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(The minutes will be agreed at the next AGM of the Patients Forum in September 2005 - the presentation only is given here.) Meredith Vivian, Head of Patient and
Public Involvement, Department of Health
“Thank you very much
for inviting me. It is a
very good opportunity for me to give you some early thinking from the
Department of Health.
Before I say what my presentation is for, can I just take 30
seconds to remind you all about what the PPI system looks like? We will
probably have differing levels of familiarity and I’d quite like us
all to be familiar with the base line. It all came through
various pieces of legislation, primarily the Health and Social Care Act
2001 and the NHS Reform Act 2002.
That gave us a series of mechanisms which essentially replaced
the CHCs. Let me just
quickly run through what they are:
I think it is important
to be familiar with the starting point and that, if you like is the
system. There is
another element that you’ll be familiar with and that is Section 11 of
the Health and Social Care Act, which is a duty on the NHS to involve
and consult patients and the public.
Putting those pieces together we end up with what we call the PPI
system. You’ll know that the
Government has recently gone through an Arms Length Body Review in
relation to the Department’s non-departmental bodies, i.e. the quangos
that essentially support delivery of health services.
The drive there was to see whether, through rationalising these
arms length bodies, it would be possible to deliver some savings, to cut
out duplication and basically to make better use of available funding.
There were 40 arms length bodies and the intention was them bring
it down to about 20 to free £½ a billion for front line delivery. One of the casualties
of the Review was the one element that I didn’t say in my introduction
which is the organisation the Commission for Patient and Public
Involvement in Health.
The fundamental role is to support the 571 Patients Forums.
I say support and there are lots of elements of that:
Essentially it provides
the wherewithal for Forums to do their business as effectively as
possible. The Commission also had
some other functions including promoting greater involvement of patients
and the public and reporting back to the Secretary of State the product
of PPI. That is the context and
what I’d like to do today in the remaining time is to talk through
with you our early thinking about how we take forward the Commission’s
functions to best effect. I’d like you to bear in mind that what I
am going to say today are our ideas, part of the process that I am going
through at the moment is to share some ideas, hear some feedback and get
people’s views about those ideas, whether they can see improvements,
areas for development or things that I might say and you say “what
about x or y?” For me
this is an opportunity to get your feedback as much as for you to hear
what I’ve got to say. Bearing
that in mind, what we discuss today may look different as a result of
this engagement exercise that I am currently going through.
If in three months’ time you see something dramatically
different from what I am saying today then that’s because we have been
listening to what people have to say and taking account of it.
I do want you to have the opportunity to ask me questions as we
go along. Let me take you through
the various elements. First
of all to squash a misconception. One
of the options considered during the ALB Review was for the HealthCare
Commission to take over the primary role of CPPIH.
It was thought that the HealthCare Commission might be a good
vehicle for supporting Patients Forums.
That was an idea tested out and in the end we didn’t like so
didn’t go for it.
There are some synergies to be had, though, between Forums and
the HealthCare Commission but I’ll come on to that in a minute.
We also considered other ALBs taking over CPPIH’s functions and
in the end there weren’t many natural fits so we have decided to go
about it in quite a different way and that’s what I’d like to test
out with you. About the HealthCare
Commission, we do think there is a job to be done in making sure Patients
Forums work well with the Commission.
They are both designed to improve health services and do it in
different ways and at different times and through different methods and
we think it is important that they are able to work together and able to
trigger each other’s activities.
For example, if HCC wants to do a themed review of a specific
area it would obviously make sense for it to alert Patients Forums of
that idea and to suggest that Forums might like to engage in that
activity, for example, services for older people.
It would be perfectly sensible for HCC to say to Forums that we
are doing a themed review on services for older people and any feedback
you could give us from a local perspective would be very helpful.
We’d be happy to work with you in terms of devising a
collection mechanism in terms of patient feedback.
That is obviously very helpful and we would want that
relationship to be developed and for communication from one to the other
to be developed. Similarly,
if a Forum is picking up important information locally, it obviously
makes sense for it to be able to trigger an activity from HCC.
