Royal Commission on the NHS Chapter 11

The NHS and the Public

11.1 The interest, support and influence of the public are essential to the well being of the NHS. Nearly all of us are its patients from birth, and over one million of us work in it. Many more contribute as members of health authorities, or through leagues of friends and other voluntary bodies. There has always been a strong tradition of involving the public in the NHS, but specific and separate consumer representation was introduced for the first time at reorganisation in 1974 when community health councils (CHCs) were set up. They were experiments, though inheritors of a long tradition. In this chapter we consider how they are getting on. We also look at arrangements for making suggestions and complaints in the NHS, and the role of informal, but nonetheless important arrangements for voluntary effort in the NHS.

Community Health Councils

11.2 The White Paper on NHS Reorganisation in England defined CHCs as “bodies to represent the views of the consumer”. The need for health authorities to know and take account of the views of local communities was emphasised and “lively and continuing interaction between management and the users of the services” identified as being of “benefit to both parties”.  The NHS reorganisation legislation established a CHC in each health district. In England and Wales half a CHC’s members are appointed by local authorities, one-third by voluntary organisations and one-sixth by regional health authori­ties or their equivalent. In Scotland and Northern Ireland the proportion of local authority members is smaller. Appointments are normally for four years. Finance is provided by Regional Health Authorities (RHAs) in England and areas elsewhere.

Function and role

11.3 The functions of CHCs outlined in the 1972 White Paper and the subsequent DHSS circular on NHS reorganisation included representing the interests of the public in each health district to the area health authority (AHA); contributing ideas on how services should be operated and developed; providing information and advice about formal complaints procedures and monitoring the volume and type of individual complaints as a measure of public satisfaction; and commenting on health authority plans and on proposals to vary services affecting the public (e.g. hospital closures), and on collabor­ation between health and related local authority services. To help CHCs carry out these functions, they were given statutory powers to secure information, visit hospitals and other institutions and access to health authorities and their senior officers. The DHSS have advised AHAs to allow a CHC representative to attend AHA meetings with the right to speak but not to vote, and to attend family practitioner committee (FPC) meetings, as observers, at the discretion of individual FPCs.

11.4    CHCs were conceived and should be seen as consumer bodies, and not as part of the management machinery of the NHS, but it is evident that in practice this simple principle is not easy to apply. Our evidence reveals much uncertainty and confusion about their role within CHCs and amongst health authorities and other bodies. Conflicting opinions were expressed about how early CHCs should be consulted and whether they should be given a formal part in the decision-making process. The Association of District Councils said:

“Given a full democratisation of the management of the health service, it would not be necessary to have CHCs and there would be a considerable administrative saving. Short of this it has been suggested to the Associ­ation by member councils that the role of the CHCs should be strengthened by giving them some powers of decision in relation to the assessment of priorities.”

Not surprisingly the Association of CHCs in England and Wales took a different view in oral evidence:

“Consumer representation is stronger when it is not involved with management, and some confusion of the representative and management roles is evident amongst members of AHAs: even if a health authority were established at district level there would continue to be a role for CHCs.”

11.5    Many CHCs submitting evidence felt that they did not have the power or the resources to fulfil their functions effectively. East Hertfordshire CHC said what many others implied:

“At the moment there is much criticism of CHCs from some quarters as a waste of money in hard times. If CHCs can achieve nothing in gaining improvements, or even in mitigating hardships, this criticism will be justified. And yet, the system is loaded against the CHC. It has little money, few staff, and no sanctions save those of public opinion.”

Indeed, some hostility towards CHCs and the way they interpreted their role was expressed in evidence to us. One district nursing officer said:

“They watch aggressively and seem permanently to be seeking to find fault with the loyal and hard pressed National Health Service staff on whose patients they are constantly requesting surveys and for whom they offer little, if any, practical help.”

However, this point of view was not widespread. Many health authorities commented on the positive part CHCs played in helping to develop health services in their districts.

CHCs at Work

11.6 A survey of the activities of 180 CHCs in 1977 gives some idea of the way they went about their work. Three out of four had carried out surveys of local services and most were represented to some degree on NHS planning Almost a third of those in the survey attended Joint Consultative Committee meetings and 30% had been involved in helping complainants to present their cases at service committee hearings. One in four CHCs were allowed to send observers to FPC meetings.

