Choice vs. voice? PPI policies and the re‐positioning of the state in England and Wales

Abstract

Context and Thesis  Changing patient and public involvement (PPI) policies in England and Wales are analysed against the background of wider National Health Service (NHS) reforms and regulatory frameworks. We argue that the growing divergence of health policies is accompanied by a re‐positioning of the state vis‐à‐vis PPI, characterized by different mixes of centralized and decentralized regulatory instruments.

Method  Analysis of legislation and official documents, and interviews with policy makers.

Findings  In England, continued hierarchical control is combined with the delegation of responsibilities for the oversight and organization of PPI to external institutions such as the Care Quality Commission and local involvement networks, in support of the government’s policy agenda of increasing marketization. In Wales, which has rejected market reforms and economic regulation, decentralization is occurring through the use of mixed regulatory approaches and networks suited to the small‐country governance model, and seeks to benefit from the close proximity of central and local actors by creating new forms of engagement while maintaining central steering of service planning. Whereas English PPI policies have emerged in tandem with a pluralistic supply‐side market and combine new institutional arrangements for patient ‘choice’ with other forms of involvement, the Welsh policies focus on ‘voice’ within a largely publicly‐delivered service.

Discussion  While the English reforms draw on theories of economic regulation and the experience of independent regulation in the utilities sector, the Welsh model of local service integration has been more influenced by reforms in local government. Such transfers of governance instruments from other public service sectors to the NHS may be problematic.

Introduction

This article suggests that the issue of citizen participation in healthcare governance needs to be understood within its regulatory and institutional contexts. Viewed in comparative perspective, the different arrangements for patient and public involvement found in Western countries are the product of state initiatives, whether resulting directly from government policy or arising more indirectly through the spaces for involvement that policies open up. We examine the contrasting cases of England and Wales, and explain how their respective patient and public involvement (PPI) policies reflect different stances towards market‐oriented healthcare reform, and different ideas about the positioning of the state vis‐à‐vis healthcare regulation. We argue that recent National Health Service (NHS) reforms in England combine elements of direct Department of Health (DH) oversight of PPI with a transfer of some regulatory functions to external institutions and instruments, of the kind said to characterize the ‘new regulatory state’. Welsh policy makers also relied on a combination of central direction and decentralized policy instruments, but have settled on a different mix of regulatory instruments that excludes certain tools associated with markets and competition. Instead Wales has given a fresh twist to command and control by promoting a model of small‐country governance that emphasizes better connections between central government and local services and greater responsiveness to local communities. We show how these broader NHS policies have resulted in strikingly different approaches to public involvement.

The notion of the new regulatory state has gained currency in several countries since the early 1990s. ¹ , ² , ³ In the United States it is associated with the rise of specialized agencies, which function to achieve a measure of governmental intervention without public ownership, but have nevertheless been criticized for their command‐style regulation. ³ In the UK, the term has different connotations concerned with the privatization of the nationalized industries and the dispersal of regulatory authority away from core state institutions, referring to the perceived shift from ‘command and control’ to the more distant ‘steering’ of networks and markets, and increased emphasis on self‐regulation. After a period of de‐regulation in the 1980s associated with the retreat from public ownership, governance came back onto the policy agenda in the 1990s as new forms of ‘responsive’ or ‘smart’ regulation gained influence. ⁴ , ⁵ Partly because of the limited control capacity of the central departments, policy makers began to explore options for shifting the burden of regulatory work to a more dispersed and diverse set of actors, networks and instruments. ⁶ , ⁷ , ⁸

Although controversial, the idea of the new regulatory state provided a convenient rubric for understanding ongoing developments in many important fields of economic and social activity, such as local government, environmental protection, the utilities, education, social care and health. From the 1990s onwards there was a delegation of regulatory functions from UK government departments to public agencies and arms‐length bodies, and sometimes to private enterprises contracted to provide public services. Within organizations, operational and regulatory functions were often separated. The regulatory landscape became more complicated, with external bodies sharing responsibility with government departments for regulating the provision of services in accordance with contract terms or the provisions of the relevant statutory regime. This might entail forms of meta‐regulation whereby organizations were required to evaluate and report on their own self‐regulation strategies to overseeing agencies. ⁹ , ¹⁰ The model of the arms‐length regulator, acting in the public interest but free from hierarchical line‐of‐command controls, was widely applied in the utilities sector and became a key building block in the regulated markets that emerged. ¹¹ , ¹²

