text:
Q1 Chair: Good
morning, ladies and gentlemen. Thank you for coming. We have a
very full agenda and a lot of ground to cover this morning. Could
I ask you to begin by introducing yourselves and saying, very
briefly, where you come from, starting with Alyson, please?
Alyson Morley:
Good morning. I am Alyson Morley, Senior Policy Consultant with
the Local Government Association. I am here to accompany our member
David Lines: I
am Councillor David Lines, representing the LGA and also The Centre
for Public Scrutiny.
Malcolm Alexander:
I am Malcolm Alexander. I am chair of the National Association
of LINks Members.
Caroline Millar:
My name is Caroline Millar. I am a partner in the Moore Adamson
Craig Partnership, which is a small independent consultancy which
trains lay people. All our partners also act as lay people in
various different capacities.
Professor Tritter:
I am Jonathan Tritter. I am a professor at Warwick Business School.
I set up and was the first chief executive of the NHS National
Centre for Involvement during its existence.
Q2 Chair: Thank
you very much for that. The first session this morning is focused
on the arrangements proposed in the Health and Social Care Bill
for patient and public accountability. The Government has said
that it is a key aim of the NHS reforms to make "NHS services
more directly accountable to patients and communities". It
is timely that you are here to give evidence on this subject this
morning because, as you are no doubt aware, there is a letter
in The Times this morning from a group of voluntary organisations
who state that "plans to make GP consortia accountable to
the public are far too weak...we urge the Government to amend
the Bill and insist on a strong independent scrutiny function
led by democratically elected representatives." So we have
the Government's aspiration and we have a view expressed pretty
trenchantly in correspondence in The Times this morning.
I would like to ask each group, please, to open the session by
telling us, relatively briefly, where you sit in terms of your
view of the extent to which the Government delivers its objectives
in the Bill as it is currently drafted and what proposals you
might have to strengthen the meeting of this test to make NHS
services more directly accountable to patients and communities.
Alyson Morley:
If I say a little about GP commissioning consortia, Councillor
Lines can then talk about Health and Well-being Boards. I heard
about the letter on the radio today, and I think that is where
there is a lack of symmetry in the Bill. We have a lot of specification
about the membership of the NHS Commissioning Board and Health
and Well-being Boards but very little on the constitutional and
governance arrangements for GP commissioning consortia.
There are two ways of making GP commissioning consortia
more accountable to the public. One is by having far greater accessibility
from the public to those Boards, so you could have advisory members
or you could have an advisory panel. In an awful lot of areas
councils and PCTs have really good mechanisms for patient and
public involvement and GP commissioning consortia need to build
on what already exists rather than reinventing the wheel.
The second way of ensuring that GP commissioning
consortia are more accountable to the public is the way they fit
in with the other accountability mechanisms, most notably the
Health and Well-being Board. You will know that GP commissioning
consortia have to make reference and have regard to the joint
strategic needs assessment, which lays out the needs, assets,
resources and health concerns of the local population and the
evidence of what will make effective health improvements. They
have to have regard to that.
In our original submission to the Government, the
LGA said that GP commissioning consortia should be required to
sign off their commissioning plans with the Health and Well-being
Board. While the NHS Commissioning Board will have responsibility
for the financial rigour of those plans, it will be up to the
Health and Well-being Board to sign off whether they were aligned
to the JSNA. We still think that that would be really helpful.
I will hand over to Councillor Lines.
David Lines: Thank
you. Chairman, first of all, I would mention that when this first
started it was in our remit of scrutiny and it has widened. I
will be the first to say that my expertise is not in the health
sector. My expertise is in governance and scrutiny. If I am asked
a question on health, I shall pass to my much wiser colleague
on that.
The background out of which both of us are coming,
in the LGA, is the three themes of subsidiarity; in other words,
localism, local decision making at the lowest appropriate level,
transparency and everything else that falls away from that in
terms of governanceif you shine a spotlight into dark crannies
it is a good way of ensuring the right sort of disciplines come
away in terms of governanceand best practice. We are not
perfect. No one is perfect. Life is about evolution. We have to
learn and we look for best examples.
If we turn to the Health and Well-being Boards, our
view, fundamentally, is that they are executive boards and, as
such, you shouldn't mark your own homework. That is why the scrutiny
role is very important. There is a debate there as to exactly
how that should be developed. As this Committee is going through
the process, the LGA is going through the process and, shall we
say, there are plenty of minds made up but it has not come to
a common view on how it will be best approached. The principal
message is that it needs to be decided locally with less prescription
from central government. If it is to go step in step with the
Localism Bill, the makeup of these boards and the balance
of political against specialist knowledge all has to be worked
out. It will be horses for courses in that respect.
Q3 Chair: If I
can develop that, you are content with a position where the precise
form of local engagement by local authorities in the process is
for local discretion rather than prescribed by statute.
David Lines: That
is the way we are going. As I say, the LGA is moving towards a
considered view on that, but that is the way it is going.
Q4 Valerie Vaz:
Does that mean there are going to be differences throughout the
country? Each part of the country will have their own Boards.
David Lines: That
is inevitable. You are caught between a rock and a hard place.
If you are devolving responsibility, you have to accept that people
are going to do things a little differently. From my own experience
in the private sector as a manager, delegating authority is the
most difficult thing in the world. So many people put it down
with one hand and take it back with the other. Keep it where it
is but push it all downresponsibility and authority. Therefore,
you have to have differences of view.
Q5 Rosie Cooper:
I have one very quick question. Do you really believe that you
have the ability, the resources and the expertise to hold people
who have been commissioning, i.e. the managers, not the GPs necessarily,
to account?
David Lines: Straight
Rosie Cooper: No.
David Lines: No.
The straight answer is "in a lot of cases", but I accept
fully in such a wideranging organisation as local government
that you are going to have the best and the worst. Is that a reason
to throw localism into the bin? No, I don't think so. I agree
resources are importantin other words, support for thisand
that is perhaps the Achilles' heel or one of the Achilles' heels
in this and needs to be worked through. What will happen is that
certain critical things will be looked at and studied and others
will have to take a back seat. There is an inherent risk in that,
and those that make this legislation and those that have to carry
out this legislation must realise that.
Q6 Rosie Cooper:
While you are getting the expertise, the system will be letting
Alyson Morley:
But this doesn't come out of nowhere, and in an awful lot of places
there is already really good joint commissioning between GP commissioning
clusters and councils. You will know that in many areas there
are joint arrangements now with PCTs and local government setting
up as one organisation. There are probably about 18 councils and
areas where this is happening. So we can build on what
Q7 Rosie Cooper:
But have they commissioned anything yet?
Alyson Morley:
Yes, they are commissioning services. They are commissioning joint
services as we speak.
Rosie Cooper: That is
Alyson Morley:
Joint commissioning has been going on sinceI can't remember
which Health and Social Care Act it was. But there is good joint
commissioning. There is also an incredibly strong business case
for joint commissioning. GPs will realise that it is cheaper to
pay for health and social care support at a low level which prevents
later high intensity care. Not only is that better for their budgets,
but it is better for the outcomes of their patients.
Chair: I am going to move
on to Malcolm Alexander, please.
Malcolm Alexander:
Thank you very much. My involvement with commissioning and public
involvement goes back a number of years and the real issue is
that for the community to influence commissioning it needs to
have real influence, real power, resources and capacity. What
has happened over the past few years is that that has been undermined
and destroyed and we are in a situation now where we need to rebuild
the capacity of LINks to develop into HealthWatch organisations.
I would say that localism has been a disaster for
LINks. It has meant that across the country we have absolutely
fantastic LINks in one area and appalling LINks in other areas,
which means that people really suffer from having organisations
that cannot properly represent their interests. Culturally, GPs
find it very, very difficult, in my experience, to collaborate
with the community in terms of decision making. They love it when
people come in and talk about the colour of the wallpaper and
they love it when they come in and do little jobs for themthe
helpmate approachbut collaboration between patients and
GPs is rare. My colleague will tell you some very good examples,
but I can tell you, from my experience over quite a lot of the
country, that it is usually very weak.
What we badly need is to have the capacity to influence
commissioning. One, we desperately need lay involvement in the
commissioning boards. Two, we need HealthWatch to be there, sitting,
observing and participating in commissioning decisions. We need
HealthWatch to be working actively with local authorities, but
independence is the key. The proposals at the moment that make
HealthWatch accountable to local authorities, we think, will be
an absolute disaster. But the even bigger disaster at the moment
is that the funding which has come from the centre for LINks and
the development of HealthWatch, which is the same as last year
with inflation, once it gets to the local authority is being cut
in half. This means that many LINks are going to perhaps tumble
over the next financial year and the capacity to develop HealthWatch
will be infinitesimal in many parts of the country. We are facing
a real disaster. Yesterday, talking to the Department of Health,
that is number one on their risk register with respect to the
development of HealthWatch for the next 18 months or so.
One more thing is that the relationship between
the local HealthWatch and national HealthWatch will be crucial
and elections from local HealthWatch up to the HealthWatch England
body will be essential. Accountability and democracy must go side
by side, both locally in HealthWatch and nationally in HealthWatch
England. Capacity building has to be a function which HealthWatch
England is able to carry on to make sure that every HealthWatch
across the country reaches a certain level of capacity so that
they can properly work with and represent the local community
and also have real influence. That question of influence in commissioning
is absolutely fundamental. It is, in my experience, one of the
most difficult things a community can do and we need real power
and influence to be able to do it effectively.
