New organisations are being set up in the NHS to provide information, advice and support to patients and their carers. Dr Gerard Panting explains how they will work

Along with an undertaking to improve funding and staffing, the NHS Plan promised that by 2002 every trust would have an advocacy and liaison service for patients, underlining the Government’s commitment to redesign the health service around the needs of patients.

As a result, the first wave of pathfinder sites for the Patient Advocacy and Liaison Service (PALS), as it was then known, came into being in April 2001. Every NHS trust and PCT in England should now have a PALS in place.

The ‘A’ of the PALS acronym now signifies ‘advice’, instead of ‘advocacy’, so what does PALS actually do?

What is PALS?

PALS’ key role is to help patients and their carers with any problems they encounter in gaining access to health services or, if patients are concerned about their care, in exploring the possible solutions, and generally to provide support (Box 1, below).

Box 1: The core functions of PALS
  • PALS services will be identifiable and accessible to patients, their carers, friends and families
  • Provision of on the spot help in every trust with the power to negotiate immediate solutions or speedy resolution of problems. PALS will listen and provide relevant information and support to help resolve service users’ concerns quickly and efficiently. They will liaise with staff and managers, and, where appropriate, with other PALS services, health and related organisations, to facilitate a resolution
  • PALS will act as a gateway to appropriate independent advice and advocacy support from local and national sources, including Independent Complaints Advocacy Services. Staff employed in PALS will be well briefed on links to organisations able to facilitate provision of appropriate advice and support
  • PALS will provide accurate information to patients, carers and families, about the trust’s services, and other health related issues, using accredited, reliable sources
  • PALS will act as a catalyst for change and improvement.They will be a key source of information and feedback for the trust and be an early warning system for trusts.They will monitor problems and proactively seek patients’ experience of healthcare, including problems arising, and highlight gaps in services by:
    • developing and maintaining an information resource capable of collating and analysing all issues dealt with by PALS
    • providing information, advice and training on their service and issues raised by service users to staff
    • PALS should submit regular anonymised reports to the trust board, and will also liaise with service managers, directorates and the board on policy issues that involve PALS and customer care/service user issues
    • Establishing and maintaining clear formal routes for feeding back emerging themes to clinical governance and quality, and to individual departments
  • PALS will operate within a local network with other PALS in their area and work across organisational boundaries, to ensure a seamless service for patients who move between and use different parts of the NHS for the care they need. In this way they will ensure that patients’ concerns are picked up and dealt with in the most appropriate way for the person concerned. PCT PALS will be expected to lead on cross-boundary issues
  • PALS should support staff at all levels within the organisation to develop a responsive culture.This will partly be achieved through training staff to be sensitive and receptive to listening to feedback from patients and enabling people to see the consequences of their behaviour or action. PALS will build on good practice currently taking place in the trust around providing opportunities for patients, their carers and relatives to influence every level of the service. PALS must be seen as a culture, a function of the organisation rather than the job. All members of staff have a role to act as a PAL regardless of where they work or what they do.The implementation of a PALS service should not mean that other staff within the organisation transfer responsibility to PALS to respond to concerns and issues raised directly with them

PALS staff are employed by and accountable to the trusts, with lead PALS having direct access to the chief executive and other key managers in the organisation.

The strategic health authorities have the job of performance managing PALS but, given the differing needs of different communities, there is no single service model that can be universally applied. Consequently, PALS are likely to vary significantly from place to place. In a PCT, the work of PALS will depend on fostering good working relationships with GPs and managers and developing links with external bodies and other agencies such as social services.

Who can be a PAL?

The person specification set out in the model job description demands an understanding of health issues and preferably an understanding of the voluntary and social care sectors as well as the NHS complaints procedures. PALS must have experience of working with people in the health and/or social care context, and good communication skills are an absolute must.

The job involves some data collection so computer literacy, including knowledge of spreadsheets,is another essential.There are many demands on a PAL’s time, so good organisational skills are important, too.

Essential personal attributes include sensitivity, tact and diplomacy, assertiveness and tenacity, self-motivation and a high degree of personal integrity. These must be combined with a flexible and adaptable approach and a willingness to work outside normal working hours on occasions and the ability to contribute in a team environment. In short – a computer literate saint with attitude!


Volunteers may also be used, although they should not be considered an easy or cheap option and it is important to ensure that those coming forward do so for the right reasons.

Whether regular or volunteer, PALS are expected to look out for and speak up for "clients”. However, they are not expected to act as advocates, which is presumably why PALS was changed from an advocacy and liaison to an advice and liaison service.


The Department of Health literature on PALS illustrates the structural diversity that may be encountered in response to the differing local needs. It cites Herefordshire PCT as delivering:

"a PALS service across a widely dispersed rural community, mental health and primary care settings.The service is based on a central co-ordinator, leading and encouraging the work of specified local staff, with a commitment to training and support. PALS locations have been set up in each service reception area, with reception staff taking on the ‘visible, first point of contact, role’ to promote the service and offer information.”

It goes on to say:

"The co-ordinator actively seeks out and supports PALS ‘champions’ in each service. The ‘champions’ encourage staff in their service to adopt a culture that enables all staff to deal positively with patients’concerns or, if appropriate, refer them to the PALS co-ordinator. The PCT’s approach also centres on establishing good working links with relevant support agencies.”

PALS and complaints

One clear concern is that PALS might simply become a proxy for a complaints service. Patients will have the choice of raising their concerns through PALS or, if they wish to make a formal complaint, using the NHS complaints procedure.

However, as PALS will inevitably be the first port of call for some complainants, there must be close collaboration between the complaints department and the PALS office. The distinction is that PALS is not there to investigate or resolve complaints but to inform and support individuals so that they can use the complaints procedure if they wish to.

The PALS documentation states that a key PALS role is to help people to talk through their concerns so that they can identify the nature of the problem and work out the options for resolving the issue, including using the formal complaints procedure, and explain the potential consequences of each option.

PALS will work with independent advocacy services, providing information about them to patients and their carers as and when necessary. However, despite this liaison and support role, PALS officers should not act as casework advocates within the complaints procedure.

Over and above all their responsibilities with patients and their carers, PALS staff are expected to take an active part in training other staff members to ensure that they understand the PALS role and also in training the volunteers involved in PALS.

Commission for Patient and Public Involvement in Health

The Commission for Patient and Public Involvement in Health (CPPIH) was established in January 2003 under the NHS Reform and Health Professions Act 2002. It was set up to oversee the Patient and Public Involvement Forums, and the Independent Complaints Advocacy Services which began to be rolled out nationally in September 2003. The Commission will also keep an overview of patient and public involvement in healthcare and carry out national reviews of services from the patient’s perspective, making recommendations to the Secretary of State.

Independent Complaints Advocacy Services

Independent Complaints Advocacy Services (ICAS) are independent bodies whose remit is to advise patients and carers who have a complaint about local health services in primary and secondary care.

ICAS staff explain the complaints procedure, advise potential complainants about their options and generally assist in the presentation of complaints. So in many ways they can be seen as successor bodies to the Community Health Councils, which in England (but not in Wales) will be disbanded in December 2003.

Guidelines in Practice, November 2003, Volume 6(11)
© 2003 MGP Ltd
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