Contact: Denise Holden ex 7338

e-mail: [email protected]

1. Summary and Purpose

1.1. The purpose of this report is to alert Members to proposals from the NHS to vary or develop health services provided to people living in the area of the Committee.

1.2. Proposals that are considered to be substantial in nature will be subject to formal consultation. The nature and scope of this consultation should be discussed with the Committee at the earliest opportunity.

1.3. The response of the Committee will take account of the criteria adopted by the Committee on 29 July 2003 with particular emphasis on the duties placed on the NHS by Section 11 of the Health and Social Care Act 2001.

1.4. The Report is presented to the Committee in 2 parts:

_ Items for information: these alert the Committee to forthcoming proposals from the NHS to vary or change services. This provides the Committee with and opportunity to determine if the proposal would be considered substantial and assess the need to establish a formal joint committee

_ Items for action: these set out the actions required by the Committee to respond to proposals from the NHS to substantially change or vary NHS services.

1.5. This report and recommendations provide members with an opportunity to influence and improve the delivery of NHS and therefore support the delivery of Aim 5 (Improving Services) of the Corporate Strategy.

Items for Information

2. Mid and South West Hants Cluster: surgical services reconfiguration

2.1. The Committee has been apprised of the intention of the review the options for a reconfiguring surgical services across SUHT, WEHT, Lymington Hospital and Andover Hospital.

2.2. The lead individual for this work will be Mark Hackett, Chief Executive of SUHT

2.3. The case of need, and the options for providing surgical services to this population needs to be established to allow members to determine if the changes are substantial.

3. Winchester and Eastleigh Health Care Trust: temporary closure of Endoscopy Services at Andover War Memorial Hospital

3.1. The Trust will provide the Committee with an up-date on the position at AWMH in March.

Items Requiring Action

4. Blackwater Valley and Hart PCT: Modernising Health Services at Fleet Hospital

4.1. The Committee notes the focus of the proposal on maintaining services in the community as close to people homes as possible.

4.2. The PCT provides the Committee with a report of the outcomes of the consultation process.

5. Maternity Services in South East Hampshire

5.1. The Committee notes the document distributed by Portsmouth City PCT; this can be accessed on Better maternity services

5.2. Members appointed to the Joint Committee will provide a regular up-date on progress.

6. Department of Health: Future Arrangements for the support of Patient and Public Involvement in Health

6.1. The draft response is attached at Appendix One for consideration by the Committee.

7. Framework for Assessing Substantial Change

7.1. The joint committee for Health Overview and Scrutiny in Hampshire and the Isle of Wight has endorsed the document approved by the Committee

7.2. This has been shared widely with NHS senior staff and the Independent reconfiguration Panel

7.3. Comments and feedback have been invited. The closing date for this process is 15 March.

8. Healthcare Commission: Performance Assessment Framework

8.1. The Healthcare Commission launched this consultation in late November 2004.

8.2. Details of the full document can be found on Healthcare Commission

8.3. A draft copy of the response is attached at Appendix Two.

9. Commission for Social Care Inspection: Consultation on Draft Standards for Improving the Regulatory Process

9.1. CSCI produced two documents for consultation in late November and early December. These can be found on CSCI

9.2. As there were a number of common issues raised by each document and for ease of reference a combined response has been prepared for members to consider

9.3. The draft response is attached at Appendix Three.

Recommendations

Items for Information

10. Mid and South West Hants Cluster: surgical services reconfiguration

10.1. The Hampshire and Isle of Wight Joint Committee is advised of the OSCs whose populations will be affected by the proposed changes

10.2. The Committee is briefed on the joint arrangements established

10.3. The draft framework for assessing substantial change informs the development of the proposals for reconfiguring surgical services

11. Winchester and Eastleigh Health Care NHS Trust: temporary closure of Endoscopy Services at Andover Hospital

11.1. The Committee is apprised of the any decisions taken with regard to the Endoscopy service at Andover Hospital at its meeting in March 2005.