Caroline Millar:
I would like to support what Malcolm Alexander has said. So far,
we have talked a lot about structures, but the real question is
where the lay people sit within these structures and how much
influence they have. We have lay people on all sorts of committeescouncil
committees, health committeesbut it is my personal experience
and the experience of the people we work with that the overriding
feeling many of them have is one of frustration. They don't feel
they make a difference, and this is where the capacity-building
element really comes in. It is about resources. It is also about
attitudes and behaviours. Lay people very often get asked, at
the end of the meeting, "So what's the lay perspective on
this?" There is one lay person sitting in the room and they
are suddenly burdened with this responsibility. They may well
be capable of giving a view, but their views are not built into
the structure in such a way that they are given full attention.
We need to develop the capacity of individuals and also the capacity of groups, HealthWatch certainly, locally and nationally, but also all these other groups which exist out there. The voluntary sector has a huge wealth of experience and understanding of what people with particular conditions require and what local communities think and feel about things that are happening. I don't see a proper route for those views to be aggregated and fed into commissioning decisions, which are the really crucial ones we are talking about, and I worry that lay people who currently sit on these groups will suddenly be given this responsibility for these vast amounts of money. Are they capable of making these decisions? Is it appropriate to ask these people to make these decisions?
Having said that, our preferred model is that there is a lot to be done down at the bottom. We need to do work in GPs' practices, and again this is a capacity and skills issue. Most of the GPs' practices we work with will tell you that they talk to their patients and know what patients want. Very, very few of them have any proper and effective ways of doing that. We know that patient participation groups can be very successful. But where we see them being successful is the result of a huge commitment from the practice itself, usually from one individual with a major input of resources, and it has to be an ongoing thing. This is not a question of just calling them up and asking, "What colour shall we paint the walls?" This is having an ongoing relationship where they can see the impact of what they have said to you. So if they are giving information, that information is passed on and fed up into the system. We want to see that aggregated up at consortia level so that consortia also understand what patients are thinking. Then, if there are individuals who can move up through the system with training support, through the HealthWatch or through other means, those individuals may be in a position to contribute to highlevel commissioning discussions. But we must not assume that just by sticking people on some committee somewhere we are going to get the lay input and public perspective. That is probably the most important aspect we need to think about.
Professor Tritter:
I welcome the Committee's inquiry into this area. I think it is
incredibly important. I am concerned about the lack of patient
and public involvement in commissioning, and particularly the
dilution of the 2007 Act, the rewriting of section 221(2)(d) suggesting
that HealthWatch is now far less about commissioning and far more
about the promotion of choice.
I don't think GPs are much closer to their patients.
They have a patient list, but if you ask them what proportion
of that patient list they see on an annual basis, it is about
a third. Secondly, that patient list does not represent all those
who need or utilise health services within that locality. Thirdly,
the patient list is not representative of the community in any
real way. GPs do not have any track record in terms of Joint Strategic
Needs Assessment and absolutely no experience of doing public
involvement. A study in 2006 looking at how GP surgeries were
using PPGspatient participation groupsfound that
less than twothirds of them had any experience of that despite
20 years of encouragement, and, further, that those surgeries
which did have patient participation groups were more likely to
be in affluent and less deprived populations.
The final thing I wanted to mention is that it is
a shame HealthWatch is the name that was chosen, as this is the
name of a charity established in 1991 looking at evidencebased
medicine. It is essential that we find a way of having HealthWatch
as a local basis for patient and public involvement engaging with
the actual GP commissioning process rather than secured solely
to the Health and Well-being Boards.
Finally, there needs to be a way to identify how
local HealthWatches are working. One mechanism which might be
used is that the annual reports they have to submit be subject
to some external review which would identify how they have been
doing involvement, what have been the outcomes and impacts of
that involvement and what weaknesses could be identified to try
and intervene to support their development. That is a very different
mechanism. When LINks was introduced, I engaged with the Care
Quality Commission to try and encourage them to do this and align
their regulatory processes with the involvement that was supposed
to go on at LINks. This never happened. I hope HealthWatch provides
another opportunity for this kind of mechanism to be used.
Q8 Nadine Dorries:
Isn't there a slight difference between lay people, as in your
lay patient, and the people who sit on organisations such as the
Patients Association, the Alzheimer's Society or the Stroke Association?
When we talk about patient involvement, are we talking about those
people who have made their life's work being involved in organisations
such as the Patients Association, or are we talking about the
patient who just visits the GP once every few weeks? It seems
to me as though the input from the two would be vastly different
in terms of knowledge and ability to influence. Therefore, when
we talk about patient involvement, what are we talking about?
Are we talking about the patient who is involved, part of an association
and incredibly informed on particular areas of commissioning,
or are we talking about the retired lady who lives in Acacia Close
who would just like to do a little more for her GP practice? Which
one would provide the most input and which one should we be concentrating
Malcolm Alexander:
It is all of those really. In terms of local public involvement
work, it is about strategy. The strategy is probably that you
would have a steering group, or the leading group in a LINk or
a HealthWatch, which would be made up of lay people with some
experience of the serviceperhaps people who are in local
voluntary sector organisations, so they have that kind of experience.
For example, if somebody has MS and they are part of the MS Society,
they know about local services and they bring that experience
into the local body. Other people will have a range of different
experiences that bring them there. Then there will be the outreach
work, which is fundamental, which is about going into the communities,
meeting with groups and talking about issues that concern them,
perhaps campaigning issues. Sometimes it is about the closure
of a clinic or a hospital which, actually, is the one thing that
really mobilises people. If you want to get people going, you
have to close a hospital. That is the tragedy of public involvement
work in a way.
People will contribute at different levels of experience
and knowledge. But how do you value those bits of information
that people bring? It is like during your surgeries with people
coming and bringing you a story. The weakness of the LINk and
the Patients' Forum is that it lost the capacity to listen to
complaints because when CHCs closed complaints and advice went
and it broke up the organisation. HealthWatch is an attempt to
reunite the organisation and bring complaints back in. If you
don't hear the voice of the user, you can never build an organisation,
in my view, in terms of properly representing the community.
Caroline Millar:
Could I just add to that? There is a tendency to forget the well
people most of the time, and this may be part of the point you
were making. We hear a lot from people who have longterm
conditions, and it is very important that we do. But I know of
examples of LINks who have not really made contact with their
well populations. There are parts of London where there are lots
of young, active working people and the issues for them may be
completely different. They may be about sexual health or they
may be about childbirth. They are quite different issues from
the sort of people who are represented often through the voluntary
sector groups that you are talking about. Often they are not heard.
That is why the onus should be on HealthWatch, or whatever it
is called, and also on local authorities to go out and find those
There are very good examples in local government
of outreach work, of physically going out of the building, going
to where the young mothers are, going to the day centres and talking
to people. I see this happening in some of the provider services
in Hackney, for example, where I am involved. Those kinds of approaches
need to be used so that we can find out what patients, the generality
of patients and the public, who may be separate from patients,
Q9 Nadine Dorries:
I do take that, but you criticised patient involvement to an extent,
or criticised GPs, rather, inasmuch as the people who get involved
in GP services at the moment tend to talk about the colour or
the pattern of the wallpaper. Isn't it the case that if somebody
isn't a person who is involved with the MS Society or with the
Alzheimer's association, who has a specific singlefocus
interest in a particular condition, what those lay people are
concerned about when they become involved in their GP practice
is the pattern of the wallpaper and is the experience that they
are greeted with in their GP practice because they themselves
do not feel qualified or knowledgeable enough to input on issues
such as how young people's sexual health services or how MS services
are provided? They don't feel qualified to comment on that. Therefore
they become more involved in the GP experience that the patient
receives when they arrive at their practice, such as opening hours
and telephone helplines and that kind of thing, rather than actual
commissioning for care.
Caroline Millar:
Those things are extremely important.
Nadine Dorries: They are,
of course, yes. I'm not saying they are not.
Caroline Millar:
They are part of the picture of what happens when the service
is being commissioned.
Malcolm Alexander:
You can do an experiment. If you meet people inside a GP's surgery,
they are very placid. If they are sitting with GPs
Q10 Valerie Vaz:
Because they are sick.
Malcolm Alexander:
Valerie Vaz: I'm sorry.
I go in there.
Malcolm Alexander:
No, I don't mean that. I mean patient's groups. If you meet patient's
groups inside a GP's surgery, they are very placid. They sit with
the GPs and they are all patting each other on the back and being
terribly nice to each other. If you have a meeting in the community
and you say to people, "Tell us about your GP," it is
a totally different story. They will tell you about their experiences
of general practice and about the sort of services they receive.
They will give you very, very rich information. It is fantastic.
You just have to go to a community group and say, "Tell us
about general practice," and people are full of ideas.
I have one more thing. If you then say to people,
"Tell us what would make a really good service"and
I have done this many times, you get a group of people together
and say to them, "How can we improve this particular service?"there
is a wealth of ideas that come out. A technique we have used is
building up quality standards based on the views of patientsthe
publicand it is a fantastic technique.
Q11 Valerie Vaz:
That is absolutely right. It picks up the point that Professor
Tritter made about the GPs
Nadine Dorries: I hadn't
actually finished, Chair.
Valerie Vaz:seeing
people who are ill and the people who they don't see. That is
the key point.
Malcolm Alexander:
Alyson Morley: One of the issues here,
the challenge, is capturing all of this and everyone having access.
What happens quite often with these consultations is you have
an enormously rich tapestry of all sorts of information, demands
and ideas on how to make the services better in a community, but
what you don't have is the putting together of that. The joint
strategic needs assessment is a really good opportunity to put
that together and for everyone to draw on that. So every single
GP doesn't have to reach out to every single member of their community.