However, despite a recognition that institutional forms are changing, many writers remain sceptical about the claim that hierarchical regulation has given way to de‐centred governance. ¹³ , ¹⁴ They point to the resilience of command institutions, the uneven implementation of reforms across sectors and the possibility that delegation in some areas can be accompanied by continued use of top‐down controls in others. Just as the concept of ‘command and control’ represented a convenient oversimplification of a complex reality, ¹⁵ so it can be argued that evolving alternatives are more mixed and heterogeneous than the new regulatory state thesis allows. One strand of research in the United States has focused on the ‘tools of government’ deployed by the state as supplements to more direct modes of regulation in efforts to achieve policy objectives. ¹⁶ The governance of public services in the UK is arguably increasingly characterized by ‘centralized decentralization’, ¹⁷ involving different combinations of continued hierarchical control with elements of delegation and devolution. ¹⁸ Whereas in England decentralization has taken the form of the delegation of contractual powers and responsibilities to public purchasers and other agencies, ¹⁹ in support of the government’s agenda for marketization and increasing economic incentives, in Wales the emphasis has been more on initiatives intended to increase engagement with local communities. The mixed nature of regulatory arrangements has been accentuated by the administrative devolution introduced by the Blair government. The creation of national assemblies or parliaments in Wales, Scotland and Northern Ireland led to a transfer of significant devolved powers in areas such as health and social care, and also different approaches to regulation.

While certain market‐oriented governance elements associated with the ‘new regulatory state’ are clearly recognizable in the English NHS, ²⁰ , ²¹ they are less evident in the context of developments in Wales, Scotland and Northern Ireland. In all the UK countries the challenge has been to move beyond the internal market of the Thatcher/Major years, either to develop an improved market‐oriented system or return to a form of hierarchical integration compatible with a 21^st‐century health service. We compare England with Wales to show how Welsh policy makers have shied away from de‐centred governance, while also being anxious to avoid a straightforward return to old‐style centralization. Welsh policy makers justify their chosen regulatory arrangements with arguments about the advantages of small‐scale government, in terms of improved responsiveness and better co‐ordination between services.

These developments appear to run counter to the widely claimed trend towards global convergence of healthcare systems, ²² , ²³ , ²⁴ and presumably towards convergent regulatory frameworks and PPI policies. European institutions are attempting to harmonize aspects of healthcare governance in relation to matters such as the free movement of services, patients’ rights and citizen participation. The European Commission has recently issued a draft directive promoting trade in health services and cross‐border patient rights. ²⁵ In 2000 the Council of Europe recommended that governments should ‘create legal structures and policies that support the promotion of citizens’ participation and patients’ rights’ (p. 9). ²⁶ Yet as two of us have argued elsewhere, ²⁷ national health policies continue to develop along divergent paths, often under the influence of non‐convergent institutional forces. Contrasting political contexts, differences in the constitutional mechanisms of multi‐level governance and different institutional arrangements within the devolved governments have all played a part in the genesis of divergent policies. ²⁸

NHS policy divergence and PPI

UK devolution opened the way for divergent health policies that quickly affected PPI. ²⁷ , ²⁸ , ²⁹ , ³⁰ After a brief period following Labour’s 1997 election victory which saw a general shift from the previous internal market to a softer purchaser/provider system with enhanced performance management and planning, England broke ranks with the other countries to propose a new supply‐side market. From 2002 onwards, English policy makers attempted to create a system with a bigger role for private‐sector hospitals, semi‐autonomous NHS foundation hospitals, standard reimbursement tariffs for a range of interventions for both public and private providers, an arms‐length regulator spanning both sectors and greater patient choice of provider for elective surgery. The other home countries did not emulate these policies, at first continuing with soft forms of purchaser/provider contracting and then, in the cases of Scotland and Wales, electing to end the purchaser/provider split to create unified NHS bodies. The different stances towards the market crystallized in the PPI area around the issue of patient choice and how this might be reconciled with other aspects of PPI.