11.7 It is almost impossible to determine from the available evidence whether or not CHCs are fulfilling their functions of representing consumers and channelling local opinions to health authorities, and five years is not long enough for any new institution to realise its full potential. However, some aspects of their role deserve review at this stage.

Informing the public

11.8     It is part of a CHC’s role not only to tell people how to complain about services but to contribute ideas for the development of services. To do this they need to inform the public about the availability of local services and propose changes and developments in them. Most CHCs acknowledge that this task is difficult to perform well with limited resources. The siting of CHC offices is also important here and health authorities should encourage them to find “High Street” or easily accessible premises wherever possible.

Monitoring local services

11.9     To do this effectively, CHCs clearly need full access to relevant information. In the main they have the co-operation of health authorities with one major exception. In England and Wales family practitioner committees often appear to resist CHC attempts to assess family practitioner services. Many  CHCs  told  us  that  this  was  their  greatest  stumbling  block.   We recommend that CHCs should have right of access to FPC meetings and their equivalent in Scotland and Northern Ireland. If FPCs are abolished as we propose in Chapter 20, CHCs should have access to the meetings of the committees which take over FPC functions.

Representing public opinion

11.10    CHCs are better able to pursue the interests of the consumer if they survey opinion about local health services from time to time. Many CHCs have done this, but effective public opinion sampling is expensive and health authorities may not find it easy to meet the costs involved. In addition, if CHCs are to make an effective contribution to the way in which health services are provided in the future they need to be fully consulted by health authorities about their plans. They may need more support if they are to assess local health issues effectively. On the other hand, it is not their function to do the health authority’s job. A balance has to be struck. We recommend that CHCs are given more resources to enable them to inform the public fully about local services.


11.11 In our view CHCs have been an experiment which should be supported further along the lines suggested above. They need to be involved at the formative stages of policy development. The health departments should give them more specific advice on the role they are expected to play. If the structural changes recommended in Chapter 20 are introduced it will be important that the close identification of CHCs with relatively small popula­tions is retained.

Suggestions and Complaints Procedures

11.12 It is difficult to write about complaints without giving the impression that the NHS is constantly being criticised by the people who use it, that the normal relationship between patient and health worker is one of confrontation, and that only elaborate procedures will protect the patient from the risks of going to his GP or being admitted to hospital. This is a wholly misleading picture: there are about 200 million contacts between GPs and their patients each year and a similar order of contacts between patients and those who provide dental, pharmaceutical and ophthalmic services. In 1978 there were 1,465 complaints about these services which got as far as a hearing in the UK. Over six million in-patient treatments were provided in hospitals and nearly nine million new out-patients were seen. Written complaints were made by less than one per cent of patients. What we say in the following paragraphs should be read with these figures in mind.

11.13 However well intentioned those who provide the services are, things can go wrong. The NHS is just as liable to human error as any other large There has to be a mechanism for mistakes to be corrected. This should be seen as a positive contribution to making the NHS more efficient. We have referred in the heading to this section to “suggestions and complaints” and the emphasis should be that way round. Nonetheless, few of us actively welcome suggestions from outsiders about how to do our jobs, however kindly they are meant, and however beneficial to our ultimate welfare they may be. There needs, therefore, to be a simple and well understood mechanism through which people who use the NHS can suggest how it can be improved and complain when things go wrong.

Family practitioner services

11.14 In England and Wales complaints about GPs, dentists, opticians and pharmacists providing NHS services have to be made in writing to the FPC administrator within eight weeks of the event which gave rise to it. An informal procedure also exists which aims to explain and clarify matters and remove misunderstandings between patient and practitioner without resort to the full service committee procedure. Where this informal procedure is used, a lay member of the FPC is appointed to conduct the investigation, with medical advice if necessary, within a fortnight of the complaint being received. If the matter is not resolved there the complaint can be dealt with formally. However, there are many complaints which, not being concerned with breach of contract, fall outside this procedure.

11.15 A formal complaint is referred to the appropriate service committee, whose chairman will initially consider whether a breach of contract is involved. If a hearing is necessary, the complainant and practitioner are invited to present their cases and can call witnesses. Both are allowed to use paid or voluntary help in the preparation of their case, but at the hearing only unpaid “friends” can take part. The decision reached by the service committee can be appealed against by either party to the Secretary of State. If an appeal is made, an oral hearing can be arranged at which both parties are entitled to legal representation. Although there are no separate FPCs in Scotland and Northern Ireland the service committee procedure operates in these countries. In 1978, 1,253 service committee cases were dealt with in England, over half of which were related to general medical practice. A breach of contract was found in just under a third. In the same year 48 cases were dealt with in Wales, 134 in Scotland and 30 in N Ireland.