That is already done through tenants' and residents' associations,
local assemblies and local mother and toddler groups, for example.
They need to make the most of what already exists.
Chair: Nadine, you wanted to come back.
Q12 Nadine Dorries:
Yes. I wanted to ask, just to complete my questioning, do you
feel, up to now, that patients have had a bad shot at input and
with defining how they input into services provided by GPs? Do
you think it has been bad for them up to now? If you do, do you
think that the Bill now provides patients with the platform to
have their voice heard and have a greater involvement, as the
Bill says in its statement, "better patient accountability"?
Do you think that the Bill provides that opportunity? I know there
are problemsand you have articulated those in your opening
statementsbut do you feel that, from where they are now
to where the Bill puts them, the Bill puts them in a better place
to have their voice heard?
Professor Tritter:
The Bill does specify a requirement of the GP consortia to do
patient and public involvement, which it never has had before.
In that sense, GPs now have to do it and they never used to have
to do it, so that is an improvement. Since most of them have not
done it, and have not done it in relation to the array of services
that are provided, it is a big challenge for them.
As to this issue of lay involvement, I think Malcolm
is entirely right. The mode, the mechanism that one uses for engagement,
is really important. There are things they do in southern Sweden
around having an open forum where you bring together health providers
and members of the public and patients to talk about health priorities.
It is a very different context in which to discuss those things
than sitting in the waiting room in a surgery and talking about
the wallpaper or how services should be provided.
Q13 David Tredinnick:
On this general point, I have one question. To what extent should
the voice of the user extend to patients requesting specific treatments?
A lot of us are being lobbied at the moment by the Chinese medical
community and the acupuncturists about regulation, and a lot of
people very often want to go down that route. How are we going
to manage that in the general context of choice?
Malcolm Alexander:
It is an interesting issue in terms of commissioning. I have done
quite a lot of work with complementary therapies where we have
had rooms full of people with PCTs. The rooms full of people have
said, "We want complementary medicine" and the PCTs
have just said, "We're not interested. We're not going to
do it." This is one of the real challenges around commissioning.
When people really want something as a community, they organise
and they make the demands. What duty does that place on the commissioner
to concede to those demands or to negotiate over those demands?
There are two different things. One is what has been agreed and
decided by those who are most actively involved as commissioners
and the other is those things which are wanted by the wider community.
We have to try to deal with that issue in terms of what resources
are available.
Q14 Chair: I am
starting to feel giddy on behalf of these consortia. They have,
on the one hand, to respond to the joint strategic needs assessment
and the relationship with the local authority, they have to deal
with consultation groups and HealthWatch direct patient involvement
and they have to deal with the National Commissioning Board. Which
way are they going to turn?
David Lines: And
they have to look after their patients.
Chair: Occasionally the
patient gets a look-in.
Professor Tritter:
NICE, in some sense, is an adjudicating authority on what services
are reasonable to be provided on the NHS. They weigh up evidence
in terms of the existing efficacy, the cost and quality life year
adjustments and involve patients and the public in their consultations.
That is a mechanism to adjudicate between individual patient demands
and those things that are deemed appropriate in terms of biomedicine.
Malcolm Alexander:
Yes, but in terms of your question, of course, it is interesting
the Bill does not actually place HealthWatch together with the
consortia. The Bill keeps them separate, which is quite odd and
difficult to understand. The answer is that general practice locally
needs to develop good strong relationships with their patients
and wider communities so that those relationships enable negotiation
and discussion to take place about local issues. But we need quite
a developed idea of how we can democratically get people involved
with commissioning boards at a level where they can have real
influence. It is a very poor model and GPs will be pulled and
pushed in all sorts of different ways. It will only work from
the point of view of the public if we can get the HealthWatch
bodies properly working, supported and able to develop and grow
to have the methods available to them to conduct a proper negotiation
with the GPs in the consortia. If that happens, GPs won't not
be pushed and pulled in quite the same way.
Q15 David Tredinnick:
I have a quick supplementary to Malcolm Alexander. You mentioned
complementary and alternative medicine, and it just happens that
I chair that group in Parliament and have done for many years.
Another point that is made to me by people demanding
those services is they are less expensive. As we are trying to
find an efficiency gap, isn't that something else we should be
looking at?
Malcolm Alexander:
That is a point frequently made by people who choose complementary
therapies. This is slightly outside the discussion, but I suppose
the answer is that if patient choice is a genuine thing and people
say, "This is what I choose" and the doctor says, "You
can't have it," we have a really serious problem. Patient
choice, if it is a serious business, is not just about what other
people choose for you or other people's agendas. It is about the
public's right to be able to influence that agenda.
Q16 Chair: Though,
as Professor Tritter says, presumably, if they are spending public
money, there must be accountability for efficacy as well.
Malcolm Alexander:
Yes, of course, there is, but are we to ignore the evidence of
the patient who says, "This treatment has been very successful
for me"?
Chair: No, certainly
Malcolm Alexander:
Historically, many treatments have been used by the medical profession.
We can go back to insulin therapy in mental health work, which
was extremely dangerous. We should respect genuine patient choices.
Q17 Rosie Cooper:
Basically following on from that, I am repeatedly saying that
the Bill is high on autonomy and low on accountability and I am
repeatedly told that patients will have a greater voice. I have
yet to see one bit of evidence base for that and it drives me
In the Bill, the specified governance arrangements,
for me, are virtually nonexistent, and those which are there
I will categorically say I see as pathetic. It says that they
will hold one public meeting a year and, beyond this, there is
no requirement as to how they would conduct their business. Anyone
involved in the Health Service who ever attends a trust AGM knows
how ineffectual and ineffective they are. I used to bribe people
to come to mine and if I found one genuine member of the public
I was always very, very lucky. This is absolutely true. We would
have to dragoon staff to come to make up the numbers so I wasn't
talking to myself. Maybe that is a reflection on me, but no. I
understand all my colleagues have the same problem.
Looking at the governance arrangements, we really
do need nonexecutive directors pummelled right through this,
and perhaps a requirement that one of those nonexecutive
directors should be of that particular area, representing the
public. I do understand there is an argument that a group might
get to be that person, but not if you have proper arrangements
for interviewing and all the rest of it. I never ended up with
one of those in my life and I always had a really good, strong
local voice in there to fight with the rest of us who were trying
to make a decisiona real voice. The truth is that is how
I got involved in the Health Service. One AGM a year is not good
enough and I believe that consortia meetings should be held in
public, but I fear that this private and confidential or commercial
confidentiality nonsense will mean that those meetings will be
held in private. That, to me, is a game changer. You are not going
to have real people on the board involved in making those decisionsno
What I am really saying is that I don't think anyone
has expressed a view that says what they have seen here is good
enough. What is your view about nonexecutives, what is your
view about meeting in private and what, in this scenario, would
be a good model of governance for you? Remember that I used to
be a local councillor. I don't believe there is enough expertise
in there to even remotely challenge the expertise of commissioners,
former PCT people, who have been doing it for thousands of years
and know the intricate detail. When you have Health and Well-being
Boards challenging what may very well be a really good clinical
decision made by a consortium and there's a row, I've asked the
Secretary of State who decides. We have got the answer, which
is The Independent Reconfiguration Panel, which is no different
to now.
Chair: I think that's
an essay question, Rosie.
Q18 Rosie Cooper:
I am trying to summarise it because it is just so silly.
David Lines: My
English master used to give us questions like that with the first
foolscap page, and then you had to write another 10 after that.
But, if I can pick up some of the themes there, I thinkand
this is more a personal observation from a governance point of
viewthis Bill is trying to be all things to all men and
women. In other words, in layman's terms, if I can use that expression,
in governance terms, it is trying to micro-manage and macro-manage
at the same level. That is a great mistake.
I would then move on to the Government's arrangements.
Yes, you have picked up one meeting, constitution. Why bother,
because it won't be effective? If you are serious about it, do
it properly or don't bother to do it at all. I am being equally
as plain-speaking as you on this.
Q19 Rosie Cooper:
No, it is good.
David Lines: That
is my observation. I am a little bemused, just to go back to the
original point, that scrutiny committees are not well equipped.
I think possibly, maybe a hundred years ago, that was said about
Select Committees, but I am scarcely going to be the one to level
that criticism at a Select Committee. Scrutiny committees have
only been in existence for 10 years. It is a growing process.
Does that mean that they should stop? Then there is a discussion
about lay people getting involved in providing choice. Actually,
I am a layman.
Rosie Cooper: So am I.
David Lines: I
am an elected layman, elected by laymen and women. Rather than
bundle everything into an unmanageable ball of wool with bits
and pieces everywhere, let us separate it out and say, "What
do you want to do here?" "What do you want to do there?"
and "What do you want to do there?" Why reinvent the
wheel? We have a hundredsofyearsold system,
parish councils. On that are built district councils, MPs, county
councils. Yes, it is mind boggling and it is bureaucratic, but
it is there. Let us reshape that. There is another Bill going
through Parliament about localism. Let us reshape that and reshape
this at the same time. In five years' time I think you will find
the best scrutiny committees will be as good as this Committee.
Q20 Rosie Cooper:
Absolutely. Forgive me. I have obviously expressed myself really
badly. It is not that they won't get the ability do it. It is
whether you have got it absolutely now to challenge the system
over the next 18 months when it is going to race ahead.
David Lines: Could
I pick up on the comments of my colleagues here? In effect, they
said that no one has got there. We all, whether you want to do
it down the public sector, the council way, or you want to do
it through the voluntary sector, they all need support and that
is the bigI repeat itthe big Achilles' heel here.