Traditionally most NHS patients have been referred by their general practitioners (GPs) to hospitals within their immediate localities, and any choice of provider has depended on informal communication between GP and patient. However, in 2006, the English NHS introduced a Choose and Book system whereby NHS patients awaiting referral for surgery could select from four or more available hospitals. Within months, the government announced that, in addition to local hospitals, patients could select from a ‘national menu’ of NHS foundation trusts and independent sector treatment centres (ISTCs). The incoming Brown government announced its intention to widen this further to a ‘free choice’ system, in which patients referred for most kinds of planned treatments could opt for any foundation hospital, ISTC or private hospital in the ‘extended choice network’. ³¹ The rules permitted both public and private hospitals to market and advertise their services. At present, there remains a yawning gap between policy and implementation, with limited patient access to information on outcomes, and limited participation of private providers. ³² Arguably the real consequence of the policy is the ability of Trusts and clinics to more effectively manage their waiting lists by channelling patients towards the units with most capacity. But in terms of the policy discourse, the move to increase choice clearly supports the growth of the new NHS market, both because of the likelihood that many prospective patients will select private hospitals, and because real choice will require an expansion of provider capacity, again benefiting the private sector (p. 14). ³³

There was little political support for the English market proposals in the Welsh Assembly Government (WAG) and a perception that competition and choice would not suit a sparsely‐populated country with geographically isolated hospitals. Major policy differences quickly emerged because of Wales’ unwillingness to replicate the key elements of market reform in England described above. Thus the Welsh NHS has no foundation trusts or ISTCs and makes no use of standard tariffs. Welsh policy makers were doubtful that the English Commission for Healthcare Audit and Inspection (Healthcare Commission) would be sufficiently attuned to the different Welsh standards, especially in the PPI area. They were unsympathetic to the idea of an arms‐length regulator, which they believed reduced Ministerial accountability, and created a new body, Health Inspectorate Wales (HIW), within the WAG to take over the Commission’s functions (with the exception of certain continuing responsibilities such as a shared annual ‘state of health’ report, and some England and Wales service reviews). Patient choice was widely perceived in WAG circles as a building block in a consumerist healthcare market. Welsh policy makers preferred to emphasize improved service integration and PPI policies centring on representative local bodies and opportunities for collective voice.

We turn now to consider the shift in English policy away from an earlier concern with promoting the voice element of PPI by means of NHS bodies towards a mixed approach emphasizing choice and economic regulation in addition to voice, and with operational responsibility for public involvement being delegated to de‐centred networks rather than to core NHS bodies. This contrasts with a Welsh approach in which PPI activity continues to be steered directly from the central departments, though with the fresh twists associated with the policies of localism and small‐country governance.

The analysis of policy divergence that follows is based on preliminary research undertaken in connection with two overlapping studies of public involvement and commissioning in the NHS supported respectively by the European Commission and the British Department of Health. The authors have reviewed UK policy documents, recent legislation and the academic commentary, and also draw on interviews (n = 16) with policy makers, civil servants and NHS managers in Wales.

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England: de‐centred networks and arms‐length regulation

Since the millennium there have been two distinct phases of PPI reform in England: the first concerned with the strengthening of involvement in tandem with existing NHS bodies and the second with the development of area‐based ‘networks’ comprising a wider range of agencies and actors. ³⁴ , ³⁵ The first wave of reforms is already discussed extensively in the published literature. ³⁶ , ³⁷ , ³⁸ , ³⁹ One key element was the section 11 duty under the Health and Social Care Act, 2001. This duty required NHS bodies to involve and consult the public in the planning of the provision of services and the development of ‘proposals for changes in the way those services are provided’, and in decisions ‘affecting the operation of those services’. Another was the abolition of Community Health Councils and their replacement by Patient and Public Involvement Forums (PPIfs) for each Primary Care Trust (PCT) and NHS Trust in England, in line with the provisions of the National Health Service and Health Care Professions Act, 2002. PPIfs were overseen and managed by the Commission for Patient and Public Involvement in Health (CPPIH), which contracted with about 140 not‐for‐profit organizations tasked with supporting individual forums. Problems identified by PPIfs could be referred to local government Overview and Scrutiny Committees (OSCs), empowered to investigate and if necessary refer the matter to the Secretary of State. The third component was the establishment, under the Health and Social Care (Community Health and Standards) Act 2003, of the Healthcare Commission (formally the Commission for Healthcare Audit and Inspection) with wide‐ranging responsibilities for promoting improvement in the quality of health and health care. The establishment of CPPIH and the Healthcare Commission introduced an external element into the oversight of PPI arrangements by giving powers to ‘non‐departmental government bodies’ at arms‐length from the DH. The Commission’s PPI responsibilities included conducting patient surveys and involving patient groups through service user consultation on specific issues. From 2006 the Commission applied core standards on PPI in its ‘annual health check’ of NHS organizations, and supervised the process of self‐assessment by Trusts on whether they have achieved these and other standards (including core standard 17 relating to PPI).

