Examination of Witnesses (Questions 40
- 59)
THURSDAY 2 NOVEMBER 2000
MR COLIN
REEVES CBE, MR
BILL MCCARTHY,
MR DAVID
WALDEN, MR
HUGH TAYLOR
CB AND MR
PETER COATES
Chairman
40. I know Eileen wants to come in, in detail,
on CHCs, so we may spend a moment or two on that, but can I, just
very briefly, move on to Care Trusts, I feel this may be your
area again, Mr Walden, and it is nothing personal that we are
pursuing your area of interests. I was very interested in the
proposals for Care Trusts because, as you well know, I have long
argued for a much closer relationship between the NHS and local
government. What I wonder is, in terms of the announcement in
July, had local authorities been consulted on this proposal, had
they been involved in dialogue with the Government over what was
proposed within the White Paper, on Care Trusts specifically?
(Mr Walden) Very much so, because in the work that
led up to the NHS Plan in July there were a number of Modernisation
Action Teams set up to look at different aspects of the NHS and
social care. One of those Modernisation Action Teams was on partnership
working, and the discussions very much centred around how to get
better integrated care. The actual term Care Trusts was not discussed,
but the concept of bringing health and social care closer together
in a single commissioning and providing organisation most certainly
was.
41. Right. Can I ask you, looking ahead, what
you see will be the remaining functions of local authority social
services departments, when we move in the direction of Care Trusts?
Like the rest of the Committee, I was away from the UK last week,
but I am told that the Home Office Minister of State made some
detailed comments with regard to the possibility of child protection
being removed from local authorities. This is something that has
come to me second-hand, it may be completely inaccurate, but is
this something that you are aware of, do you see there being a
future role for social services, or will it completely disappear
into either health or some other organisation?
(Mr Walden) The NHS Plan, in its description of Care
Trusts, talks about them operating, from the social care point
of view, under delegated authority from the local authority, so
that they are building very much on the Health Act 1999 partnership
flexibilities, which authorities are increasingly beginning to
take advantage of. That does not remove the need for the local
authority and its social services department to continue to have
overview of the delivery of the social care functions, whether
they go for a pooled budget, or whatever. And I do not believe
that the position of Care Trusts, when they are a voluntary coming
together, will be different, the local authority will have an
ongoing accountability and supervisory function.
42. So, going back to my question about child
protection, you are not aware of any proposals within Government
to remove child protection from the remit of your Department,
and specifically from local authorities?
(Mr Walden) These are matters that are always being
looked at, and the development of new Whitehall machinery, and
so on, will no doubt raise further issues about how best to co-ordinate
planning and delivery of services at both the strategic and the
operational level. But I am not aware of any specific proposals
in the area you mention.
43. Ten years on from now, will there be such
a thing as a social services department in local authorities,
do you think?
(Mr Walden) I think that is quite a difficult question
to answer.
44. I know it is a difficult question.
(Mr Walden) I would be foolish to speculate, frankly.
I think we are trying to get those bits of the health and social
care system that absolutely need to work together effectively
for the benefit of patients to get into a closer relationship.
What that spells for the longer term will depend partly on how
many Care Trusts there are, what the speed of development is and
whether they are seen to be a model of choice, if you like, covering
a range of different services. That may well be the case.
45. Can I put to you one other practical area
of concern. When we undertook our inquiry into the relationship
between the NHS and local authorities, we looked in detail at
joint working in certain areas and at the way in which, and it
is going back a couple of years now, many areas were trying to
kind of circumvent the statutory difficulties they had, that,
at that stage, I appreciate that things have moved on quite markedly,
in a positive direction, since then, but at that stage was obstructing
them from working together. I have a recollection, and I mentioned
it in questions subsequently, of visiting somewhere in the South
West of England, where we were looking at community provision
on mental health, and we came across an example where the local
health service were actually paying the social care fees of an
individual patient, for this patient to access social care services
that he could not otherwise access by virtue of the barrier presented
by the fees. Now one slight worry I have got about what is being
proposed by Care Trusts is the way in which this kind of situation
may be worsened in some ways, that we could end up, possibly,
with what is currently free care ending up as charged care, that
kind of cost-shunting onto local authorities. Has this been looked
at, at all, within the context of the Care Trusts proposal? I
appreciate that the Health Act Joint Funding Provisions make a
difference here, and I welcome those, genuinely; but one of the
areas of concern that I have had raised with me is the way in
which we could end up in Care Trusts with currently free services
becoming, within the remit of the Care Trusts, charged. Is that
something that you are concerned about, aware of, or are there
mechanisms that will be introduced to stop that happening?