Q21 Chair: Can
I bring in Caroline Millar who has been sat patiently?
Caroline Millar:
Perhaps the distinction that would be useful to make here is to
distinguish between the public as the moral owners of the Health
Service, if we like, and those people who are users of the Health
Service. We need to be much clearer about these distinctions.
We talk about patient engagement and patient involvement and we
talk about public engagement and public involvement. They are
different things and in those two different capacities people
have different needs.
You are absolutely right, that in governance arrangements
we need to acknowledge that the governance arrangements are there
to serve the public as the moral owners of the Health Service.
Therefore it is vital that in the structures those people have
a voicea substantial voice, not just the one voice in the
room. It is not just about local councillors or democratic representatives.
It is other people with other perspectives as well. If you take
the example of nonexecutives on primary care trust boards
or governors in foundation trusts, those are the sort of models
you might look at. On paper they look like they could do the job,
but I still think there is something very, very important about
the status those people have within the organisation and the culture
and the behaviours of the people who run the services, the GP
commissioners or the local authorities, and those organisations
to be able to hear and respond to the lay perspective, the public
perspective. It is to do with power really.
Q22 Rosie Cooper:
Forgive me. That is why I believe there should be nonexecutives
with a vote at the table. That is really important. I would not
be misled about foundation trust governors. They are just an arm
of management and never beyond that. There is a voice there, but
they, again, aren't strong enough to challenge. It is a great
model and I totally believe in it. That is why my criticism is
not that they can't evolve to the point at which they will be
great. I just don't believe they are great now.
Caroline Millar:
Your anxiety is about what is going to happen now. There are lots
of nonexecutives on primary care trust boards knocking around
and they are all going to be out of the picture. So where are
the people and what is there to support the system now? There
is some anxiety there.
Chair: Rosie, this is
an evidence session, so can I
Rosie Cooper: Forgive
me. I did ask, what model of governance?
Chair: You did, and I
was wanting to bring Malcolm in to answer that question, then
Professor Tritter and then Alyson Morley.
Malcolm Alexander:
I suppose behind this is, "Who is going to own the consortia?",
in a way, because the involvement of the private sector in buying
up practices is going to have a significant effect upon this whole
system. Behind the GPs, who might be in the frontline, there might
be companies who are employing them. Where our taxpayers' money
goes is fundamental.
There is an experiment in Scotland at the moment
about electing the chairs of Health Boards. I can't see any reason
why 50% of the members of a commissioning board can't be lay,
and I can't see any reason why some of those people, or all of
them, couldn't be elected locally. Certainly the chairs should
be elected locally. We do need a huge amount of democracy in the
system. Health has always been rather resistant to democracy and
PCTs have not always been very inclusive. We need to acknowledge
that. For example, in Hackney it has taken three years for us
to get a lay observer seat on the PCT board. Just as they are
about to close, they invited us to join them, which I thought
was somewhat cynical.
In terms of openness, it is fundamental that they
should always meet in public. We can't understand why foundation
trusts meet in private. All bodies making highlevel decisions
about health care and about resources must meet in public. I don't
think it is negotiable. The onemeetingayear
business is absolute nonsense. There should be the capacity for
the public not only to elect some of the NEDs, or all of the NEDs,
but HealthWatch should be there as lay observers and there should
be constant interaction and participation in the work and the
commissioning arrangements in the commissioning consortia.
Professor Tritter:
I agree with a lot of what has been said. The accountability isn't
sufficient. I think that we get too caught up in this notion of
"lay". The lay member of a research ethics committee
is probably a professor of epidemiology. Most of us wear local
hats simultaneously, so "lay" is not necessarily a useful
way of conceptualising it. It might be better to think of diversity.
What you want at any decisionmaking body is a diversity
of voices reflecting a diversity of views within the community.
If you are going to have nonexecutive directors, it might
be worth specifying the different kinds of constituency you would
hope that they were there to represent.
Q23 Chair: Can
you have a diverse board without representatives from outside
the health community on it?
Professor Tritter:
I don't think so, but it depends what you mean by "health
Q24 Chair: I guess
by "lay" I might mean outside the health community.
Professor Tritter:
You could, for instance, look at the Scouts and Guides, who have
had a very bad role in terms of supporting LINks, but they are
a different way of thinking about civil society within a locality.
So there would be other constituencies. I live in Leamington Spa.
In Kenilworth everything is run by the Lions Club. The Lions Club
would be a really good place to go and look for people who have
some sense of what that community wanted in health.
Alyson Morley:
I want to respond to your concern about "How do we make it
good now?" You are absolutely right. It is certainly incredibly
patchy, but we know that in some areas things are working very
well. For example, I was talking to a councillor from Westminster
very recently who was saying that their Health Overview and Scrutiny
Committee, and also in terms of joint commissioning, have a really
good relationship with their local LINks. They feel that they
are working really well and are getting into it. The LINks are
making serious differences to the way commissioning works so that
services really do work for people and they are commissioned from
the point of view of those individuals rather than convenience
for individual organisations.
What we don't have is any systematic evaluation of
that. The Local Government Association and many others have consistently
called for some sort of evaluation of what we already have, and
I would agree with all of the other panellists that the proposals
aren't sufficient. What also isn't sufficient is our idea of what
"good" looks like already. To try and do something about
this, the Local Government Association and the Patients Association
are going to be evaluating what LINks already do to identify where
there is good practice already and seek to publicise that so we
can build on the best. The problem at the moment, with the rhetoric
around "building on the best", is that we don't really
know what "good" looks like.
We accept that there should be local variation, going
back to Jonathan's point that in his area the Lions Club is an
organisation that is deeply rooted in the community. That will
be different in different areas, but we will be able, if we evaluate
things to see what is working now, to have a better chance of
this. At the moment we are working in the dark.
Q25 Chair: Do
you think that if we evaluated best practice we would find some
constants that we could apply generally?
Alyson Morley:
Q26 Chair: Because
at the moment the Government's policy appears to be that this
will be developed locally. Out of experience of good practice,
is it possible to set out some parameters of good practice that
still leave local flexibility but, none the less, deliver an assurance
of standards across the system?
Alyson Morley:
Yes, and that is certainly the LGA's view, that localism should
not mean that you have a wildly varying consistency in standards.
The services you havethe how you do it or the what you
doshould be based on values and those values are transparency.
Another huge challenge with HealthWatch is we are doing a piece
of research with the Patients Association about the awareness
of LINks, and very few people, even visitors to the Patients Association
site, are aware of LINks and don't really know what they do. We
have a real challenge there. So, one is transparency, communication,
and another transparency challenge is that local authorities and
GP commissioning consortia will be working to completely different
populations, possibly. That is really confusing.
The other issue is inclusiveness, and absolutely
your points that people need to be included as lay members. But
there needs to be a broader inclusion of their voices in other
ways. You can't put everyone on a board. You need to find other
Q27 Chair: It
wasn't really an invitation to draw out what those elements of
good practice are here. It would be very helpful for the Committee
to have thoughts from any of the panellists on what constitutes
good practice in terms of patient and public accountability; the
extent to which it is possible to preserve local variation while
still applying consistent principles of good practice.
Caroline Millar:
Could I say something?
Chair: Yes.
Caroline Millar:
There is a lot of evidence that there are things which work and
things which don't work. There are a lot of examples of good practice
and there are a lot of lists of principles of good practice out
there. I have lost track of the number of times I have sat in
rooms and people have said, "What is it? Is it transparency,
accountability or what?" We know this stuff. My experience
in the NHSand this may change with more local government
involvementis that although people know what good practice
looks like, they are reluctant or they don't find the time to
go outside and find out how it works and how it looks. It becomes
a process that they have to do but they will try and find the
cheapest and quickest way of doing it, and that is where it falls
down so often. It is not that there are not wonderful beacons
of excellent practice, but my concern is how you mainstream good
practice across the whole piece without focusing on what it is
you have toThe only way you can do this is by saying, "This
is what you have to achieve". So it is looking at the ends
rather than all the processes that go into it.
Q28 Mr Sharma:
First, my apologies for arriving late. I just followed David's
last point, when Malcolm was responding to it, about patient choice
of any alternative therapies, their own choice to go where they
want to get help from. We get a lot of requests from those who
are qualified doctorsmaybe not in British standards, but
certainly they have achieved their qualifications in other therapies
from other countries like India, Pakistan and Bangladeshin
homoeopathy, Ayurvedic medicine and others. But when they request
the doctors, the GPs, to find those alternatives they are refusing
to do it. They are not supporting it. What do you think, Malcolm,
is the best way for those people to get it because, within the
system, it is not provided? I come from that background where
it is very popular and a lot of people who came in the 1950s and
1960s are still very fond of those alternative therapies.
Malcolm Alexander:
I suppose the only way for people to obtain those services is
by trying to influence the commissioners and by campaigning. There
are examples in Sefton, in Camden and other parts of the country
where people have campaigned very hard to try to get the services
they want locally, not Ayurvedic medicine but certainly homeopathy,
which has been in the Health Service since 1948. It is an NHS
service. There has been a kind of battle going on between people
who were trying to access services which they have experience
of as being very positive and successful and a medical establishment
that rejects those services.
In terms of commissioning, it has been a huge battle
for patients to convince commissioners and I don't know whether
it is going to change in terms of GP commissioning. I rather doubt
it. The situation will be much more complex and I think there
is a real tension between GPs as commissioners making decisions
about what is appropriate for an area and patients wanting huge
amounts of choice. There is a real problem, a real dilemma, in
trying to find some accommodation between those two positions.