Items for Action

12. Blackwater Valley and Hart PCT: Modernising Health Services at Fleet Hospital

12.1. Any comments members wish to make to the PCT on the proposal are sent to the Chairman by the 7 February 2005.

13. Maternity Services in South East Hampshire

13.1. Members note the document produced by Portsmouth City PCT

13.2. Members are apprised of the progress of the joint committee on a regular basis

14. Department of Health: Future Arrangements for the support of Patient and Public Involvement in Health

14.1. The draft response is agreed by Members

15. Framework for Assessing Substantial Change

15.1. The outcome of the consultation process is reported at the next meeting

16. Healthcare Commission

16.1. Members agree the response to the Healthcare Commission

17. Commission for Social Care Inspection

17.1. Members agree the draft response from the Committee

Section 100 D - Local Government Act 1972 - background papers

The following documents disclose facts or matters on which this report, or an important part of it, is based and has been relied upon to a material extent in the preparation of this report.

NB the list excludes:

1. Published works

2. Documents that disclose exempt or confidential information as defined in the Act.

File Location

None

Appendix One

Draft Response to the consultation on The Future of Patient and Public Involvement Forums

1. I am writing on behalf of Hampshire County Council Health Overview and Scrutiny Committee in response to the current consultation on the national and regional structures to support Patient and Public Involvement Forums.

2. The Committee has decided to respond in writing to the consultation rather than complete the on-line questionnaire, which inappropriately limits the scope of the consultation process and does not allow for a full and genuine dialogue regarding the options for supporting the Forums when the Commission for Patient and Public Involvement in Health (CPPIH) is abolished. It is difficult not to come to the view that decisions have already been taken regarding the way forward and that the current consultation will not inform this process. It would be deeply disappointing if this were the case.

3. The Committee strongly supports the role of the Forums as an independent body working alongside (not within) the local NHS to strengthen and improve the delivery of health services. Our experience of working with the Patients Forums suggests that CPPIH has not been effective in enabling the Forums to operate in a supportive environment. Forum Support Organisations have been variable in their performance and the regional offices of CPPIH seem to have imposed a bureaucratic burden that inhibits rather than supports the activities of the Forums. We therefore support the abolition of CPPIH, although we were surprised that this decision was not subject to consultation.

4. Many of the issues currently facing the Forums were well rehearsed in the lead up to the abolition of CHCs, as evidenced in the lengthy discussions that took place in both the House of Commons and House of Lords. The lessons learnt from the first year of operation of the Forums must inform the next steps to be taken if the hard work and commitment of many front line Forum members is to be harnessed to good effect. The Committee is deeply concerned that there is a danger that the approach outlined by the Department of Health does not appear to take account of this experience.

5. It must be remembered that Forum members are drawn from the community and give their time voluntarily. They must have the support necessary to ensure that they have appropriate administrative back-up and access to specialist advice about health and health services when this is required. The arrangements for providing this support to the Forums must be consistent and of high quality, there may therefore be a benefit in looking at a national contract for these services. The model developed to support CHCs in Wales provides an example of what can be achieved in this respect. Equally the Forums need to be established in a way that most effectively enables them to discharge their statutory duties across the communities they serve. We do not believe the current focus on NHS organisations is the best way to achieve this objective, particularly with regard to the need to engage with vulnerable or hard to reach groups.

6. It must also be remembered that the Forums are just one part of a complex set of arrangements for putting patients and the public at the heart of decision making about health services. The Forums need to be able to operate in a way that complements other interests in improving health and health services. The scope for the Forums to be coterminous with Local Authority boundaries now needs to be considered, providing an opportunity for the Forums to be more responsive to local people and integrated with other community development initiatives such as Local Strategic Partnerships and well as providing a more effective route for links with Health Overview and Scrutiny Committees (OSCs). At present this interface is too weak and variable.