That relationship needs to be strong and active and ongoing but
there is not going to be any managerial relationship or any direction
from one to the other. It
is one of good practice and partnership. One thing that is clear that the ALB Review specifies, is that appointments to Patients Forums will be undertaken by the NHS Appointments Commission. The thinking behind that is that the Appointments Commission is an organisation set up and funded to be specialist at appointments. It didn’t seem sensible for the appointment process to Forums to be done by another organisation. This seemed to be duplicating and wasting resources. The Appointments Commission is now being scaled up to take on this extra work which, obviously is a major piece of activity for it, 5 – 10,000 extra people to go through its processes. One thing that I am keen to clarify is that the appointment process to Forums needs to be much more rigorous and a bit sharper. I had a sense that a number of people who joined Forums were not absolutely clear what Forums were all about and what their role was and, therefore, whether or not they were suitable. Similarly, I think the
appointment process, to-date, may be different depending where you are
and we would be very keen to see that there is a much more rigorous and
standard approach to appointments to Forums.
We are in the process now of working that through with the
Appointments Commission and CPPIH to make sure that the lessons learned
are fed into the new appointment processes. The next stage to talk through with you is staff support to Forums. We have been in several minds about this. There is something to be said for staffing support all to come from one organisation so that staff are all recruited on the same basis, they are all governed by the same terms and conditions, they are all employed to something that they all recognise as being a consistent and standard approach. Finding a single organisation that we can just say: “Look, here you are.” to take on this function isn’t as easy as that. We don’t want to give it to an organisation that isn’t appropriate. Rather than make decisions on the issue of staff support now we think it better to seek the views of Forums on the nature of the support they need and how best for it to be delivered. The way we want to
perform this process, and we are about to kick it off, is through an
extensive engagement exercise where we ask a lot of people (a) what has
been your experience to date and (b) what kind of support would you like
to help you deliver in the future. We are going to be
going through that in a range of ways.
We are certainly going to be asking Forum members generally.
We also want to learn from the current arrangements, the Forum
Support Organisations that have been contracted by the Commission, we
want to ask their experiences. We
certainly will be asking a number of other groups who will have had
contact with Forums and been able to observe how they work, including
the NHS and groups like this one. We
are going to do it in a number of ways.
We want to go through a survey process where everyone has a
chance to have a view. We are going to be commissioning a research company to run
qualitative research as well around the country so that we can get some
in depth views from a number of sources.
There will also be opportunities to feed into a website database.
It is absolutely essential that whatever arrangements we come up
with they need to be informed by the people who are affected by them but
who have to deal with them on an everyday basis. One of the areas that a
lot of people have commented to us is necessary is one of a natural home
for advice, information, expertise, research and evidence bases about
PPI generally. I bet if I went round the room now and asked you all to
come up with a definition of PPI and what its value is, we’d get the
same number of different answers as there are people.
It has become some kind of quasi science that, I think, gets in
the way, quite often of delivering the benefits that can accrue from PPI.
After all, it is there to deliver improved services
and enhance patient experience. Bearing that in mind, and also
bearing in mind that the NHS has a duty to involve patients and the
public so it needs support to do it, Forums, I believe need much more
than just staff support. They
need the wherewithal, the insight, the understanding how to manage
themselves, how to operate with their partners, how to operate in
meetings, how to do monitoring visits, how to write up the reports and
how to guide seems to be absolutely fundamental.
There is another element as well. You will be aware that across
Government there is a really strong drive brewing, and I think it is
going to get bigger after the next election, and that is around
community development and citizen engagement.
It always makes me laugh because every Government department does
something around citizen engagement as if every citizen only relates to
that department. Of course,
they are all the same people but we all treat them as if they are
peculiar to ourselves.
There is a real need to work more strategically across
departments to say, look, if you are wanting to be more involved in the
police service or in the prison service or in the health service, what
you will be doing will be very similar in some respects;
some of the skills you’ll need will be similar, if not the
same, some of the relationships you’ll need to develop will be
similar. There is
something to be said here for insuring a consistent approach and making
best use of what we all know will always be limited resources. I am describing three
areas of development – supporting the NHS to do PPI well, supporting
Forums in their particular role and working across Government.
What we have in mind is a centre which isn’t necessarily an
organisation but is more of an initiative.
Let’s call it for the sake of argument the Centre for Patient
and Public Involvement. We
don’t picture a great monolithic organisation which sucks up loads of
resources. We are talking more about making best use of the skills and
expertise that’s out there but bringing it into one home. Once again, it’s probable but not necessarily the
case that we might contract out that set of arrangements.
We’ll also be asking people like yourselves, Forum members and
across Government for their views.