Q29 Mr Sharma:
Do you think it is a prejudice, rather than providing the services,
on one
Malcolm Alexander:
I think, yes, it is partly prejudice. But, in a way, to me it
is more fundamental than that. The political support for patient
choice and, at the same time, dismissing the choice of the individual
is a fundamental flaw in the thinking of commissioning and the
medical establishment.
Professor Tritter:
There is an issue about the nature of the evidence. Thus far,
there are not largescale trials that produce evidence around
complementary and alternative therapies. Rather than simply lobbying
for them to be provided, it would be better to lobby for the funding
of those trials to generate the evidence, which is what we use
in the system to justify what we spend public money on in the
Q30 Chair: There
is inevitably a tension between the choice exercised by an individual
patient and the requirement of somebody in charge of a public
budget to determine priorities that will not always reflect the
individual choice of the individual patient.
Malcolm Alexander:
To expand the point, how on earth can a group of GP commissioners
make decisions if there are so many choices available to the public?
It is impossible. It is impossible for them ever to make sensible
commissioning decisions if patients can choose whatever they want.
There is an incompatibility there.
David Lines: Welcome
to democracy.
Chair: Yes. There is no
escape from that dilemma in a publicly funded health system. It
is intrinsic in the system that we have established.
Q31 Dr Wollaston:
It has been very interesting to hear the panel say that everybody
knows what good practice looks like, but equally we know what
bad practice looks like. The point that has been made about homeopathy
also raises another issue. What happens if these participation
groups are taken over by singleissue groups who are campaigning
very vigorously and effectively for treatments that are not perhaps
evidence based, or for treatments that then crowd out other important
priorities? How do you feel we should get that balance right and
not allow singleissue groups to take over?
Professor Tritter:
That is a really important point. Voluntary sector organisations
are wonderfully diverse, but they have a particular agenda. So
Breast Cancer Care will be very in favour of breast cancer. They
are not against kidney cancer or leukaemia, but they have a particular
constituency of interests and those are the ones they promote.
The only way around is to think about balance and diversity and
ensuring there is also variation in timing, having term limits
on the ways in which those representatives are able to have a
particular kind of opportunity to express their voice.
Malcolm Alexander:
Interestingly, I was the chief executive of the Association of
CHCs for England and Wales and so I had a lot of experience about
what happened across the country with CHCs. They weren't taken
over, you know. I never came across a CHC that was taken over
by a singleinterest group and I don't think I have come
across a LINk that has been taken over by a singleinterest
group. It is about good governance and it is about having a wide
membership. It is about a wide membership that helps to determine
priorities and agree a programme of work. If you have good governance
in your organisation you don't get these takeovers. It is extremely
Dr Wollaston: That is
Caroline Millar:
And it is about outreach. It is about going and finding the people
that you are not hearing from and finding out what their views
are in a systematic way, using all sorts of different methods,
and bringing that information back to the board or table. You
will only hear the singleinterest groups if you don't go
out and find out what other people are thinking. But when you
do you find a broader view.
Q32 Dr Wollaston:
Yes, as Malcolm was saying earlier, going out there and canvassing
people outside, so having diversity.
Malcolm Alexander:
Yes. That is the experience, providing you keep bringing people
in. If the steering group of an organisation allows it to be dominated
by a single issue, clearly that is extremely damaging, but it
does not happen, in my experience.
Alyson Morley:
The best LINks have been networks of networks that bring in people
who don't necessarily want to sit on a LINk. For example, if you
take young people, it is very unlikely that an average young person
will want to be an active member of a HealthWatch. But groups
of young people, whether they are youth councils in schools, members
of youth clubs, members of faith groups or different tenants'
groups, may well have really strong views on health issues, especially
around sexual health services, domestic violence and mental health
services. If you can find ways of linking with existing groups,
you don't necessarily have to have everyone at the table all the
time. The best LINks already do that, building on good community
development strategies within councils.
Q33 Dr Wollaston:
Thank you. Can I follow this up, because that has been very helpful?
If there was a single amendment you could make to the Bill, have
you thought about wording that you would like to have within the
Bill to make all this good practice happen?
Professor Tritter:
One of the things missing is the consequences of involvement.
There is nothing in the Bill. You could put in a requirement to
involve people, but unless you measure whether or not that involvement
has led to some change of any activity it is almost meaningless.
I worked with Northern Ireland to develop a framework for measuring
the impact of involvement, and that is identifying both examples
which did work and examples that did not work and how you might
do them differently. Something which is about the impact of involvement
is at least as important as providing the requirement to involve.
In the response to your last inquiry, the Government
said that one of the things the NHS Commissioning Board might
do is produce guidance on how to do involvement for the consortia.
It seems to me a key part of that guidance should be about what
should be measured, what should be documented, in terms of how
involvement is taking place and what impact or influence that
involvement has on their decisions.
Malcolm Alexander:
I agree. The National Commissioning Board has a very important
duty in promoting good practice in commissioning. In terms of
amendments, the issue about lay involvement in the boards and
elected lay members is fundamental. In terms of HealthWatch, elections
to the local HealthWatch and HealthWatch England are fundamental.
LINks and patients' forums have been far too inward looking, and
I absolutely agree with the point about community development.
We need to get them outward looking, we need to make them democratic,
we need them to be inclusive and we need the relationship between
the public and the commissioning boards to be one where there
is real accountability, real democracy and engagement. The past
few years have been a very difficult time for effective public
involvement and there may be an opportunity here to create something
which is more profound. But unless we have elections to the different
parts of the system, I don't think it is going to happen.
Q34 Chair: Does
anybody else want to come in on Sarah's question?
Alyson Morley:
I wanted to say that one of the areas we have not really focused
on is the accountability of national bodies. Jonathan talked about
the accountability of the NHS Commissioning Board. There are real
issues about the accountability of Public Health England. At the
moment there is almost nothing in the Bill about Public Health
England. In fact, it is not mentioned because those powers are
vested with the Secretary of State. There is also no relationship
between Public Health England which will be responsible, we think,
for commissioning, and provide planning for a lot of public health
services, which, after all, are absolutely crucial in all of this,
and no accountability framework between them and Health and Well-being
Boards or between them and the NHS Commissioning Board or between
them and HealthWatch. There is a vast gap in the Bill about how
we hold Public Health England to account.
Professor Tritter:
That is really important because 15% of the quality outcomes framework
for GPs is going to be around commissioning public health interventions,
but how does that come in to the ways in which GP consortia are
supposed to be commissioning services? With the Health Protection
Agency we have developed a people's panel of a thousand people
across England randomly, identified initially through MORI surveys.
That provides you with one of the only attempts to engage with
public rather than patient involvement around these kinds of issues.
I do hope that when the HPA becomes integrated in Public Health
England and the Department of Health they take the opportunity
to move the people's panel into that new body.
David Lines: In
terms of an amendmentand this is not the LGA but the local
politician speaking, if you likeI would like to see more
emphasis on input rather than output. A lot of this is output
based. The patient goes in. What do we do with them? Can we provide
them with this, that, and the other? I am a great believer in
"Sound body, sound mind". I would like to see the roles
that the councils take, and districts and boroughs particularly,
in terms of increasing opportunities for leisure and other activities
like that.
I would like to give an example of good practice. Being chairman of the LSP, I invited the chief executive and the chairman of the local PCT to come along to our leisure centre, which we had upgraded, and already they were doing patient referrals. Essentially, I did a sales pitch. I went round the absolutely fabulous centre we havefull and really very impressiveand I said, "I am approaching you from three points of view: one, please continue referring your customers to us; two, you are a corporate entity and I wish to give you corporate membership", because I would have thought of all the organisations, private or public, you would expect that particular organisation to look after the health and wellbeing of their own organisation, "and, third, I want to approach you from a capital point of view", because they do have capital. We have one major centre and three satellites and I had wanted to develop the three satellites by putting our services closer to our clients. If I had the free will to put in an amendment, that is what I would like to see, because prevention, as they say, is better than cure.
Q35 Valerie Vaz:
That quite neatly picks up the points I wanted to make. Given
that we have this current system and we have the Health and Well-being
Boards, which maybe are not as democratically accountable as we
think they should be in terms of elected people, could each one
of you give me your comments on the current makeup of the
Health and Well-being Boards? And, secondly, given that we have
the system, how would you, in the perfect world, make this system
work and make it democratically accountable?
Chair: Who would like
to go first? Professor Tritter.
Professor Tritter:
Thank you so much. Some of the things you have already alluded
to: the ways in which HealthWatch is represented; the role of
public health and the director of public health on the way in
which the Joint Strategic Needs Assessment would be carried out
and, most importantly, that point I made last time, the need to
be accountable for the impact of the involvement that takes place.
Unless you do that, there is no way to identify weaknesses or
think about developing the ways in which you are involving patients.
Malcolm Alexander:
I would support that absolutely. There is no point in doing public
involvement unless you can demonstrate that it has a real impact,
not just because that is spending public money well, but also
because the public will cease to want to be involved if they don't
have an impact and they can't directly see the impact they are
having at whatever level. There should be lots of councillors
on Health and Well-being Boards, not just one, for the same reasons
you were talking about to do with diversity. There also ought
to be supported and trained expert lay people sitting there too
who can hold them to account.