7. We would also wish to see consideration given to a stronger alignment of the Forums, with the `local presence' envisaged by the Healthcare Commission, working with OSCs to provide local intelligence about the performance of health services. The options outlined in the consultation framework do not take account of these opportunities. The benefits of such an approach would be:

· Access to an established infrastructure that is independent of health but orientated towards local communities

· Increased opportunities for partnership working across different populations

· An ability to contribute to local strategic planning and then participate in implementation

· Links with local Community Councils and Volunteer Bureaus

· Provision of local intelligence to national regulatory and assessment bodies

8. Funding is obviously a key concern. The budget allocated to CHCs was enhanced when CPPIH was launched. This must be properly targeted to ensure that the work of the Forums is supported and we would question whether the current deployment of funds achieves this. Revised arrangements for supporting the Forums need to be realistic and be able to deliver demonstrable value for money.

9. Although we would support the need for there to be a source of advice to Forums we would question whether this should take the form of the `Centre for Excellence' described. We have already alluded to the fact that the Forums are just one part of a complex network supporting patient and public involvement in the NHS; a significant amount of good practice and training is already provided through a variety of routes and the value of duplicating this for the Forums would need to be carefully examined.

10. Access to appropriate advice is of particular importance and it is of concern that, some 14 months after their establishment , the training to Forum members seems to be so limited. The responsibility of the Forums in reflecting the views of the public and patients requires greater emphasis to ensure that members understand they do not represent these constituencies and therefore should not comment on their behalf. Similarly the `fit' of the Forums with different elements of patient and public involvement arrangements is poorly understood in some areas, with some Forum members not even being aware that they are able to refer matters of concern to OSCs.

11. Methods for engaging patients and the public represent a considerable body of knowledge, often linked with regional centres or academic institutes. It may be more appropriate therefore to consider the value of a `virtual' centre providing a base for information exchange, sharing good practice and offer training and development opportunities, open to all contributing to engagement and involvement. The advantage of a virtual site would be ease of access to up-to-date information for all involved in patient and public involvement activities to support local developments. The Centre for Public Scrutiny already has the infrastructure for supporting this type of work and it may be possible that, rather than duplicating this, the opportunities for collaborative working could be explored more fully.

12. The final point that we wish to make relates to the need for ICAS services to be integrated with the work of the Forums. The arrangements for providing these services currently appear to be very variable across the country. If a national body for supporting the Forums were to be considered then there is no reason why the latter stages of assistance to complainants could not be provided through this network.

Appendix Two

Assessment of the performance of healthcare organisations: response to consultation

1. This is the response of Hampshire County Council's Health Review Committee to the public consultation that the Commission is currently undertaking. We have, to the fullest extent possible, replied to the questions set out under the various chapter headings. This is however a very complex document that runs to nearly 100 pages. Our first general comment would therefore be whether this is an appropriate format for this type of consultation exercise. Simple measures, such as numbering paragraphs, would help with the feedback process but other options for obtaining comment would have been helpful to encourage different communities to respond. Your document makes specific reference to the needs of different audiences, which our Committee would strongly support; these can only be addressed by different methods of engagement, shaped by the needs of the constituency in question. The emphasis placed improving information to patients and the public through the assessment process is particularly helpful.

2. Local feedback and involvement will be an essential element of any credible system of performance assessment and the Commission must ensure that robust systems are in place for securing this engagement across a wide variety of different health economies. We have written to you previously offering to contribute to the establishment of a `local presence' in Hampshire (attached at Annexe One). It is disappointing that we have not received a response to this proposal, nor information about how this work is progressing elsewhere.

Chapter One: Relevant Assessment

Effective Engagement

3. The objective of engaging with the public, patients and healthcare professionals to inform the assessment process is laudable and should be supported. This will require effective local arrangements for achieving this and the document is not clear how this can be achieved. In Hampshire we have a variety of resources that could be used in this way. This includes Local Authority Health Overview and Scrutiny Committees, district and borough councils and a very active voluntary sector.