That is another part of our engagement exercise. What kind of roles will
this organisation play, how can it best do it, and indeed what is the
added value that it will bring to the playing field?
We believe there is a role for this type of exercise but we want
to be sure that it delivers something sensible. The way that I perceive
it, certainly around the Patients Forum dynamic, is for it to have,
let’s say a board of trustees or governors who are themselves Patients
Forum members and they then oversee the support and advice and
information that is given to Patients Forums
rather than having this top down board of excellence telling
smaller organisations how to do things.
We’ll have it the other way where we have what’s happening on
the ground feeding into this exercise and out of this comes the advice
that is relevant and informed by real experience. Those are the sorts of
elements that we are thinking through.
There is lots of detail still needed and, of course, I don’t
want to go into that detail at this stage as we need to hear what people
have to say about the ideas and what they say will then form the detail. There are some
important elements to keep in mind.
First of all, we are very keen to learn from what has happened so
far. It is not just a
question of saying we are doing something new, let’s start from
scratch. That isn’t very
helpful because, of course, that would be throwing out useful feedback.
Also lots has happened that is good and we want to make sure we
continue to capture that and feed that into the way we take things
forward. That means
from 1974 onwards – for the CHC historians who will know how relevant
that is. There has been lots of CHC good practice which I am not sure
has been captured to date and I think we need to ensure that is fed in,
it is still relevant. There’s
been lots of learning from the Patient Forum activity to date and,
indeed, CPPIH work to date. There
is something to be said, also, for building relationships around all of
this. It is my observation
again that there are relationship difficulties out there in the PPI
world. An effective
Patients Forum is always going to be one which has a good relationship
with its partners, not a table thumping, ‘you’ve got it wrong’
type of relationship. There’s
also an important piece of work to be done about clarifying distinctive
roles. In the
PPI system and how it relates to the NHS and local government, there is
absolutely no point in there being duplication of resources and all it
does is mess up the playing field.
There is a job to be done in clarifying roles and making sure
that those players stick to their position.
There is no point in an Overview and Scrutiny Committee fighting
with a Patients Forum about what their roles are.
They have different roles and need to be doing them separately
but in partnership. There is also a very important job to be done in
relation to the NHS.
In the end all the PPI system is there to do specific jobs but
their biggest job is with the NHS and it needs a great deal of support
to do that. The area about
working across Government is very important too.
We can’t waste our resources duplicating things or, worse
still, leaving gaps. That is the picture at
the moment and I am going to pause there as I would really like your
feedback and am very happy to answer as many questions as you can throw
at me. Q: Brian
McGinnis (L’Arche) “Isn’t there quite a strong case for
having, let’s call it a consumer body, which does its own thing in
toto both locally and nationally so it appoints its own members, it
appoints and manages its own staff and it has its own research except
for resources. Although
you mentioned creating a new, real or imaginary centre, the
Government’s strategy seems actually to fragment that independent,
‘outside the structures’ consumer body rather than to bring it
together. Is this because
you are still scared of what happened with ASCHEW or is there a more
logical explanation of fragmentation as opposed to unification?” A.
“To be honest with you, I am not sure that we are scared as an
organisation. We’ve had
time to work with CPPIH now and I think it is fair to say that the very
fact that it has had these functions to perform, some of which have
worked against each other, has proved very difficult.
Fragmentation is the pejorative way of describing it.
The way I describe it is putting the right function in a body
which can deliver it to best effect. I personally don’t see the need
for a central body to perform a role which brings it all together, which
is essentially the national picture.
The centre I have described will certainly be able to pull
together the views and experiences as they become apparent and whether
that be just at the local level or whether it can aggregate it up
through the regions at a national level.
Whether or not you need a national, central body to do
everything, I don’t see that. I do accept, though, that we don’t have
fragmentation so that parts don’t speak to each other.
I think there is a coordination role we need to be very careful
about.” Q. Sally
Brierley, Health Link: “Leading on from that, I think I agree with
you in terms of a national body but I do think you need a national voice
and I think that is more along the lines of what you were saying about
having Patient Forum members on a board in the centre so that it is
actually Patients Forum members.
Perhaps we could look to have a national voice for Patients Forum
members. I
don’t think it is enough to leave it for Patients Forum members to
come together as and when they like.