Malcolm Alexander:
I would like to see more councillors on the boards. I am a bit
dubious at the role of HealthWatch on the Health and Well-being
Boards, in terms of their membership, and I am worried about their
independence. They need to be more accountable. But there is something
else, I think. We haven't spoken about this, but participative
budgeting and citizens' juries are really important models that
have been successful in bringing people in to look at complex
decisions. That is a really important part of how we spend money
locally, which is the participative budgeting part of it, and
how we get people involved in really critical local decisions,
and that is the citizens' jury part of it. With that model, getting
more accountability on the Health and Well-being Board, HealthWatch
being a participating observer rather than a decision maker is
important in terms of its ability to hold the body to account
on behalf of the public. These methods of involving the public
in more critical and more detailed ways in terms of decision making
are fundamental.
Q36 Chair: It
is striking that you focus your answer to Valerie on the Health
and Well-being Board and not on the consortium, which is where
the health
Professor Tritter:
I thought that was the question.
Q37 Chair: In
terms of increased public accountabilityand the question
has been glossed over in this session so farI am unclear
where our witnesses actually stand and what your views are on
the makeup of the consortium and the consortium board.
David Lines: You
have hit the nail on the head, Chairmanclarity of role.
We are trying to make GP consortia democratic bodies. We are trying
to do different things to other different aspects. We should be
very clear about what is going on. If we just address Health and
Well-being Boards, I welcome the welcoming of local elected members
on that. That is important because, as I said, what is the point
in reinventing the wheel? You have a structure there. It may not
be functioning well but it is structured and it is supported.
It may not be supported well, but at least those things can be
addressed rather than throw the whole thing up in the air.
There is a dilemma still with Health and Well-being Boards because there is a suggestion that we want to put it at a local level and you give choice. Having delegated that authority and that responsibility, some might go for proportional representation, and that could end up nonsensical. The big danger I see with Health and Well-being Boards is they become too cumbersome. I don't know if people are fans or know of C. Northcote Parkinson and his observations on the British Cabinet system, but essentially, my observation in business and in my short political career is that, once they extend into double figures, committees tend to be exponentially less effective. That is what you don't want. Health and Well-being Boards are executive, so, yes, have democratic representation there but have people in there who know what they are talking about as well from a specialist point of view. You are mixing your democracy and your specialism. The specialists, the NEDs perhaps, advise the executive directors to do that. I would say leave the poor doctors out of it. Let them get on with what they are good at.
Alyson Morley:
We have had meetings with the BMA, the Royal College of GPs, the
family doctorall of the GP stakeholders, basicallywho
are very keen on this and they are pretty positive on some aspects,
especially a closer relationship with local councils. We published
a joint statement, but one of the things they did say about Health
and Well-being Boards is, "If it's a talking shop, we will
come along because we have to, or a rep will come along, but we
won't pay any attention to it. They have to do things." There
is a balance to be struck between not being a talking shop but
being able to include all of those voices. At the moment, councils
have advisory groups, reference boards and citizens' panels. There
is a whole range of hearing those voices without having to have
them at every single meeting.
Q38 Rosie Cooper:
How do you make a consortium listen to you? I think that is where
the Chairman was going. What we are all doing is jumping into
the bit we understand. Health and Well-being Boards are things
we see, but this new consortium, this new commissioning bodythis
is the bit I was trying to get to earlieris saying, "We're
not going to do hips any more. We're going to do massive brain
surgery," or "We're not going to do this any more."
They are really intricate decisions, clinicallyled decisions,
but decisions a patient would have a view about. It is about all
of this stuff that we have talked aboutand I almost go
right back to where we started. How do you make consortia listen
or have a duty? I know it is there, but it is quite different
to actually being around the table with a vote. Frankly, where
is the cash coming from to support this patient involvement, even
if you are just talking about Health and Well-being Boards, never
mind where the real action is going to be going on behind closed
doors making decisions that you will feel the effect of?
The final bit: in these constrained times, do local authorities see the NHS as a cashrich organisation that they can tap into, because we are all going to get into a real descending race to the bottom if this is where we are going?
Chair: Before you answer
that, I am conscious we want to move on to the second session
at 11.45. David wants to come in. Does any other member of the
Committee want to put a final question?
Q39 David Tredinnick:
Are there sufficient mechanisms in this Bill to encourage healthy
living? If we are going to cut the costs of the Health Service,
I believe strongly that we need to reduce demand. This has come
up in very many meetings, and I do not get the feeling that there
is enough of this. I also want to link this to a question about
accountability. Under the Bill, local authorities will no longer
be required to have Health Overview and Scrutiny Committees but
will continue to have oversight and scrutiny powers which they
may discharge how they see fit. Is this a strengthening or a weakening
of local health scrutiny or will it make no real difference? Two
questions: how do we cut demand for services and what about accountability?
Is there a difference between requirements to act and scrutiny
Chair: Can you answer
that together with Rosie's question about the consortia?
David Lines: That
is just echoing what I said earlier. There seems to be a stunning
logic, to me, that if you make people healthier, inevitablyand
I am forthright in what I sayit will mean a reduced demand
for services. Set that against a growing populationand
we don't want to get too complicated in our theoretical discussion,
but if we accept that and you reduce your inputthat is
less contention for a lot of services, including alternative medicines
and things like that. I am a lifelong advocate of that,
that through healthy exercise, healthy lives, one can incorporate
cultural things. This is a wellbeingtype of Bill as well
and its impact on employment and on productivity has wider considerations.
I would hope that Parliament will look at the bigger picture of
what is going on.
It is a very detailed situation, and clearly this
Committee has to attend to its portion, but this is part of a
production line, if I may use that analogy. It is part of a production
line and the unfortunate part of the production line is we are
creating, not deliberately, unwell people and we are struggling
now with how to deal with them. Surely, if you go further down
the production line or back in the production line and actually
reduce the input, then, hopefully, some of the problems you have
will be reduced. That is my little speech on that.
Alyson Morley:
To finish off on that, absolutely. To go back to what Sir Derek
Wanless said, and that is to address your point about "Is
the NHS just a source of cash?", clearly the NHS is not cash
rich. It has to make £20 billion worth of savings and we
all know that NHS inflation runs significantly higher than ordinary
inflation. It is not cash rich. It is richer than councils, but
that is saying absolutely nothing at the moment. We know, as Derek
Wanless said, that the NHS in the long term is not sustainable
if we carry on with these health patterns. What we need to do
is to go back to public health interventions. We know that good
housing, a good start in early life, educational attainment, community
safetyall of thesehave massive beneficial effects
on people's health and their need for health treatments. Talking
to GPs, they do get this and they do understand it. The difficulty
will be finding the evidence base for this in the short term,
but certainly there is a growing evidence base that things like
active walking groups can improve mental health, people's risk
factors for diabetes and heart disease in the short term as well
as the long term. So GPs are willing to be convinced that there
is a good public health case.
I wanted to say something about your point as to whether the change will make any difference with health overview and scrutiny. That is a tricky one which we are currently debating within the LGA. We have not come to any decisions, but when we do we will certainly give you our decision making. On the one hand, in some places health scrutiny has been somewhat marginalised because the powers reside in a committee that is subsidiary to the council and some would argue that giving that power to the council ups the profile of health scrutiny. On the other hand, you could say, as the council is a provider and a commissioner of services, it could be a conflict of interest for the council to be making decisions, but there are provisions within council constitutions already about conflicts of interest. When we have had those discussions amongst ourselves and come to an agreed decision, we will let you know.
Q40 Chair: Now
the closing brief observations.
Malcolm Alexander:
On the issue that David Tredinnick raised about reducing use of
the Service, there is a big issue about continuity of care, especially
in poor urban communities where care is not well integrated. That
is when you get overuse and excessive use of A&E departments
and so forth. Good continuity of care is absolutely essential.
On the issue of Overview and Scrutiny Committees,
there are lots of very, very good examples of successful Overview
and Scrutiny Committees. I would be very sorry to see their role
diminished. A lot of good reporting, a lot of good recommendations
and good interaction with the community is often the case and
I would like to see that role properly strengthened.
On the issue of the consortia, a lot of GPs are feeling they are not going to have very much influence in the consortia. But the issue that we raised before about the role, the lay presence in the consortia, is absolutely fundamental, and a democratic lay presence in the consortia is fundamental.
Caroline Millar:
Very quickly, I absolutely agree that there is a role for scrutiny.
Health and Well-being Boards need to be scrutinised somehow, and
there are very good examples of where that has happened, where
Overview and Scrutiny has worked well.
On the point of consortia boards, somehow the consortia
have to be held to account for this public involvement, and there
needs to be something structural in there to make sure they do
it and that the evidence is out there so that the Health and Well-being
Board can see what is happening within the consortia. We might
have concerns that that information may not be easily available
all the time.
Professor Tritter:
On that last point, the Health and Well-being Boards have responsibility
to do the Joint Strategic Needs Assessment and to develop a joint
strategy for meeting those needs and that is then fed to the consortia
to try and implement in terms of commissioning health. That is
a very loose link. There is very limited accountability, and that
needs to be strengthened. It may well be the guidance from the
NHS Commissioning Board on how to do involvement provides one
mechanism of holding them to account in the way that they do patient
and public involvement. They also have a responsibility around
the QOF
to do 15% on public health, and yet there is not a lot of evidence
that the GPs know that much around public health. The role of
the director of public health is not into the consortium but only
into the Health and Well-being Boards, so where those services
are going to be commissioned is unclear.
The final point is about choice and continuity of care. The evidence of Sweden, which has far more patient choice and has patient choice in terms of primary care for the last five years, shows that a lot of that has led to a loss of continuity of care and also a lot of patients receiving services outside of Sweden, going to Finland and Estonia. The implications of the EU Health Directive on patient mobility may have significant impact on how a local GP consortium actually ends up finding they have to spend more money than they thought they had to.