What really matters

4. Although there will be legitimate variation across healthcare organisations it is crucial that people are able to access the healthcare they need, regardless of ability to pay. Pressures on some services are such that long waiting times do exist, particularly in those areas that are not measured as a national target. Although the time from consultation to admission will help address this Commission must be vigilant about `hidden' waits for services. Performance assessment that looks at the patient's journey, whatever the starting point is appropriate and timely. It is not clear if the process suggested will enable this level of local intelligence to inform the assessment.

Additional Considerations

5. The Commission could ask that healthcare organisations provide examples of work they have undertaken to inform commissioning decisions. This would have the benefit of giving greater priority to areas such as health needs assessment that have not been well developed in some Trusts. Other prerequisites to `getting the basics right' need to recognise the interdependencies that exist between care providers and include strategies for engaging with patients and the public, inter-organisational and partnership working and joint working arrangements. Examples of good practice could be disseminated nationally whilst areas requiring improvements could be addressed through a local network of interests.

Presenting Findings

6. It would be helpful if, when presenting findings, information could be included setting out the action that can be taken should an individual experience services that do not meet the required standards. This would give the healthcare organisations the chance to identify and take action to remedy any shortfalls in performance without having to resort to the complaints process. In many areas PALS already provide this service, although this may not be formalised or consistent. Action taken in this way would provide practical evidence of improvement.

Chapter Two: Guiding principles

Failings in Provision

7. The organisation being assessed should be able to demonstrate that it has arrangements in place to monitor that services are being provided in the right way and at the right time. Where the Commission does identify systemic failures there needs to be an understanding of the responsibility for addressing these and clarity about the resource implications this may bring. We are particularly sensitive to this point as our health economy is under considerable financial pressure, which effectively curtails flexibility in funding provision. Inevitably this requires that choices are made about priorities and service improvements.

Improving Services

8. If a healthcare organisation is able to show support for local priorities that are different from those set nationally, the assessment framework should be able to accommodate this. Although there does need to be consistency across services, and we would support this, national targets should not be exclusively pursued if other local action would bring greater benefit to the population.

9. There may also be times when work needs to take place across health and social care services and mechanisms need to be in place to enable the Commission to work alongside CSCI to ensure that assessments processes are properly aligned. In this respect the review programme outlined is very welcome and we would ask that consideration be given to inviting OSCs to contribute a local perspective to this work.

Fairness and Transparency

10. The assessment of performance should concentrate on the improvements that the organisation in question is able to delver. If issues arise that relate to factors outside the remit of the organisation then this must be reflected in the reporting.

11. An appeal process would be helpful should the organisation consider that there are material local considerations that have not been taken into account.

Chapter Three: Approach to Assessment

Phased Introduction

12. The phased approach suggested is probably sensible given the scale of the change that the Commission is seeking to introduce. In order to increase sensitivity to local intelligence the wider health community (e.g. OSCs, Patients Forums or other key stakeholders) could be invited to endorse/support particular examples of good practice in relation to the core standards as early as next year. Although this may not contribute to the overall assessment it could be referred to as additional information and would begin to give a sense of the way in which the Trust was working across a particular community.

13. Other work, which is required in other national directives but not currently included in the standards, could be assessed. This could include for example a report on progress with health equity audits or local thresholds/ arrangements for prescribing NICE drugs. Other indicators able to contribute to understanding performance could be based on NICE interventions but locally specific. All of these are evidenced and should be easily demonstrable, an example would be the provision for foot care assessment for people with diabetes. We have recently looked at this issue locally and have been surprised at the significant variation that exists across different PCT areas.

Using Information

14. It would be useful to be able to contribute to the shaping of the programme of assessment as it affects our local Trusts. Our Committee has been very active in building working relationships across Hampshire and could constructively contribute to the generation of local intelligence.