I do feel we should be putting in place some sort of framework
by which they could be encouraged to do that – for a whole
variety of reasons, not just being a national voice for patients but
also sharing best practice, divvying up the workload, looking at issues
which cross Strategic Health Authority areas or regions.
I would like to see something along those lines. The other thing I
wanted to say was this issue of the number of Forums. You said 571.
Is there any notion that perhaps we have too many Forums at the
moment? And just so
you don’t think it is me coming from my history with CHCs, to say that
the Vice-Chair of CPPIH said at the Socialist Health Association
Conference in May that she thought there were probably too many Forums.
Perhaps we should be moving towards one Forum per local health
community. I wondered if you had any thoughts along that line?” A. The distinction you
draw is really important – the national patients voice versus the
national Patients Forum voice. I see the need for the national Patients
Forum voice because it is a particular set of voices, specific to their
functions and that they can elicit views in a particular way.
We need to get away from the national patients voice.
There are lots of organisations that can bring to the table the
national patients voice depending on the issues, disease specific,
population specific and so forth so I think that is a very helpful
distinction and thanks for that. On the number of
Patients Forums, to be honest with you I think there are too many as
well. I think the
solution about the right number is tricky because if we have
independent, statutory bodies attached to things like health economies
that is extraordinarily difficult to define and will always shift, I
suspect. It is
finding the right vehicle to attach a Forum to.
I take on board the question and it is something that I am
particularly keen to explore. Q. Bill
Marks (Hackney Health Scrutiny Commission) “The
most important thing is networking between Forum members.
Without networking you are effectively completely useless.
There isn’t the mechanism available for us to do it.
We can trust our Forum “Hindrance” Organisation to do it and
we don’t have the resources to find the contacts for other Forum
members. Networking
is important but I am not quite sure how we can do that with effective
regional organisations at least but preferably a national organisation
that would have a database of members.
There is a case for a national organisation. One other area that is
important to Forum members, speaking as a Forum member but it hasn’t
affected me yet, is nitpicking over expenses.
I was talking to one of my members last night who said that his
Forum Hindrance Organisation had refused to pay any expenses because he
had actually made a claim for travelling at peak time in order to get to
a board meeting in the morning. Why
was he travelling at peak time, it didn’t matter if he got to the
board meeting late. It’s a stupid example but is absolutely typical of
what is going on in our part of London.
As a member of the Hackney Health Scrutiny Commission, we find it
very difficult to work with Forums.
We are not being given their details. We write repeatedly to our
FHO, which is CEMVO who refuse to make any contact with us.
They do not reply to letters.
So how can OSCs and Forums work together, we are not making
contact.” A. I can’t say much
about all of that but I tend to agree with you.
The relationship between OSCs
and Forums is really important. Staff
support for Forums has been one simply one of an administrative nature,
good or bad quality. This support is often around communication, it’s liasing,
getting to grips with local organisations on behalf of the Forum.
One thing that always strikes me – we are always talking about
how important Forums are, their powers etc but we have to remember, the
proportionate issue here. It
is a small group of volunteers giving up their time freely and I think
one of the issues around staff support is that the best way you can
enable those volunteers to be effective is to take off the burden of
some of these other issues that are essentially a waste of their time,
i.e. setting up things or creating things, to allow the Forums to go in
and do their specific special role which they are there to do.
I think a very close look at staff support for the future is
absolutely fundamental.
As regards to knowing who is on your Patients Forum,
It is just fundamental. They
are public bodies and they should be known to the public, I think.” Q. Carol
Herrity (Royal Mencap) “Coming
largely from the fact that Mencap has been involved in partnership
boards around oversight of learning disability services at a borough
level, we have been getting into some of the issues around how do you
involve local parents and people with learning disabilities at quite
strategic levels on quite important issues.
One of the things that is really important is the resources to
employ staff at the right level and that picks up on the point that you
have just made. I would add another function in relation to staff which
is always overlooked and may be you need to talk to the Plain English
people. In order for the
Health Service to talk to lay people or to professionals from other
technical backgrounds, there needs to be a common language. That means developing capacity within statutory services to
learn to speak plain English. That’s a real challenge. You not only have to speak plain English you also have to
speak in key points. You can’t go for your forty-page document to tell
it how it is. People with a
learning disability are actually very good at challenging that sort of
waffle. You really do have
to say what you mean. What is also important, from my experience, is
that you don’t just have the great and the good appointed by the
Commission, you have somebody who also has links with patient groups –
either because they come from one or they are willing to go to one, to
report back and to listen and to get involved in the local patient
community, not just be a person on their own, isolated, perhaps a bit
too precious.” A.