Chair: Thank you very
much. You have given us, as ever, plenty of food for thought.
Thank you very much.


text:
Outdoor Photographer Magazine Subscription
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From its database comprising hundreds of business publications, Mercury Magazines applies category and title targeting to present consumers with relevant publications, based upon various pre-qualification criteria pertaining to industry and job demographics. From a targeted list of titles, consumers select only those they want and proceed effortlessly through the sign up process.
The editorial emphasis of Outdoor Photographer magazine is on the practical use of the cameras in the field. It looks at the modern photographic world by encouraging photography as part of a lifestyle. It motivates readers to make use of equipment and their talents in conjunction with recreational activities. In addition, its articles intend to inspire readers to seek new equipment, try new techniques and travel to new destinations. Sign up for a free subscription at the Mercury Magazines website, while supplies last.
This offer is only valid for residents of:
- United States

subset: commoncrawl


text:
Portivo Lounge opened her doors on 5th July 2013. A beautiful red brick structure, she was built in 1894 as a corn mill in the prosperous Gloucester Docks. Restored in 2010 as part of the Gloucester Quays redevelopment, she sits proud on the main entrance. She's no shrimp with seating for 50 downstairs, 70 upstairs and a further 40 on the sun trap outside.
Interesting fact
Portivo was probably the closest fit-out to date, with the Mayor of Gloucester walking in the front door whilst cleaners and builders were sneaking out the back!


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Looking for admissions, majors or financial aid? Visit our Admissions Site.
The major in Management Information Systems is designed to guide you in acquiring the foundation of knowledge and marketable skills that will qualify you for entry-level positions as systems analysts, programmer/analysts, application programmers or information center specialists. Graduates will be sensitive to the expanding role information systems play in society and understand the evolving implications of their professional, ethical, legal and social responsibilities.
return to program details
Prerequisite Courses:
Requirements for the Major:
48 semester credits including an 18-credit business core, a 15-credit MIS core, and a Business Analyst or an Information Technology Concentration.
Requirements for the Business Core:
Requirements for the MIS Core:
Complete one of the concentrations listed below:
Business Analyst Concentration
Information Technology Concentration
For detailed course descriptions, please go to the current catalog HERE.
What alumni say
"The Computer Science Department gave me plenty of opportunities to apply what I was studying. Between assisting other students in the computer lab and my own lab assignments, I managed to receive a very complete education."
– K.C. Morrison '96
Senior Computer Analyst Programmer at Graphic Data Services
Today computing is a component of any career. Everybody needs some fundamental understanding of what computers are, how they work and what they can and can't do.
For the computing professional, some potential careers include:
• programming
• system design and analysis
• hardware and software engineering
• information and systems science
• project management
• education
• research
• data processing
• communications
Computing applications abound in:
• the arts and humanities
• natural and social sciences
• medicine
• entertainment
• government
• transportation
Grand View maintains strong ties with the Des Moines area business community. Computer Information students have completed internships for the U.S. Department of Agriculture, the Department of Natural Resources, The Principal Financial Group and Wells Fargo Bank. Students have found opportunities in the financial and insurance industries as well.
Management Information Systems
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text:
Help with customer support
Budget £20-250 GBP
18 freelancers are bidding on average £109 for this job
Dear Madam/Sir, My name is Nremoredjo Juanita and I have 4 years experience as a customer support agent. Please provide me with more information about your company. Kind regards, Juanita Nremoredjo
I would love to work on your project. I have been in this industry for 3 years and such jobs are my daily practice. This is my first time on this site and hence you can see that I do not have any ratings/testimon More
I am working as TeamLeader for an MNC company and handling the process for customer handling, I can do this job easily with quality and customer satisfaction.
My customer support experience, English language, IT knowledge. Experience with working remote on several other projects
Working with words is a passion for me. Through different projects, I have edited and proofread hundreds of papers and written some powerful content too. I am excited at the possibility of working with you in this capa More
Hi, I am Bilal Khan. I have done MBA HRM and have about 14 years of experience working in different capacities including Customer Services, Sales and Administration & HR. I am really interested in this project. I h More
I'll give you the best result by using my vast experience and creative skills on your project and i'm sure you'll like to work with me again. So chat to show you samples of similar projects I've completed. Thanks.
I have previous experience with customer service working for vodafone UK. I'm very helping and accurate ,willing to learn anything for completing the task,readily available most of the time.


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Recently there were few topics( on TF ) about Reviewers and their work. 2 years ago i was "last noob", I didn't have any HTML, CSS and other skills. And i just want to say "Thank you!" and I think there are couple of thousand people through marketplaces can also say "Thank you"! Keep going.
Forgive me if someone's feelings was hurt
So Reviewers helped you to improve your skills? Can you tell us more about it, please…
^ It's simple, more rejections -> more learning. For example try to remember movies from 80's-90's.
And yes, I received instructions in which direction I need to move
+1 Every GR reviewer I've interacted with has always been really helpful to me in improving my items whenever I asked them for help! So thank you reviewers.
OrangeIdea said
And yes, I received instructions in which direction I need to move
+1 Me too, always.
I understand frustration of some members, they need little more experience. Sometimes I'm unable to see true feedback meaning of soft rejected item and than I little struggle, but I can't blame reviewer for that. One way to be more objective and avoid 'blind mode' is to leave design away some time (4-5 days) and than come back to it.
For sure more reviewers, or at least two-three reviewers only for TF (like @jremick mentioned) will shorten process time for all soft rejected items, than reviewers will have more time for little more detailed/precise feedback. That will be move in the right direction, also that move will exclude all those threads about reviewers, asking for help trough forum etc.
I totally agree with OrangeIdea. But I have to admit: when my first theme was rejected for the first time with that "robotized" hard rejection message, I almost had to hit myself to don't complain about the reviewer
Some people don't know how to handle with rejection and that's why the forums are flooded with threads about people complaining.
One way to be more objective and avoid 'blind mode' is to leave design away some time (4-5 days) and than come back to it.That sounds like a good lesson. And that is not:
The overall quality of your submission does not meet our aesthetic and technical requirements and will need to be improved before being resubmitted. Unfortunately we're not able to provide more specific feedback for your submission at this time.
^ That is for hard rejected mate. If you receive something like that leave that project immediately and start new one, without regrets, that is my lesson number 2.
Pirenko said
I almost had to hit myself to don't complain about the reviewer
@pebas, tnx, i'll consider it. Actually, I've got pretty nice reviews in russian OpenCart community so I was a little bit confused with hard rejection. I'm here trying to find what was so terribly wrong in my theme so I can avoid it in future. To be honest I didn't get much yet. In some topics experienced users give some advices, in other topics they give opposite advices.
sorry for getting me, but I recently got accepted my first article and I really like 6/5 rejections and helped me a lot to learn and I will continue to send even if you reject that as you said the friend rejection = learning / experience. And it has to be constant. regards
disculpen por meterme, pero yo hace poco me aceptaron mi primer articulo y la verdad que tuve como 6/5 rechazos y me sirvieron mucho para aprender y voy a seguir enviando incluso si se rechazan por que como bien dice el amigo rechazo = un aprendizaje/experiencia. Y se tiene que ser constante. Saludos


text:
Results for (918)-338-5904
Phone Number Details
Phone Number: 9183385904
Due to number portability, some numbers may have been transferred to a new service provider and nearby city.
Premium Information is up to date and includes owner name, most recent address, and much more.
About BARTLESVILLE, OK
Location Type: City
Complaints about 918-338-5904
Caller Type: No Complaints
File a Complaint About 918-338-5904
No complaints filed for 918-338-5904.


text:
Cortona will be your base as you travel through the surrounding Tuscan hill country. In Umbria, explore two walled citiesmedieval Assisi, home to the exquisite Basilica of St. Francis; and Perugia, an ancient Etruscan city-state. Then, journey to tiny Montepulciano, set in the heart of Chianti country. In Siena, navigate narrow cobblestone streets lined with gothic buildings, visit the citys magnificent Duomo and stroll the Pi-azza del Campo, one of the loveliest squares in Italy. Finally, experience the brilliant artistic and architectural heritage of Florence, the Cradle of the Renaissance.
Approximately $2,195 per person, plus airfare and VAT, based on double occupancy.
Begin in Ennis, County Clare, and travel to the ancient Burren and Cliffs of Moher. Appreciate the countrys epic literary heritage at Coole Park in County Galway. Cruise to the Aran Island of Inishmore, and see the limestone Rock of Cashel in County Tipperary before touring the high-lights of Kilkenny. Visit the Irish National Heritage Park in County Wexford, the Waterford Crystal Visitor Centre, Jerpoint Abbey and the famous Dunbrody Famine Ship.
Approximately $2,495 per person, plus airfare and VAT, based on double occupancy.
Start in historic Athens, and marvel at the Acropolis, Olympic Stadium and Constitution Square. Transfer to diverse Rethymnon, Island of Crete, where you will tour the Palace of Knossos archaeological site, center of the extinct Minoan civilization. Then stroll through Chania and journey to the ancient Minoan city of Akrotiri, on Santorini Island, and enjoy fantastic panoramic views from the top of Mt. Profitis. After cruising to the nearby Caldera Islet of Thirassia, visit a local winery in Ia.
Approximately $3,095 per person, plus airfare and VAT, based on double occupancy.
Note: You will receive a $100 early booking discount per person if your deposit is received by March 15, 2007.