The PPIfs, based in Trusts and PCTs, were tasked with monitoring and reviewing the operation of services, and required to provide advice and information to patients and their carers, to obtain their views, and to make reports and recommendations. However, the viability of this system was soon questioned as the NHS landscape changed and it became apparent that they would not fit with planned governance arrangements in the new NHS Foundation Trusts (paras 33, 34). ⁴⁰

In this paper we focus more on a second wave of reforms, brought in partly to address perceived weaknesses of the previous arrangements but arguably also because they mesh more coherently with the market policies described above. These reforms centre on new institutional arrangements for PPI introduced by the Local Government and Public Involvement in Health Act 2007 and the Health and Social Care Act 2008. In terms of the new regulatory state thesis, the key developments are the creation of co‐ordinating PPI organizations outside the core NHS, greater reliance on networks as opposed to integrated organizations and the strengthening of arms‐length oversight via the creation of a new super‐regulator whose remit includes involvement.

De‐centred networks

Just 5 years after their inception, PPIfs were abolished and replaced by local involvement networks (LINks), which became operational in April 2008, although some Local Authorities were permitted to start later before a final cut‐off of 1 October 2008. The explanation for this abrupt change in policy direction is complicated and contested. ⁴¹ The 2006 review of PPI ⁴² , ⁴³ highlighted various problems in the operation of PPIfs, including their failure to represent local communities; their inability to encompass the patient’s journey through health and social care services due to their attachment to particular NHS bodies; and the confused relationship between the internal PPI activity of Trusts, the role of PPIfs and the role of OSCs. Frustration with the performance of the CPPIH also seems to have been a factor (para 83). ⁴¹ The government justified the abolition of PPIfs with reference to unanticipated and fundamental changes in service organization. ⁴⁴ The shift to a reduced number of PCTs covering larger areas and increased numbers of Foundation Trusts was at odds with the original model of PPIfs based on older NHS organizations. Other factors cited by government related to the emerging market included greater choice of service providers and service delivery, the increased emphasis on the role of PCTs as service commissioners and the growing importance of the commissioning process as a means of improving services. The government also referred to the need for better integration of health and social care, and the shift in social care towards personalization of services, self‐directed support and direct payments.

The solution adopted by the government, based on the recommendations of the Expert Panel set up to examine evidence from the government’s PPI review, ⁴⁵ was to create networks of local and community organizations, no longer attached to, or captured by, NHS bodies but covering a defined local government area. LINks were set up outside the line of command of both the NHS and local government, supported by an independent body (the ‘host’) under contract with the local authority. Although many factors were involved, the effect was to create a mechanism which adapted PPI to a regulatory environment supporting provider pluralism.

The government faced the problem that the top‐down creation of LINks by fiat would not fit with the bottom‐up engagement implicit in the network concept. Consequently the 2007 Act was unusually permissive in allowing LINks freedom to determine their own governance structures and membership rules. Where members of the PPIfs had been appointed by the CPPIH, recruitment arrangements for the new bodies were more open, and it was envisaged that both voluntary organizations and individuals would be involved (p. 15). ⁴⁵ As LINks cover both heath and social services and can make recommendations on issues affecting multiple services, the networks potentially involve a diverse range of actors and agencies.

The concern to avoid top‐down prescription has led to criticism that plans for the internal organization of LINks lacked sufficient detail (para 152). ⁴¹ The House of Commons Health Committee (HCHC) described two models that had featured in the policy discourse. The first, based on best practice in the PPIfs, relies on a core group of members running the LINk, sitting on Trusts’ boards, undertaking surveys or visits, producing reports and so on. The second model presents LINks as a looser network, having no real core and operating as ‘a sort of junction box or a sort of facilitative mechanism’ (paras 115–121). ⁴¹ In both models there are no limits on the number or diversity of participants. DH guidance allows for a combination of the two types, while emphasizing that the structure of the LINk should be dependent on local decisions and conditions.