Very good points. In
our team we have recently produced a number of documents and we have put
them through the crystal marking process and it is extraordinary how
much it makes you work at saying what you mean as opposed to presenting
it in a way that might look or sound attractive and it is a very good
discipline. Certainly the centre idea I describe in the way that it
supports the NHS get better in engaging with patients would certainly be
the area we would focus on.
The other point you made, which was really interesting, was about
who you have on Forums or, indeed, who you have on representative
committees in the NHS. It
is a bit of a dilemma, I always think, because some of you may remember
that the Patients Forum regulations actually require half of the
membership of a Forum to be nominated from the voluntary and patient
groups sector specifically for that point, to bring in the local
community view. A Forum
benefits from that insight, experience and knowledge of the local
community. Similarly
that would be true for the NHS. It
would obviously be sensible to have interests that come across the board
particularly from those with interests in the learning disability field
where the interest is an informed one.
But then you get a different perspective where people say that if
you have those views, you have a Patients Forum with, say, people from
Mencap, Mind and Help the Aged, then they become rather single issue
biased. Then we have that
tricky dilemma. I
think the right answer is to have a wide range of interests and for the
Forums to have the wherewithal and advice to break out of that single
interest trap over time.” Q. Gerda
Loosemore-Reppen (Sign) “I
am interested in those discussions about who represents the view of
people who don’t usually get onto those groups because of
communication difficulties and other special needs.
The CPPIH and the Forums have been criticised for being rather
unrepresentative of local communities, by and large, and I think CPPIH
- in my experience - has been trying to do something about it.
From Sign’s point of view – having had a Department of Health
funded project to increase deaf representation on PPI Forums – we have
had some fruitful discussions with CPPIH.
That leads me on to talking about the appointments process;
unless some changes are made to the NHS appointments procedure, people
from those backgrounds aren’t going to jump through the hoops.
They need to be encouraged, supported and helped to fill in forms
where English is not the first language.
There need to be some training programmes also for potential
communities or capacity-building to use the current phrase, for those
groups to redress the balance. I
also agree with what Carol Herrity said. The NHS has been very much caught on the back foot in terms
of explaining how they do things.
For example, to explain the structure of current decision-making
in the NHS to lay people would be a very useful starting point.” A.
“Here is another very interesting dilemma.
I agree with you that it is necessary for communities to be
represented in these sorts of exercises and Forums.
Then you get another school of thought which says: “well,
actually, in a community that may have several hundred thousand people,
how can you expect seven, ten or twenty people to be representative of
it? I agree with you
that we need to make sure that it is possible to join a Forum and that
the process is as accessible as possible. It is essential that the Forum is not there in
its own right, since it can’t be representative, it has to make sure
that it goes and gets the views of those of the representative
community. I know that the Commission has been really
determined to address what is an imbalance at the moment and all credit
to them for doing so.” Q. Beverley
Beech (AIMS) “I
would like to follow on from that.
I feel very strongly that on all these bodies where they are
asking for lay people to be representative, the selection should be done
by the lay people. I think the system trawls for the people, but in the end you
have a list of thirty five possibilies and I think from that list the
lay people then select the most appropriate people to be representing
them. I think there is far
too much cherry picking going on in the system and this seems to be a
way that we can get round that.” A.
“It is an interesting point. I tend to agree with you.
It would be interesting to know what the response would be like
in a health economy area. There’d
be thirty five names, let’s suppose, would the idea be to put them in
the local newspaper or something?
We won’t go into the details now.
There’s also something to be said for a Forum’s legitimacy to
represent the views of local people since the local people have said:
”We are happy for you to represent our views.”
There’s some democracy in it. Q. Carol
Herrity (Mencap) Picking
up on those issues, I don’t think I got across this point before. I wasn’t saying that people should be representing a
particular organisation but rather that if they don’t (or even if they
do) they should be expected -
as part of their duties – to go out to at least one other to feed back
about the work to that organisation and to take forward their views and
do that on a regular basis. That
way you are exposing people to a wider range of views than just their
own or their organisation’s. A.
