Select Committee on Health Minutes of Evidence

Examination of Witnesses (Questions 40 - 59)




  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.


  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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