NHS ‘service providers’ have a statutory duty to respond to requests for information and to recommendations made by a LINk, and LINks have powers to enter NHS premises to observe services, subject to certain safeguards. Independent providers are not bound by the 2007 Act but their service contracts will require them to respond to requests for information from LINks, and to permit LINks to observe publicly funded services. LINks themselves will be subject to an external regulatory regime based on localized performance management, peer review and assessment against national performance benchmarks. ⁴⁶

The HCHC had expressed concerns over the implementation of the so called ‘section 11’ consultation duty [section 11 the 2001 Act (para 239‐51] later consolidated into section 242 of the NHS Act 2006). ⁴¹ The duty was further ‘enhanced’ in section 234 of the 2007 Act ⁴⁷ but in a way that gave rise to further controversy. This change clarified and altered the range of issues on which the public must be involved, and created a new duty for PCTs and strategic health authorities to respond to consultations. But in adding new duties it also appears to have narrowed the range of matters on which the public must be involved, now excluding questions of how services are provided, or who provides these services (allowing no consultation on the desirability of use of independent providers). The effect, in our view, is to restrict the scope of involvement to issues affecting user experience and choice. ³⁵

The development of a bridging mechanism to link the grassroots voices represented in LINks to national policy debates was left to a voluntary sector initiative, ‘National Voices’, a charitable body consisting of voluntary organizations representing service users. This is conceived as ‘an ‘organization of organizations’, a network of national not‐for‐profit organizations that champion the interests of service users, patients and carers and will give them a complementary, co‐ordinated voice (p. 5). ⁴⁸ The government has welcomed this initiative and pledged co‐operation but it remains unclear how the embryonic national network will be co‐ordinated with networks at the local level.

The arms‐length regulation of involvement

English policy makers had drawn increasingly on concepts from economic regulation theory and the experience of the utilities sector and other health systems. ⁴⁹ , ⁵⁰ , ⁵¹ The English NHS had had an arms‐length regulator enforcing quality standards including those relating to PPI in the form of the Healthcare Commission since 2004, ⁵² as well as several other arms‐length bodies overseeing different spheres of activity. The Health and Social Care Act 2008 simplified the regulatory framework by merging three current bodies (the Healthcare Commission, the Commission of Social Care Inspection and the Mental Health Act Commission) into a single super‐regulator – the Care Quality Commission (CQC) – with an expanded range of regulatory powers, including powers affecting the PPI field.

Service providers, whether public or private, carrying out ‘regulated activities’ in health or social care in England are required to register with the CQC and are subject to its standard setting and inspection regime. The Commission may enter and inspect regulated premises and has a wider range of enforcement powers than those available to previous regulators, including the issuing of penalty notices and the commencement of criminal proceedings. It has powers to vary, suspend or cancel registration.

The CQC was established ‘to protect and promote the health, safety and welfare of people who use health and social care services’ (HSC Act 2008 s3.1). Specific matters to which the Commission must have regard under the Act include: (a) views expressed by or on behalf of members of the public about health and social care services, (b) experiences of people who use health and social care services and their families and friends, (c) views expressed by local involvement networks about the provision of health and social care services in their areas and (d) the need to protect and promote the rights of people who use health and social care services (s. 4).

The most significant extension of power for the new regulator, however, is its responsibility for the regulation of involvement itself, backed up by the enforcement sanctions mentioned above. This part of the vision set out in the White Paper, A Stronger Local Voice, is concerned to ensure that NHS organizations comply with and fulfil their duties to involve and consult: ‘The regulators will seek to develop assessment criteria to measure performance against national standards…Current core standards for the NHS include the need to seek out and take account of the views of patients, carers and others in designing, planning, delivering, and improving healthcare services’ (p. 20). ⁴⁵ The 2008 Act accordingly provides that the CQC must publish a ‘statement on user involvement’, describing ‘how it proposes to (a) promote awareness among service users and carers of its functions, (b) promote and engage in discussion with service users and carers about the provision of health and social care services and about the way in which the Commission exercises its functions, (c) ensure that proper regard is had to the views expressed by service users and carers, and (d) arrange for any of its functions to be exercised by, or with the assistance of, service users and carers’ [s 5(1)].