Balance of approach

15. We would agree that there needs to be a balance in the burden of inspection and monitoring with a more flexible self-assessment approach. This can only be achieved if there is a strong local focus with the engagement of all relevant organisations. This will need a genuine focus on building strong links across diverse health economies. Although alluded to in the consultation document it is not clear how this would be taken forward in the relatively short time frame that exists before the roll out of the assessment process. This needs further consideration. A `tick-box' approach must be avoided.

Chapter Four: Core Standards

Self Assessment

16. We have already commented on the value of a self-assessment process that incorporates the views of other in the local health community. Our concern remains that the core standards, although important, are not what matters most to local people.

Supporting Guidance

17. This seems to be moving in the right direction but requires a considerable investment at step 2 if the assessment is to be transparent.

18. It would also be helpful for OSCs to have the capacity to refer a matter to the Commission should a concern about a Trusts' performance emerge and local action has not resolved this.

Assessing Outcomes

19. Outcomes have been notoriously difficult to measure in the past. If this is to be credible then there needs to be absolute clarity about what is meant by an outcome and how it is measured.

Measuring targets

20. If the targets are to be used in this way they do need to focus on the performance of the individual Trust and not be used as a comparator with others. This has previously contributed to the loss of credibility of the assessment process. Equally those conducting the assessment must be consistently in how they apply the assessment criteria.

Using resources

21. We would strongly endorse the use of outcomes data that included an assessment of the way in which resources are used by the Trust. The four questions to be asked as part of the assessment are very helpful and will draw out problems that might not otherwise be addressed.

Links with other regulators

22. Our Committee would strongly support the steps to ensure that there are links with other regulators. These may be national or local. We would also wish to see a commitment to working in partnership with others where issues of common interest are identified. The Commission for Social Care Inspection (CSCI) for example is currently consulting on its approach to regulation and assessment of social services providers. It would be helpful if there was a common approach to this work wherever possible, both for the sake of consistency and in recognition of the interdependencies that can exist with regard to health and social care provision.

Chapter Five: Making Progress

New targets

23. The emphasis placed on streamlining the standards that the NHS is expected to comply with will be welcomed by many, as will the recognition that the complexities of the healthcare system will require a flexible approach to assessing individual Trusts.

24. The Committee would agree that the core standards need to be seen in the context of local accountability, this being the case there is a greater need for the reporting back to reflect what is important to patients and the public

25. If a Trust is judged to be unsatisfactory of failing there needs to be a clear system for reassuring the public that care will not be compromised. There is no doubt that Trusts branded as `0' star, do receive a higher public profile. Where the Trust is delivering front line services (e.g. an ambulance trust) people have no idea of what this may mean for service provision. It would be helpful if this point could be considered in the new arrangements you are proposing.

Improvement Reviews

26. We have commented previously on the value of these reviews as part of the assessment process. In terms of prioritising topics, a joint approach with CSCI and possibly overview and scrutiny committees would be helpful.

Chapter Six: Annual Ratings

Publishing results

27. We have previously suggested that additional information could be included in next year's results to give a richer picture of the performance of an individual Trust. The new system is complex and it is important that people understand exactly what performance is being evaluated and what this means for local services.

28. The `dashboard' approach that gives people the chance to look at different aspects of performance in more detail has considerable merit.

Rating Performance

29. Consistency in the measurement of performance will be a crucial aspect of the rating process. This has been devalued in recent years and needs to be robust if the new assessment process is to delver the required information and improvement.

Leadership and capacity

30. We would concur with the comment that, at least initially, leadership and organisational capacity need to be treated differently. If a set of rules is to be used to determine an overall rating that includes this aspect of a Trust's performance these must be carefully framed to ensure that they accurately reflect good performance (as opposed to compliance with the rules!).

Chapter Seven: Independent Healthcare

Proportionate Inspection

31. It is important that any inspection and regulation is proportionate, whether this is the private or public sector. The consultation document rightly notes that traditional patterns of healthcare provision are changing. The independent sector is inextricably linked with this change and should therefore be subject to the same assessment and evaluation processes as the NHS. The inference in the document that the independent sector would be treated differently from the NHS does not sit easily with current policy for extending the contribution this sector makes to NHS provision.