11.16 It was put to us that this procedure favoured the practitioner because complaints had to be made to those who are responsible for administering the service in question. However, the decision about whether a complaint should be referred to a service committee is made by a layman and the service committee itself has a majority of lay members. Other criticisms are that the service committee cannot require the production of patient records or insist that they should be made available to the complainant to help him to prepare his case and that the time limit of eight weeks for making a complaint is too Many feel that the procedures are generally too formal and complicated.

11.17 An approach to tackling these problems was made in a consultative document published by the DHSS in 1978. The proposals provide for an extension of the informal procedure with the aim of removing misunderstand­ings and attempting to resolve a complaint quickly and simply. Committees for dealing with formal complaints should be independent, the Chairman being selected from a panel of three appointed by the Lord Chancellor from within each region, with voting rights. The service committee would also include two independent members, one lay and one professional. This might go some way to removing the criticism of bias. Service committees would also have the power to ask for the case notes to be released for examination by the The time limit for submission of complaints would be extended from eight weeks to six months. Finally, in  an  attempt  to  simplify  the procedure, the DHSS suggested that service committees should be reduced in size from seven to five members (including the chairman and the two independent members), and that oral complaints to an FPC officer should be allowed.

11.18     In   general   these   recommendations, together with proposals to improve publicity and the public’s understanding of the complaints procedure, should go a long way to meeting the criticisms of the existing system. However, we have reached no conclusion on the recommendation that case notes should be released to complainants. It can be argued that the release of case notes will often be important when there is dispute about a practitioner’s actions, and that in the long run it might lead to greater frankness between doctor and patient. On the other hand, the present confidentiality of case notes allows a practitioner to record fully his impressions and judgments in detail which is of considerable value to himself and others caring for the patient later. The potential release of case notes might in some cases result in the keeping of a brief defensive set of notes with perhaps another set in some other form. We are not convinced that extending the time limit for complaints is necessary. If oral complaints are allowed then eight weeks seems to be an adequate time for formal complaints to be lodged.

Hospital services

11.19 No statutory procedure is laid down for patients to complain about hospital services or make suggestions for improving them. Each health authority has the right to deal with complaints in its own way, subject to guidance from the health departments. If a patient wishes to complain formally about some aspect of the hospital service, he must do so in writing to the district administrator responsible for a particular hospital. Informal complaints or suggestions may be dealt with on the spot by the head of a If investigations follow from either kind of complaint, the complainant has to be told of the outcome of the investigation and that he can pursue his complaint with higher authorities if he remains dissatisfied.

11.20 In 1976 there were about 15,600 written complaints resulting from hospital treatments in England and Wales and 1,570 in Scotland in 1975. The Health Service Commissioner received 712 complaints in 1978 although he was able to accept only 138 of these as falling within his terms of reference. There is no record nationally of the number of complaints about hospital services which come into CHC offices, but one estimate suggests that in England and Wales this figure might have been more than 9,000 in 1976. Nor is there any record of complaints made orally.

11.21 The Davies Committee on hospital complaints procedure in England and Wales published its report in 1973. The committee identified gaps in the procedures which they felt were inevitable because existing guidance did not provide properly for handling suggestions and complaints. The main recom­mendation of the Committee, that health authorities should have a uniform written code of practice for handling complaints in the hospital service, was accepted by the DHSS and the Welsh Office in 1976. After consultation, a code of practice was drawn up which applies to all complaints about health services, except those which relate to family practitioner services. This code is currently being re-drafted by the DHSS in the light of comments made during consultation and is likely to be published later this year.

11.22 A major recommendation of the Davies Committee was that an investigating panel outside the jurisdiction of the Health Service Commissioner should be established in each health service region to investigate complaints, including complaints involving clinical matters. The then Secretary of State asked for a review of the present jurisdiction of the Health Service Commis­sioner for England, Wales and Scotland, by the Select Committee on the Parliamentary Commissioner. The main reason for this was concern that there might be an overlap of functions between the suggested regional panels and the Health Service Commissioner which would lead to confusion.