One issue raised by the transfer of the independent regulator model into the quintessentially ‘command’ environment of the NHS is about just how independent from government the CQC will be. Critics have been concerned that the 2008 Act provides that the Commission‘must have regard to such aspects of government policy as the Secretary of State may direct’ [s. 4(2)] and with possible overlap in the activities of the CQC and DH in specifying standards. There have also been questions about how far the Commission’s economic efficiency goals might be in tension with quality assurance. Overall CQC’s remit centres rather more on choice than ‘voice’, especially at the national policy level.

As is the case with networks more generally, the emerging English PPI framework represents a hybrid combination of hierarchical command and market elements. ⁵³ , ⁵⁴ Statutory duties enforced by hierarchical controls, contractual relationships and voluntary action all play a role. Consistent with the model of de‐centred governance considered earlier, operational and regulatory responsibilities are frequently separated, and as in the regulated markets created in sectors such as the utilities there is an independent regulator.

Wales and the new localism

After 2001 when England began introducing new patient choice policies, Wales adopted a more incremental approach to reform building on existing structures. The WAG’s first major policy document, the NHS Plan for Wales, articulated a vision of partnership encompassing both individual patients and communities. The Health Minister’s foreword set the Plan firmly in the context of policies to counteract disadvantage and social exclusion, emphasizing ‘the importance of building and supporting strong communities where the values of citizenship and collective action can grow’ (p. 5). ⁵⁵ The Plan unveiled a vision of an NHS ‘driven by the views and involvement of individuals and communities in the design, delivery and monitoring of health services’ (p. 35). ⁵⁵ Patient choice was not ruled out, but it was patient ‘voice’– the right to be informed, to express views and be understood – that received explicit endorsement.

Creating an infrastructure for engagement

The Plan laid the foundations for what was to be called the ‘new localism’ of the NHS in Wales. The creation in 2003 of 22 Local Health Boards (LHBs) operating alongside local government authorities, with ‘co‐terminosity’ of purchasers in the two sectors, is something that does not apply to English PCTs. Together with the retention of Community Health Councils (abolished in England in 2003), this was the central plank of the Assembly’s strategy to bring a greater local voice to NHS decision making. The Health (Wales) Act 2003, based on the first all‐Wales Bill to undergo pre‐legislative scrutiny by the National Assembly and the Westminster Parliament, made provision for a range of new duties and powers for Welsh CHCs, including the right to be consulted about major service changes and the extension of oversight to primary care.

The institutional infrastructure to support PPI policies was developed through initiatives at various levels. ³⁵ As far as NHS bodies are concerned, NHS Trusts and LHBs were required to undertake a baseline assessment and annual reports on progress regarding PPI, which are an element in the performance assessment framework monitored by WAG. Practical suggestions for the elaboration of Welsh PPI policies were set out in the guidance paper, Signposts ⁵⁶ and Signposts II. ⁵⁷ At the community level, a number of umbrella social development programmes provided project‐based funding for schemes initiated by local people and organizations. In most cases these did not have an exclusive health focus but were concerned with more general issues of disadvantage and social exclusion. There was the paradox that while most schemes were brought into being as part of the strong policy direction set by the WAG, their raison d’être was the creation of sustainable bottom‐up developments whose content by definition could not be determined from above. Examples include: Communities First, a project to support bottom‐up social development projects launched by the WAG’s Department for Social Justice and Regeneration in 2002; Local Health Alliances, a Welsh Office initiative dating back to 1999 which required local authorities, NHS bodies and other stakeholders to come together to identify and deal with health issues in local communities; and Sustainable Health Action Research Programmes, an initiative to support action research projects in the areas of health, housing, unemployment, social distress and poor access to services. Although questions have been raised about the sustainability of individual projects when core funding ends, and a degree of disconnection between micro level projects and macro policy, Welsh policy makers continue to see these programmes as ‘slow growth’, long‐term ventures that will need to learn lessons over time.