(Mr Walden) I think our view would be that Care Trusts
build very much on the sorts of arrangements that you suggested
were possible now, under the Health Act flexibilities, and which,
I think, you welcomed, in bringing closer together health and
social care. So, to that extent, there is no fundamental difference
in the move to Care Trusts, in itself, in the problem you outlined.
Local authorities, as I say, will be delegating their functions
into Care Trusts, but they will still be responsible for setting
charges and what charges they set and how those are set. There
will always be discussions at the interface between health and
social care as to precisely how that is managed and who of the
various partners does what. But I do not think that is a new problem,
if I may say so, and I think, as you say, having pooled budgets
and agreements at the outset as to what the purpose of the Care
Trust is and how the various partners are contributing to deliver
those purposes ought to stop games-playing, between agencies to
try to move costs to different parts of the system, because they
will have to sit down and agree how that Care Trust is going to
operate.
Chairman: I will give you time to catch your
breath now, I think.
Mrs Gordon
46. Unless he does the CHCs as well. Chapter
10 of the National Plan, Community Health Councils. I suppose
I should declare an interest, in that I was a member of my local
Community Health Council for a numerous amount of years, both
as a local authority representative and as a co-opted member.
And, having talked to my local CHC, I think the first question
is, why was it that the Community Health Councils were involved
in the consultation on the National Plan, that they went to numerous
meetings about this, they had a big input into other sections
of the National Plan, and you obviously valued their views on
those issues, why is it then that there was a total lack of consultation
on their own future, and, as it turns out, their own demise?
(Mr Taylor) Not yet.
47. Hopefully not.
(Mr Taylor) It is not, I am afraid, going to take
you very long to plumb the depths of the ignorance of this particular
group on this, as an issue. I am going to answer your questions,
though I just have to say that this is not my area within the
Department of Health, and if I cannot answer your questions properly,
obviously, we will have to come back to you.
Mr Burns: Perhaps the Minister can answer the
question next week.
Mrs Gordon
48. But they are here, so I have got to ask
them.
(Mr Taylor) I think the first point is that it is
certainly the case that we did value the role that members and
representatives of Community Health Councils played during the
consultation process leading up to the Plan, which was a deliberately
inclusive approach. And the whole question of changing the culture
of the NHS to ensure that it is really a patient-centred service
was, of course, one of the key messages that came out of the public
consultation and the wider consultation, the process of talking
to not just patients' representatives but people across the spectrum.
And so, eventually, what happened was, all that material was pulled
together, and Ministers, at the end of the Plan process, sat down
to make decisions about the way forward; and one of the decisions
they came to was specifically the set of proposals in Chapter
10 of the Plan, which they saw as overtaking the role of Community
Health Councils. And that was how the thing happened. What we
now have is a process of consultation about how to implement,
in detail, Chapter 10 of the Plan, and again that is something
in which we want to involve members of Community Health Councils.
49. Just from a personal point of view, I think
the new proposals just fragment patients' representation, and
I am not sure that they will get a better service. Community Health
Councils, I do not think anybody who is involved with them would
not admit that they needed the reform, certainly they had a sad
lack of resources and were stretched on the patient advocacy side,
certainly within the last ten years, when people are more aware
of their rights, and having to go on various boards, they are
on everything now, so their resources were certainly stretched.
I would have liked to see them actually expanded, rather than
abolished, because I think, with these new groups, there is just
going to be confusion. Perhaps I can ask, on the Patient Advocacy
Service, and the Patients', so-called, Forums, who are these going
to be accountable to, and it just seems to me that, the Advocacy
Service will be based within the trust, how can you ensure that
they will be independent?
(Mr Taylor) I think, as I have said, since we are
talking to all the key stakeholders in this at the moment about
how the precise remits of these bodies should be determined, how
the membership should be appointed, it would be silly of me to
speculate about that, and, indeed, counterproductive. But this
is all about ensuring that patients have a stronger and better
role, so, in the end, it is the different fora themselves, the
Advocacy Service, the Patients' Forum, in particular, who will,
as it were, protect their own freedoms, protect their own independence.
But the method of selection, and so on, obviously will come into
that, and that is one of the things that is being discussed at
the moment.
50. One of the things that concerns me is that,
the Patients' Forums, half of them will be randomly drawn from
respondents to the trust's annual patient survey. Now, is it going
to be out of the hat, or what does this mean, whose bright idea
was this? If I had a forum of my constituents, and I randomly
selected people who had written in to me, I am not quite sure
who I would end up with, but I could almost guarantee they would
not be representative of all my constituents.