11.23 The Select Committee’s report, “An Independent Review of Hospital Complaints in the NHS”, was published in 1977 and criticised existing procedures and mechanisms on the grounds that they were complicated, fragmented and slow. The Committee also felt that when difficult cases occurred (almost always cases with a clinical element) the enquiry procedures used had sometimes been disquieting. A further criticism was that even after using existing procedures many complainants were left dissatisfied. The Committee concluded that “a more radical approach is needed, scrapping much of the existing structure and replacing it with something better”. The report included the recommendation that there should be a simple, straightfor­ward system for handling complaints in every hospital with the emphasis on listening carefully to the patient’s or relative’s concern and dealing with it All other cases not resolved in this way, including clinical matters, should be referable by the complainant or the health authority to the Health Service Commissioner.

11.24 The main criticisms of existing arrangements made to us were similar; that there was no single established procedure; that procedures were complicated and slow; and that there was no recognised or simple procedure for an external review. We find ourselves here in the position of having to repeat much of what the two other enquiries (the Davies Committee and the Select Committee on the Parliamentary Commissioner for Administration) have already said. There is an undoubted need for a single straightforward complaints procedure. This will be facilitated by the abolition of FPCs in England and Wales which we recommend in Chapter 20.

11.25 Since no procedure is likely to be known or immediately understand­ able to all who might have cause to use it, there is a good case for making the CHCs’ role in complaints procedures a more active one. We suggest that in the literature supplied by hospitals informing patients of suggestions and com­plaints procedures the name and telephone number of local CHC offices is given prominence, together with a statement that patients can seek advice about procedures from them. CHCs should make it their business to ensure that this kind of information is readily available in all their local hospitals. However, it may be possible for CHCs to undertake a more active role as adviser and “friend” in complaints procedures only at the expense of other important aspects of their work. The full burden of the extra work should not fall on CHC secretaries; members or other volunteers might act as the patient’s friend if they are adequately briefed. More resources may be necessary in some areas if these changes are to be introduced and we so recommend.

11.26 If CHCs are to develop their role as patients’ friends, we suggest experiments with “patient advocates”, on the lines of those in the USA. The advocate’s function would be to take up problems as they arose with the person or department responsible quickly and informally. He or she would be based at a hospital or health centre, and would be a paid employee, part-time or full-time, of the CHC.

I11.27 In all this we emphasise that CHCs should not seek to encourage and advance irresponsible or trivial complaints. Although it seems clear that the great majority of complainants are not acting maliciously, every care should be taken not to encourage those who do not have genuine grievances.

11.28 All complaints procedures should include adequate informal arrange­ments for settling small problems and resolving trivial disputes. The Davies Committee made suggestions for procedures at hospital ward and departmental level which would encourage patients to make suggestions and which we hope to see included in the code of practice. FPC arrangements already include informal procedures which will be strengthened by the implementation of the recommendation (made in the DHSS consultative document) to allow oral complaints.

11.29 We agree with the Select Committee’s recommendation that the Health Service Commissioner should be allowed to accept cases involving clinical matters. We recognise the difficulties involved and it is important to ensure that patients do not use the Health Service Commissioner procedure as a trial run to collect evidence for taking legal action. Both the  Davies Committee and the Select Committee acknowledged this risk, and the latter said:

“We are deeply concerned about this problem of double jeopardy and see no complete solution to it … The only more definite means of alleviating the danger of double jeopardy is to insert a statutory bar to the courts when a complainant elects to ask the Commissioner to investigate his case. There are some relevant precedents but we ourselves doubt whether this is feasible or desirable. Therefore some danger of double jeopardy must remain. It will continue to be one of the many difficulties of the Health Service Commissioner’s task to minimise this danger.”

In his evidence to the Select Committee the then Commissioner said that he did not know of a case having been taken to court after he had dealt with it. He subsequently notified the Committee of one such case. We share the concern of the Select Committee on this issue but feel, as they did, that an independent mechanism for the review of such complaints is necessary.

11.30 Complaints procedures may operate against the best interests of patients. Whatever procedures are devised most patients will remain hesitant about using them, and this is why informal arrangements and sympathetic staff attitudes are so important. Equally important is the need to develop an effective role for CHCs, not simply as an aid to complainants, but on the much wider front of influencing health service provision to meet the needs of patients. We think that if their role is clarified and strengthened along the lines suggested earlier in this chapter, they will be able more easily to represent the views of the consumer and fulfil the functions envisaged for them at reorganisation more effectively.