32. Aligning Standards

33. The performance assessment envisaged must be applicable to both the NHS and independent sector if it is to be meaningful. We would therefore strongly support the proposal that standards are aligned. The Committee would be very concerned if public money was being directed to the independent sector without these safeguards being in place.

34. Priorities for Assessment

35. It is essential that services provided in the independent sector be considered from the point of view of the patient's journey, giving weight to the interface between the different service providers that contribute to this. The Committee has been alarmed by some assertions from the NHS that independent providers are exempt from local scrutiny processes and, because the policy is driven nationally, not required to go through the consultation process. This view is one we would vigorously contest and would look to the Commission to ensure that partnership working is an integral part of the assessment process; whatever the sector is providing the service to local people.

Appendix Three

Commission for Social Care Inspection (CSCI): Response to Consultation on Changes to the Regulation of Social Care

1. I am writing on behalf of the Health Review Committee to the consultation that CSCI are undertaking on the draft `corporate plan' and `Inspecting for Better Lives'. These are important documents and we welcome the opportunity to contribute to shaping this work. There are common issues in each document and it was therefore disappointing that these were not brought together in terms of content and the timing of the consultation process.

2. Our specific comments related to each document are set out below; there are however some general points that relate to both.

3. We do appreciate that CSCI has only been in existence since April 2004 and has brought together a number of different functions. The intention to move away from a `tick-box' approach to a move sensitive assessment of performance, informed by service users is one that we would endorse and support. There are however basic requirements that need to be meet if services are to be provided safely and appropriately to people that are vulnerable. CSCI needs to be clear that these basic standards are mandatory and universal in terms of `fitness to practice', whether the service is provided by the public, private or voluntary sector. This distinction needs to be strengthened and clarified in both documents. The regulatory process must provide a baseline, against which all service providers can be assessed; if this is not credible, or is interpreted differently by staff, then this `bottom line' will be undermined.

4. The `arms length review' undertaken by central government has taken initial steps to reduce the duplication and overlap between national regulatory bodies. The intention of CSCI to work closely with the Audit Commission is helpful but this principle could be taken further by being clearer about the way in which CSCI will work in partnership with bodies such the Healthcare Commission, particularly if the reviews included in the corporate plan are to be taken forward. Although this is alluded to in each document we believe that commitment to partnership needs to be reinforced in the guiding principles set out in the proposals, similarly this would support the intention to work with more constructively with service providers.

5. In other areas the aspirations set out would seem to overlap with the work of others, for example with regard to providing the `expert voice about social care' will require more that an improvement in IT systems and would appear to mirror the work of the `Social Care Institute for Excellence'.

6. There is a need for CSCI to have a workforce that is able to respond flexibly but consistently across the country. This needs further merits further consideration in the approach outlined. The intention to provide information that will help people make choices about the care they need will be widely supported. This will however be devalued if the regulatory process and production of additional information about quality is ambiguous or variable.

7. Issues associated with the use of terminology also need to be addressed. Both documents refer to the `judgement' of the CSCI in the regulatory process and in assessing quality. There needs to be clarity about what is meant by these terms and how they are defined.

8. Both documents seem to use the terms improvements and regulation interchangeably when describing the role of CSCI. This needs to be addressed to ensure that there is clarity about those elements of the work of CSCI that is about securing standards, which must be met. These are neither optional nor discretionary and failure to meet requirements will have consequences for the service providers in question. Whilst we would support proposals for CSCI to move away from standards which are not important from the point of view of service users, the delivery of standards that protect and safeguard the vulnerable must be rigorously enforced.

9. With regards to service improvements, these have potential to add considerable value to the way in which people exercise choice about the services they wish to access. This information will need to be collected and collated in a way that informs these decision on a `like for like' basis. This will be a challenge across the country and reinforces the need for workforce issues to be further considered.