WAG made no attempt to link policy on PPI with patient choice as in the English Choose and Book reforms, but introduced a Second Offer scheme in April 2004, offering an alternative treatment option for patients experiencing excessive delays on surgical waiting lists. Initially this scheme offered treatment at a second hospital for patients waiting more than 18 months, but the threshold was reduced to 12 months in March 2005. Currently the WAG Health Department is in the final stages of implementing its strategy to reduce maximum waiting times to 26 weeks within 3 years (‘Access 2009’), and it is anticipated that this will lead to a winding down of the Second Offer scheme. Welsh policy makers were clear that Second Offer is not a patient choice mechanism designed to shape referral pathways and patterns of service purchasing. Choice is restricted to exercising the option of stepping out of a long queue into a shorter queue at a different hospital, and the initiative is primarily about reducing waiting times.

The small‐country governance model

Over time the WAG has put its distinctive stamp on PPI policies by developing a focus on citizen voice and engagement, while rejecting the consumerist market model. As stated in the 2005 policy document Designed for Life, the strategy is to: ‘…empower the community to have its voice heard and heeded, rather than simply being given a choice of treatment location’ (p. 14). ⁵⁸ Policy makers have developed a rationale for policy divergence with England by setting health policy in the context of the Assembly’s wider strategy for the public sector, and what has been called the small‐country governance model. The policy document Making the Connections ⁵⁹ set out the case for an integrated, collaborative model of public sector service organizations, better suited to Welsh conditions than the English model of autonomous provider units in a quasi‐market. Options for the operational implementation of this vision were discussed in the 2006 Beecham Report, ⁶⁰ which proposed a revamping of government and service delivery organizations to achieve better integration at both central and local levels. Beecham suggested the creation of multi‐agency, ‘local service boards’ (LSBs) in each local government/PCT area, which would further strengthen engagement with communities. Six pilot LSBs were created in 2007–2008, with a plan to establish boards in all the 22 local government areas in 2009. WAG created a new Public Services and Performance Department (PSPD) to co‐ordinate engagement policies across the different public service sectors and oversee the inspection bodies concerned with health, social services and education.

At the time when the powers of the former England and Wales regulator, the Commission for Healthcare Improvement, were expanded to create the Healthcare Commission, WAG opted to establish its own oversight body, HIW, as an organization within government rather than an arms‐length body. Some degree of operational independence was secured by locating HIW within PSPD rather than the Department of Health & Social Services, though the inspectorate also has a close working relationship with the latter. HIW currently assesses the performance of NHS bodies against the Welsh Health Standards, last revised in 2007. Patient Experience is one of four domains to which the Welsh Health standards apply, with at least four standards relating directly to PPI.

While at first sight HIW’s remit overlaps with that of the Healthcare Commission in England, it has been created as a traditional inspectorate and lacks the Commission’s wide‐ranging powers to oversee the regulation of involvement.. HIW assesses inter alia whether NHS bodies have ‘systems in place to support and develop effective public and patient involvement in service development, including partnership working’ (p. 1), ⁶¹ but possesses no sanctions for poor performance other than a negative inspection report. In terms of the overall regulatory framework, Welsh policy makers have emphasized a balance between ‘inspection, self assessment, peer review, and support for service improvement’ (para 6.52), ⁶⁰ and an important role for ‘citizen‐centred scrutiny’ at both local and Assembly levels.

Wales’ big idea of small‐country governance is linked to a vision of centrally organized health and social services that achieve greater citizen responsiveness by improved central‐local engagement and better ‘connections’ at both departmental and local levels. Interestingly Wales, like England, has used the idea of networks as an alternative to traditional command‐and‐control structures, but in the context of ‘a new Welsh public service based on flexible networks of diverse pathways involving a range of organizations, all working to a common citizen‐centred model’ (para 2.24). ⁶⁰ Private for‐profit provision is limited mainly to social care, with a stated intention to end use of private hospitals by the NHS in Wales by 2011 (p. 9). ⁶² It is argued that ‘small scale allows an intimacy and focus which should yield highly joined‐up government’ (para 7.6), ⁶⁰ and that public service delivery can be transformed through ‘direct communication between the Assembly Government and local organizations, supported by more streamlined procedures, more joint delivery of public services, more flexibility of organizational structures, and more effective engagement with the citizen’ (para 6.11). ⁶⁰ Thus Assembly officials will serve on LSBs and Ministers will themselves be responsible for signing off local service agreements.