The Voluntary Contribution

11.31 We have received a great deal of evidence from voluntary organisa­tions and others pointing to the unique and varied contribution made by volunteers to the NHS. The Volunteer Centre identified in its evidence nine types of activities through which voluntary organisations and individual volunteers help the NHS. They were: befriending patients; providing skilled help in occupational therapy; providing specific services like canteens, libraries and trolley shops; entertaining patients; fund raising; setting up special interest groups, for example for mentally handicapped patients; running self or mutual help groups; engaging in pressure group activities; and pioneering new forms of The health departments recognise this contribution and encourage it by making grants to national organisations to enable them to extend the range of their activities or simply to continue their work when other sources of income are inadequate. Local organisations and effort probably make an even larger contribution to services in their area.

11.32 There can sometimes be difficulties in using volunteers. Permanent staff may, for example, resent them, seeing them as a potential threat in the market for labour and occasionally volunteers can make their work more The haphazard use of volunteers is obviously unwise and their activities need to be co-ordinated carefully. Many health authorities have appointed voluntary service organisers to ensure that this is done.  Some training of volunteers may be useful. One of the most valuable contributions made by voluntary organisations is to initiate new methods of local service provision and they should be left to get on with this without undue interference and without well-meaning attempts to professionalise their activities. In some areas, for example, volunteers arrange medicine deliveries for people who cannot get to the chemist, and voluntary organisations have long been pioneers in the provision of hostels. We recommend that health departments and health authorities continue to give financial support and to encourage voluntary effort in the NHS.

11.33 A variation in voluntary work in the NHS is self-help groups and There are many such groups in the UK at the present time. The contribution they make to patients suffering from particular diseases and to the development of services for them, is considerable.

11.34 Another recent development has been the establishment of patient committees in individual health centres and group practices. Their development seems to have been spontaneous resulting from the desire of one or two GPs to improve their service in line with patients’ suggestions. There are now about 20 patient committees in England and Wales with a National Association. There are local variations in function and composition, but their general aim is to encourage health professionals and patients to meet informally and work together to   improve. Patients  can  make   suggestions  and  voice complaints in an accessible and relaxed forum. Patient committees are an interesting development and may offer opportunities for the advancement of health education and community care in the local setting but they need initiative from both doctors and patients. Most of them, up to now, have been set up by highly motivated doctors and seldom in practices where there is a real need for developing a dialogue between doctors and patients. We would like to see positive steps taken to encourage the setting up of such committees and recommend that financial support should be given to enable them to get off the ground.

Conclusions and Recommendations

11.35 Since their introduction at reorganisation CHCs have made an important contribution towards ensuring that local public opinion is represented to health service management. They need additional resources to fulfil this task more effectively, and further guidance from the health departments on their role.

11.36 It is very important that patients should be able to make suggestions for improving health services. Those who have complaints about the way the NHS has treated them or their relatives must also be able to make them through a simple, fair and effective mechanism. The changes in procedures which we have discussed are likely to improve matters considerably.

11.37 The contribution made by the public, voluntary bodies and volunteers is of major benefit to the service. It should be encouraged. The development of informal patient committees is a constructive way of bringing patient views to bear on the provision of neighbourhood primary care services.

11.38    We recommend that:

  • CHCs should have right of access to FPC meetings and their equivalent in Scotland and Northern Ireland. If FPCs are abolished as we propose in Chapter 20, CHCs should have access to the committees which take over their functions (paragraph 11.9);
  • CHCs should be given more resources to enable them to inform the public fully about local services (paragraph 11.10);
  • more resources should be made available where necessary to allow CHCs to act as the “patients’ friend” in complaints procedures (paragraphs 25 and 11.26);
  • health departments and health authorities should continue to give financial support and to encourage voluntary effort in the NHS (paragraph 11.32);
  • financial support should be given to encourage the setting up of patient committees in general practice (paragraph 11.34).
  • CHCs should have right of access to FPC meetings and their equivalent in Scotland and Northern Ireland. If FPCs are abolished as we propose in Chapter 20, CHCs should have access to the committees which take over their functions (paragraph 11.9);
  • CHCs should be given more resources to enable them to inform the public fully about local services (paragraph 11.10);
  • more resources should be made available where necessary to allow CHCs to act as the “patients’ friend” in complaints procedures (paragraphs 25 and 11.26);
  • health departments and health authorities should continue to give financial support and to encourage voluntary effort in the NHS (paragraph 11.32);
  • financial support should be given to encourage the setting up of patient committees in general practice (paragraph 11.34).