Cruise the magnificent Rhine River! Stroll the winding streets of quaint Breisach, Germany. Then, see Freiburg before admiring the stunning beauty of Lake Titisee in the Black Forest. In the heart of the Alsace region, experience cosmopolitan Strasbourg, France, with its impressive Cathédrale Notre-Dame. Travel the Alsatian Wine Road, through medieval villages and bountiful vineyards, sampling some local wine along the way. Returning to Germany, explore the resort town of Baden-Baden, nestled between the Black Forest and the Baden vineyards. Ride to Hei-delberg, site of Germanys most famous university, and discover Romanesque Speyer Cathedral. Continue to Worms, center of Luthers refor-mation, and Mainz, where the historic Gutenberg Bibles were printed. Finally, sail through the Rhine Gorge to Bonn, Beethovens childhood home.
From approximately $2,345 per person, plus airfare and VAT, based on double occupancy.


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Stranding Coordinator
Phone: (541) 867-0446
University of Vermont, BA, 1988
Sea Education Association, Woods Hole, MA 8/87 to 11/87. Sea Semester - undergraduate studies of oceanography involving the operation of a sailing school research vessel on the high seas. Completed an independent study of zooplankton distribution from New England to the Caribbean Sea.
Additional Course Work:
The Biology of Marine Mammals, Graduate School of Oceanography, University of Rhode Island, 1992
Evolutionary and Ecological Determinants of Behavior, Brown University, 1993
Functional and Comparative Vertebrate Anatomy, Harvard University, 1998
Life History Studies on Marine Mammals: A Workshop on Theory, Techniques and Applications, Eckerd College and Florida Fish and Wildlife Conservation Commission, 2000
New England Aquarium, Boston, MA 8/96 – 10/05
Senior Biologist / Technician, Rescue and Rehabilitation
Responded to marine mammal and sea turtle stranding events throughout Massachusetts, New Hampshire and Maine; included husbandry and veterinary care to physically distressed animals, diagnostic testing, preparing animals for release, performing necropsy analyses, collecting and preserving tissues for archives, maintaining and analyzing database, and characterizing stranding trends over time.
Principal Investigator in 5-year study of harbor porpoise habitat utilization of Boston Harbor.
Principal Investigator in study of diagnostics and satellite telemetry of mass stranded dolphins
I am primarily interested in working with the Veterinary Diagnostic Laboratory at the OSU College of Veterinary Medicine to investigate the disease processes affecting marine mammals along the Oregon Coast.


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More information about finance
The new DEP KTM SX50 exhaust system is now available for the future of our sport...today!
We're pretty pleased with our new little ripper. The DEP KTM SX50 exhaust system comes with a choice of nickel or steel expansion pipe and then the trick looking black anodized silencer can. Yeah, we know that the kids are only starting out when they're racing an auto, but motocross is becoming more and more and young man's sport. Getting into the habit of running near the front and winning races is a good one to have and we're confident the DEP KTM SX50 exhaust system will help that. Of course it's you parents out there that will have to pick up the bill on this one though, unless your kid is willing to break open the piggy bank?! The DEP KTM SX50 exhaust system works sweet as nut on stock jetting too so you won't be spending hours fettling the bike trying to get it work.
© 2016 DirtBikeBitz.
Wheels Wings & Water Ltd.
All Rights Reserved.


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Columbia University Freshman, 18, Jumps To Her Death From 14th Floor
There is no way to discuss this in a manner that's particularly comfortable or even couth, so I'll start with the facts: Martha Corey-Ochoa, an 18-year-old Columbia University incoming freshman, was found dead on Monday at around 11 p.m. following a fall from her 14th-floor dormitory on Manhattan's West 114th Street, where her parents had dropped her off and helped her move in earlier in the day. Valedictorian of her graduating class at Dobbs Ferry High School in New York, the violinist and writer had planned to double major in English and mathematics. Her death was pronounced a suicide.
Corey-Ochoa, an only child, was described by all accounts as brilliant, shy, and intense. She was a member of the Spanish National Honor Society, a National Merit Scholarship finalist, an incredibly gifted writer, violinist, and composer. Her senior year had seen her through a challenging courseload that included four International Baccalaureate classes and Advanced Placement Calculus, along with a number of extracurricular activities. Despite her talents and flourishing academia, Martha had attempted suicide last year, for which she was briefly institutionalized. She contacted her parents shortly after their departure and told them that she was feeling suicidal. "She looked a little sad when she was saying goodbye to us," said her grieving father, George Corey-Ochoa, a Columbia alumnus, "But she was controlled. She had it together."
Tragic though this single case is, it is far from an isolated incident. Dr. Kelly Posner, Columbia's director of the Center for Suicide Risk Assessment, told the Journal News that suicide is the second leading cause of death of college freshmen. "This is just not an uncommon story. Students who transition from high school to college are often very excited about this new transition in their lives, but they're exposed to expectations and circumstances that place them at risk for psychiatric disorders, for feeling depressed or anxious, and it may exacerbate pre-existing problems."
As Columbia reaches out to console their students, and offer options for counseling, we cannot make it clear enough to everyone, of all ages, from preteens throughout adulthood, that there is help and there is hope. All of the clichés have already been said, but when something like this happens, it makes it all the more clear that we need to broadcast that depression is not a stigma, and it isn't something you need to carry on your own. Nobody who suffers should go without treatment of some kind. There is always somebody to talk to who can help you, and suicide must, absolutely must, be ruled out as an option. We lost one incredibly bright, kind individual in Martha Corey-Ochoa, but this applies to all people, everybody.
You can reach the National Suicide Prevention Lifeline 24/7 at 1-800-273-8255.


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Renton, Washington- (The Hosting News) – March 20, 2008 – Server virtualization firm, Parallels, has unveiled its fully integrated customer relationship management (CRM) system automation data center solution, which now supports Microsoft Dynamics CRM 4.0.
Serguei Beloussov, CEO of Parallels noted, "Parallels Automation for Dynamics CRM allows service providers to offer businesses a cost-effective alternative to in-house CRM solutions. This solution delivers the benefits of the Parallels Open Platform architecture combined with Dynamics CRM to help service providers tap into the hosted CRM opportunity and the broader software-as-a-service (SaaS) market."
Parallels Automation provides a complete back-office infrastructure so service providers can go to market quickly and incorporate CRM into their service offerings. Parallels Automation provides both operational and business support systems to help service providers optimize the use of server resources. Using a single login, service providers can deliver integrated offerings that include multiple services such as hosted Microsoft Exchange, hosted Windows SharePoint Services and hosted Microsoft Dynamics CRM. Service providers that already sell hosted Microsoft Exchange can use Parallels Automation to up-sell customers to Microsoft Dynamics CRM.
Microsoft Dynamics CRM 4.0 gives businesses the capability to easily create and maintain a clear view of customers from first contact through purchase and post-sales. With tools to enhance sales, marketing, and customer service processes — along with Microsoft Office Outlook compatibility — Microsoft Dynamics CRM delivers a fast, flexible and low-cost solution.
John Zanni, Director of Worldwide Hosting at Microsoft Corp. added, "With more and more customers adopting on-demand CRM solutions, there's no question this is among the fastest-growing market segments. Microsoft Dynamics CRM has multi-tenant support and a user-friendly interface, making it an appealing option for service providers to offer CRM as a service, in conjunction with offerings such as hosted Microsoft Exchange and Windows SharePoint Services. Parallels Automation provides comprehensive back-office support that enables service providers to deliver Dynamics CRM applications to attract new customers and upgrade existing hosted Exchange customers."
Parallels Automation for Dynamics CRM will be available in April 2008. The solution includes pre-defined deployments, installation services and marketing support for service providers who want to deploy hosted Dynamics CRM. Pricing includes a one-time implementation fee and monthly licensing fees based on active users. Parallels is offering promotional pricing through March 31 for customers who purchase Microsoft hosting modules or pre-order the Parallel Automation solution for hosted Dynamics CRM.
Parallels Automation allows service providers to more efficiently manage their infrastructure by providing online ordering, domain registration, service plan management, client self management, server management, workflow, billing and payments, and more. With Parallels Automation's modular design and flexible architecture, a system can expand to include new services and scale to several million customers.
The Parallels Open Platform enables hosting with Parallels virtualization and automation technology through integration with a wide range of third-party applications and systems. The Application Packaging Standard (APS), a key element of the platform, is used by ISVs and service providers to seamlessly integrate applications to offer to the more than 10 million businesses and individuals that use Parallels products.
Parallels (formerly SWsoft) is a worldwide leader in virtualization and automation software that optimizes computing for consumers, businesses, and service providers across all major hardware, operating systems, and virtualization platforms. Founded in 1999, Parallels is a fast-growing company with 900 employees in North America, Europe, and Asia.
To learn more about the new offering, please visit: www.parallels.com/automation/modules/crm.
For more information about Parallels, please visit: www.parallels.com.


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What do you get when you cross Google-mania and Publisher's Clearing House gigantor check excitement? Blingo the magic winning search engine machine.
You search as usual and, if you're incredibly lucky and are the first search after random times throughout the day, can win prizes like movie tickets, cars or $10 million. I am personally in it for the latter.


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David Cameron faces a horrible decision if the Lisbon treaty comes into force. A quick glance at the policy options makes it obvious why he doesn't want to explain what he would do. Playing hardball runs the risk of wasting the first year (term?) of a Tory government in a fruitless European battle. The pragmatic route, however, will never satisfy his party. So what to do? Here's a quick Q&A.
How can Cameron change the Lisbon treaty? Merely to start a formal renegotiation, Cameron would need to propose an Intergovernmental Conference and win the support of 14 countries – a simple majority of member states. Read more