“I understand that.” Q. John
Wilkins (London Ambulance Service) “We
have been reviewed by CHI at some time in the past and they were very
quick to say that we must make connections with the local communities
out there in the whole of London. We’ve
got two hundred and twenty languages and so far I haven’t had a direct
answer as to what would be the best way for the LAS and its Patients
Forum to connect with those communities and give them a voice.
There might be elections but we don’t seem to have got beyond
the election phase as yet. What
would you recommend that we do?
We don’t have one health economy we have about thirty three and
a third at least so we do need some advice on the best route to connect
with all these communities, to use all these languages and construct,
what for us at the moment looks like a matrix of involvement. A.
“After all this time you don’t expect me
to have an answer, do you? (laughter)
Funnily enough, I had a meeting with Trevor Phillips around this
issue when he was Chair of the GLA and he was very anxious about the way
the London Ambulance Service managed to engage with its various
populations. I
am not even going to try and come up with an answer but this is a good
example where there is expertise and advice out there somewhere but
there is currently no home to keep it and make sense of it.
This is a good role for the Centre for PPI, or a name something
like that, where it is able to glean evidence, to understand where
things work and where they don’t work and where they might work in a
different context that can be generalised to yours.
You then present the question, the problem and ask them for
advice.” Q.
Marlene Winfield (National
Programme for IT) “We are struggling very much with how to do this on an all
important question like confidentiality. I have a question.
There is an assumption that hasn’t gone unchallenged in this
discussion and that is that because you’re from a particular patient
group you cannot rise above that and speak for wider patients and it
seems to be received wisdom, certainly I come across it in the NHS.
I’m not sure it is true and because we perpetuate the
assumption that we’re paralysed by the inability to get a
representative sample of all the views that we could have to bring to
bear. I think the challenge for us is putting together a group that has
as many relevant perspectives as possible that can kick ideas around
from a lot of different views and consult more widely where appropriate.
As long as we are looking for this perfect representative sample
on the basis that no patient from any patient group is capable of
representing the views of anyone else, I think we are never going to get
to the bottom of this.” A. I take on board that
point. There are research methods for securing the views of very
many people by asking a small number so we do need to be a bit more
sophisticated in thinking it through.” Q. Elizabeth
Manero (Health Link) “I
wanted to add one more sentence on this representation issue and then I
wanted to ask a question.
It seems to me that what has just been said is that it is about
the work being representative not the individuals and that is achieved
by all the things that we have described – going out and talking to
people, just as you are doing today.
You are representing the Department of Health here and when you
go and bring back the views to Ministers about what they are going to
do, you are going to be informed by the discussions around this table
and around this table we have expertise on a huge range of specific
interests. It
is not a new formula. I
think we have to stop banging on about individuals being representative
which I find people in the NHS are obsessed with. It’s about the work
the input being representative, not the individual and there are ways in
which that needs to be achieved, there are functions and one of them is
your possible Centre for Public Involvement. Going back to the national body, my question is this. If I am a patient who needs a hip operation, who is on a waiting list, who is worried about going into hospital and I hear about MRSA. If I am listening to the radio and I hear the latest rates of MRSA and think:” Who is speaking up for me, who is exercising influence for me at the national level to make sure that this issue of MRSA is being tackled?” That means a body, an organisation, a group of people, whatever it is, who has influence, who is positioned to understand the issue and to take it to the right place in the NHS and get it sorted. What would be the answer to that question?” A.
Well, a few examples come to mind but first of all, I don’t
believe it needs a national organisation to be the patients’ champion.
There are lots of examples of organisations that have a view and an
informed view, this group is one, the LMCA is another, Health Link has
one, Harry Cayton has one, the HealthCare Commission has one.
There are lots of organisations that can bring to bear the views
and experiences of patients at a national level.
We don’t currently have a national organisation which is the
patients voice but that doesn’t mean that in the media there aren’t
lots of people representing the patient’s voice.
We know that it is a major issue for local people at a national
level around MRSA. I need to be persuaded that we need something that is
the patients voice, that is distinct from all the other voices that are
already out there.” Jonathan Ellis, Chair of the Patient Forum, then thanked Meredith Vivian for coming along to the Patients Forum and sharing his thinking. He said the Forum would look forward to hearing more about the plans as they developed. Meredith said he had found it very helpful and thanked everyone. ______________________________________________ |
| Last updated 8/10/2004 | © The Patients Forum 2004 |