(Mr Taylor) One of the obvious aims behind this is
to ensure that it is not just always the same people who are circulating
around the system. And, obviously, the aim of this is to ensure,
through this methodology, and we will have to look at in detail
how it is made to work, that there is a measure in place which
ensures that some of the people who get their voices heard in
the Forum are people who would not necessarily otherwise come
to notice through being part of existing patient representative
machinery. And that seems, to me, to be a good principle. I am
sure it will, in some cases, produce unusual and, for the trusts,
unwelcome voices, but I think that is to be welcomed.
51. Do you really think that they will have
the same commitment as regular members of the CHC, who have a
real interest in looking into the health issues, do you really
think that they will do that, if they are picked at random? One
of the other issues is that you are giving a lot more responsibility
to the scrutiny committees of local authorities; now I do not
know if my CHC was typical, but those who had the worst attendance
tended to be local councillors, for obvious reasons, that they
were incredibly busy with other things. Are the local authority
going to be able to cope with all this?
(Mr Taylor) I think the balance that is being struck
here, in the case of the Patients' Forum, is between having a
proportion of the Forum who are drawn from the total patient community,
voices of people who might not otherwise be heard, balanced by
people from stakeholder interests, people from patient groups
and elsewhere, who, as it were, can be guaranteed to provide the
long-term commitment that you are talking about. And then it seems
to me an entirely defensible proposition that, in the case of
major service reconfigurations, which is the primary role that
the scrutiny committee is intended to have, the locally-elected
representatives of the people should have the opportunity to comment
on those and to feed into the process. And that seems to me to
be a sound, democratic principle.
52. And who will have the right to make unannounced
visits to hospitals and health facilities, who will have that
role, in all these five different groups that you are having?
(Mr Taylor) First of all, I think, it is the patient
advocates and advisers who are present in the hospital who will
have to work out details of practice. But I am sure, in principle,
they will be given freedom of access to the hospital, and I am
sure the same will be true for members of the Patients' Forum.
Also bear in mind that for the first time there is to be a patients'
representative on each trust board. So I think that, as a result
of all these mechanisms, the principle of random and open and
transparent inspection will be preserved. But the details are
still to be worked out, in consultation with the stakeholder groups.
53. If I can give an instance; there was a complaint
about a particular ward in a hospital locally, and the CHC went
in that afternoon, unannounced. Now where does that come, in your
new system?
(Mr Taylor) I do not have the specific answer to that
question, but I am sure that the new arrangements which will be
put in place will mirror that kind of principle, because there
is nothing about this which is an attempt to undermine the transparency
and openness of the system; indeed, the whole thrust of what the
NHS Plan is about is to make our systems more open and more transparent
to patients.
54. Quite honestly, this seems very vague, to
me. It does not seem at all transparent or clear what is going
on. It does not say anything about what role these new groups
will have in inspecting the private and independent sector, or
primary care, which CHCs do not have at the moment as a right,
but definitely need to be included, and certainly the private
and independent sector, as we will talk about later on, if it
is going to become more involved in care, who will do that?
(Mr Taylor) I think the Care Standards Commission
has a role in that respect. What I just do want to stress is that
there is an active process of consultation going on at the moment
with the stakeholder groups, as a result of which the intention
is to issue, as it were, a comprehensive plan of action for taking
all this forward, which I hope will allay some of the concerns
that have been expressed since the decision was announced. Because,
obviously, as you say, there is a lot of detail to be fleshed
out here about how the new procedures will operate.
Chairman: Would it not be wiser, if you are
putting out a White Paper, actually to have some coherent plan?
Because I get the distinct impression that nobody really knows
what is going to replace Community Health Councils. And what worries
me, in particular, having spent a considerable time in this Committee,
over the last few years, looking at complaints issues, is that
we certainly got the message, time and time again, that the most
important thing from the complainant's point of view is for that
system to be completely independent of the local health service.
And what you appear to be offering here, with the Patients' Advocacy
Service, is a system that is tied into the local health system,
the same management, the same structure, and that worries me very
much. I would hope you will possibly take back a message from
this Committee that perhaps by next week we may have some clearer
ideas on what is happening here. Because I think, really, despite
the fact that within this White Paper, in my view, there are very
many positives, this whole area may have been better left until
the Government was in a clearer position to determine exactly
what it intended to do. John, you wanted to come in.
John Austin: I just wanted to reinforce that.
