’s two MP’s, Vincent Cable  
 and Susan Kramer since they too are representatives of people with a learning  
 disability – just as they are of all patients amongst their constituents – and are 
           entitled to be consulted.  Indeed all client-groups have reason to be grateful to  
 both of them for raising this issue on behalf of people with a learning  
 disability. 

4. i) The issue is however far more serious than an isolated instance in Richmond  
 affecting people with a learning disability.  In Julie Dent’s letter, quoted  
 above, she writes that “the Department of Health has argued strongly  
 concerning CaPL in it’s response to the Royal College of Nursing that  
 CaPL does not represent a new strategy but implementation of a previous  
 strategy.” If so, when was consultation on that previous strategy undertaken  
 by the SHA or, the PCT? 
 
ii) An answer should be readily available.  That I should not have had a reply  
 from the SHA to my February 24 letter is perhaps by the way.  Subsequently  
 however Susan Kramer has twice raised this question with Health Ministers  
 and both she and Vincent Cable have raised it with the SHA – with no reply to  
 date as I write.  

Breaches of the law affecting the planning and provision of NHS services have to be of the first consequence.  The rule of law came first, before democracy, in our history. 

Yours sincerely, 

Francis King 

cc: Vincent Cable, MP

      Susan Kramer, MP

      James Cameron, Chairman,  Julie Dent, CEO – SWLSHA

Councillors Tony Arbour, MLA, Nicki Urquhart,

Gillian Norton, Chief Executive, Jeff Jerome, Richmond Council

John Ray, Chairman Voluntary Sector Community Group

Lydia Hansbury, Richard Jeffries, CORLD KSO

David Cornwell, Sue Telfer, Richmond CVS 

_____ 

Wandsworth & Kingston Councils 

Richmond upon Thames
NHS Primary Care Trust
Council for Voluntary Service
Communitycare
UNV Online Volunteering
Richmond Citizens' Advice Bureaux
Age Concern
Addiction Support and Care Agency
Richmond Carers Centre and Crossroads Care Partnership
Creating Opportunities in Richmond for People with Learning Disabilities (C.O.R.L.D.) 
Richmond Aid
Richmond Environment Network
Richmond Youth Partnership