At the present time the small‐country governance model remains largely aspirational, with much depending on how the policies are implemented. In the PPI arena, there are question marks about whether connections across the central departments can overcome what might otherwise appear as complexity and fragmentation of responsibility, and how far local representative bodies engage in a meaningful sense with communities and citizens. Just as in England, both centralizing and decentralizing tendencies persist. The Welsh system places considerable power with the executive, which appears likely to carry forward in such areas as direct Ministerial oversight of delivery plans at the local level. At the same time, public bodies make routine use of many of the new public management‐style tools and instruments developed since the 1980s. Thus in the PPI field in Wales, as across the border, there is a mix of organizations bound by statutory duty, hierarchical command, contract or voluntary participation. Within the NHS system, ‘new public management tools’ such as performance management against standards and the ‘balanced scorecard’ (a tool for weighting policy priorities) are much in evidence. The major difference from England is that there is little attempt to use competition, contestability or external regulation to create appropriate incentives. Rather regulation of the system is achieved mainly via continuing central steering, linked to the democratic accountability of the WAG to the Assembly.

The future direction of PPI policies has been thrown into doubt by proposals to end the NHS purchaser/provider split in Wales published in 2008. ⁶³ There are plans to channel funding to hospitals via a single central NHS Board, and an intention to replace the present 22 LHBs with seven unified bodies, that will both plan and provide services. The Consultation Paper appears to foreshadow a return to centralism and seems to threaten the ‘localism’ associated with LHBs, LSBs and the associated PPI policies. The proposed unified bodies, which will also be known as LHBs, will each be aligned with a former NHS Trust and a grouping of local government authorities. ⁶⁴ The previous arrangement of one‐to‐one co‐terminosity of old LHBs and local authorities will be lost, and the principle of securing democratic accountability via inclusion of local government representatives on NHS bodies will be weakened. The Consultation Paper acknowledges that: ‘With fewer organizations, patient and public engagement will have to be secured in new ways’. ^{65 (p.6)} At the time of writing it appears likely that this will involve a further reform of CHCs to become co‐terminous with local authorities but the details of this remain unclear.

Conclusion

In England and Wales, the reconfiguration of the role of the state in healthcare governance is being accompanied by contrasting trajectories of development of once similar PPI systems. We have suggested that these transformations should be understood as (different) manifestations of the process of simultaneous centralization and decentralization that characterizes contemporary multi‐level governance in both countries. Hence the English reforms couple elements of continuing bureaucratic control with indirect steering via an arms‐length regulator, and shift responsibility for the co‐ordination of local PPI policies from NHS PCTs and Trusts to independent organizations (the host and LINks). Wales, on the other hand, is adapting traditional hierarchical command structures to work more effectively on a small scale, in the effort to change relations between the centre and periphery and to improve engagement with local communities. The English PPI framework has been adjusted to operate in the shadow of choice policies associated with the new NHS market, while PPI in Wales is about ‘voice not choice’, in the context of what remains almost exclusively a publicly‐delivered health service. Not only is the ‘new regulatory state’ thesis clearly not borne out by the Welsh experience, but it is deficient also in the English setting where the transformations fall well short of a shift to a full‐blown market in health services, and hybrid institutional arrangements are being adopted in the attempt to combat the perceived twin failures of bureaucracy and the market (p. 1). ⁶⁶ Organizational arrangements in Wales, which had already incorporated many of the familiar performance management tools of the 1990s internal market, are now being combined with newer forms of close steering linked to localism, and concerned with the WAG’s outreach into local bodies (such as LSBs). This has been reflected in PPI policies which must necessarily involve the diverse provider networks that developed in the 1990s, but which under the banner of engagement also create new channels of influence – and perhaps command – between WAG and local bodies.

Both countries have developed novel approaches to the regulation of PPI that depend on importing concepts or instruments from other domains into the health field. Thus the English economic regulation model has been transferred from the privatized utilities, while the chosen Welsh model owes much to local government. This pattern raises important issues concerning the degree of autonomy of fields and the problems that may occur as one field adopts instruments created in another. There are plausible theoretical arguments from institutional sociology ⁶⁷ that suggest that such transfers across the fields of the modern state are likely to create problems. This will be a key issue for empirical investigation as the reforms recently unveiled in the NHS in England and Wales are implemented and settle down.