I speak as a former Chair of ACHCEW, so you may guess where I
am coming from. I am concerned that this was a sort of throwaway
line, at the end of one of the chapters in the new Plan, and I
agree with the Chair that it would have been sensible, if that
was the direction in which the Government was going, to have published
a consultative document before it took the decision actually to
axe the CHCs. But what I want to put to you is this whole issue
of accountability in the NHS. The one thing about the NHS is that
there is no democratic accountability at a local level, and there
rarely has been, ever since Ken Clarke removed the local authority
representatives on the health authorities, I was a victim of that
as well, it removed any sort of local input into the planning
of health provision in the area at all. Now one of the strengths
about the CHCs was, as Eileen Gordon has said, that it was a unique
combination of people accountable to the community through the
voluntary sector as well as those accountable through the local
authority, and it was open to the regions to remedy any missing
interests in the CHC. But what seems to have been ignored is the
voluntary contribution and commitment of people in the community
and involvement of people who represented other groups in the
planning and policy formulation of local health services. And
I share the Chair's and Eileen Gordon's concern about the lack
of independence of what is being proposed to replace the CHCs,
and I wonder if any consideration has been given to that? The
other point I would make is that I think it has been recognised
that where CHCs have been working well they have been very effective
bodies, and there may have been some that have not been very effective,
but would it not have been more sensible to look at the ways in
which you could help those who have been less effective to be
more effective, rather than throwing the baby out with the bathwater
and getting rid of an institution which has served the patients
in the NHS well?
Mr Burns: I just wanted to add, on that, I wonder
if you could factually confirm, as everyone has been talking about
independence of the CHCs, and everything, that a number of members
of CHCs are actually appointed councillors from the local authorities
in the area; and so one could argue, across the political divide,
that, particularly in the run-up to general elections, they are
not necessarily as independent as this Committee might be suggesting
this morning?
Mrs Gordon: It represents all parties.
Chairman
55. I think it is actually a third are local
authority nominees, they may not be local councillors; a third
of them. Mr Taylor. I know you have drawn the short straw, but
it is an area of concern?
(Mr Taylor) I just think it is worth reiterating that,
in intent, this is about ensuring that patients are more strongly
at the heart of the NHS, that the Government is, for the first
time, proposing that there should be guaranteed patients' representatives
on trust boards; it is introducing a new role for the local authority
in the area of scrutinising major health service changes. And
although I know that many people have expressed reservations about
the decision to abolish CHCs, on the whole, I think, it is also
true that patients' groups have welcomed the thrust of much of
what is in this chapter as clear evidence of determination to
have a more transparent and open approach for patients, and to
ensure that in each hospital and each trust there is a voice for
patients which makes itself heard.
John Austin
56. Was any consideration given to perhaps putting
the patients' advocacy role, or the Patients' Advocacy and Liaison
Service, within the CHCs?
(Mr Taylor) I cannot answer that question.
Dr Brand
57. I hear everything you say. I have great
concerns about the role of the local authority, the new role.
I think it was right that they should be on the CHC, as representatives,
as indeed I was, for many, many years, but there surely is going
to be a conflict, if the local authority is the scrutineer of
the service and at the same time is a co-commissioner, and quite
often a co-provider, of the very service that they are scrutineering.
And, to me, that is not—you do away with the independent
look at what is being provided, especially if we are going to
have more and more integration between local authority services
and health services?
(Mr Taylor) I think the main thrust of the proposition
is that the local authority should be the vehicle for public scrutiny
of proposals for major health service reconfigurations, and the
proposal, I think, in the Plan, is that final decisions on that
will be passed on to a new national reconfiguration panel.
58. But, surely, the health service itself,
before it reconfigures itself, will have worked very closely with
its partner, which is the local authority; so, effectively, you
are asking the local authority to scrutinise the joint decision
that has already been made between the health authority and the
local authority. To me, that is not very transparent; well, it
is pretty transparent, it is a stitch-up?
(Mr Taylor) I am not sure that I entirely follow the
logic of that argument. It is true, of course, that these decisions
must be taken in partnership, but there are always elements of
them which are contested, where there is debate, and it seems
proper, in principle, to allow for local authority scrutiny of
that.
Dr Brand: You are doing a gallant job.
Mrs Gordon: Can I just say, finally, because
we have spent quite a lot of time on this issue, I go back to
my first point really, that I just want to put on record that,
without any consultation about this chapter, it landed on the
desks of CHCs, they were completely unaware of this, and I just
want to put on record that I think it is extremely cruel to do
this to people, whose jobs relate to the CHC, who, certainly in
our CHC, work flat out to represent patients and are doing a really
good job, and I think it was a really cruel thing to do to them.
John Austin
59. In terms of the champions of the local community,
any major changes in service, cuts or alterations, there is a
statutory duty to consult with the CHC, and the CHC effectively
has a right of veto, in that it can send it up to the Secretary
of State. Where will that go now?
(Mr Taylor) That is the role which is being passed
to the local authority, under the new proposals.
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