Draft Corporate Plan

10. The introduction to the corporate plan and vision statement moves between performance assessments and inspection without differentiating between the two, for the reasons stated earlier we believe this should be addressed. The same point applies to any judgements that CSCI makes about quality and cost effectiveness. This implies a degree of discretion that needs to be understood by both the services providers and those using the services.

11. The term `stamping out bad practice' is used frequently, but it is not clear how this will happen, or how such practice will be systematically identified.

12. We would question whether the Government and the media are the key audiences if CSCI is to be the `expert voice on social care'. Service users and service providers need to have confidence in CSCI.

13. It would be helpful if the references to `high quality evidence' could be expanded to show what this is and how it will influence the work of CSCI

14. Partnership working should be reflected in `practising what we preach'.

15. If the greatest majority of people receive services at home then there needs to be a mechanism for ensuring these are provided safely and appropriately. The section on `social trends' points to local difficulties in recruiting staff but no action is identified for CSCI to guide service providers in addressing this issue. The NHS has Workforce Development Confederations to address anticipated shortfalls in staff and ensure there are appropriately trained individuals to fill service needs; CSCI should be giving a lead to this work if the objective of improving services is to be met.

16. The policy context outlined demonstrates the scale of change that health and social care are facing but there is no indication of how CSCI is positioning itself to respond to this.

17. The section on key imperatives is muddled and uses some terminology ambiguously. It would be helpful to understand how the CSCI intends to lever change and improvement. We believe that `safe guarding people' should be the first priority of CSCI and the regulatory process that it provides; this is currently secondary to `providing leadership'. There needs to be a route identified through which CSCI can act to protect those that may be most `at risk' and the define the responsibilities of the regulators for taking action. The proposal for self assessment has merit but must account of the fact that it may not be in the interests of some service providers to report accurately on how they are performing.

18. The `need for change' comments about the inconsistency with which CSCI has tackled poor practice in the past, no reference has been made to ensuring that staff are able to deal with these problems in a consistent and timely manner. The value of addressing regulatory and registration processes will be diluted if this is not addressed as an early stage in the modernisation programme.

19. Given the lack of credibility that star ratings have, should CSCI consider moving away from these as a mechanism for assessing performance. What are the benefits of a common approach to assessment, as outlined in the current Healthcare Commission consultation?

20. Reference is made to the delivery of `better outcomes' but there is no indication of what these may be or how such indicators can be developed to inform understanding of the quality of service provided.

21. The change programme identified is ambitious and challenging, the extent to which this will be impacted on by funding constraints has not been explored fully

Inspecting for Better Lives

22. The commitment to working more closely with service users is helpful although this will bring its own challenges in terms of training and developing the workforce to do this effectively. There is no indication of how this additional capacity will be developed and funded. The notion that hairdressers or podiatrists could provide monitoring information about the quality of services is interesting but does not build confidence that there is recognition at CSCI about the skilled nature of collecting this information and the need for consistency. This suggestion needs to be revisited.

23. Further consideration could be given to providing a route through which Local Authorities, or service users themselves, could raise issues of concern relating to a service provider. Health and other Overview and Scrutiny Committees would be a valuable resource to develop in this respect. It was alarming to read that CSCI is not currently able to follow-up complaints and concerns. This must be addressed as a matter of urgency.

24. Reviews of overall services should include an assessment of partnership working and the duty to collaborate.

25. Our comments on CSCI's vision and values are included in the preceding section. It would however be helpful to include the intention to move from a `doing to' approach to a `working with' approach as part of the value statement.

26. The report on what people who use services say they want is welcome but there is no indication of how these preferences will inform the work of CSCI. There is little point in collecting information if it is not translated into practice.

27. It would be helpful to clarify how CSCI will focus activity and resources on areas where it is most needed and prioritise areas for review.