Examination of Witness (Questions 1-19)
Thursday 15 May 2003
MR DAVID
LAMMY MP
Q1 Chairman: Can I welcome you to
this morning's session of the Committee. I particularly welcome
you, Minister. We are very pleased to have you here. I think it
would be helpful to make the point that this is part of a rolling
programme. As you know, we are required to see each member of
the ministerial team at least once a year. We have not so far
met you and we are very grateful that you have agreed to come
along. I appreciate that your area of responsibility covers a
lot of different elements and we may only cover a few of those
elements this morning. I am sure you have a good idea of the ones
we would like to look at. If we do not get through all the areas
it may be that we would send written questions on to you and I
hope it would be possible for you to reply in writing. Could I
ask you to introduce yourself formally to the Committee, please?
Mr Lammy: I am David Lammy and
I am Parliamentary Under Secretary of State in the Health Department
with, as you say, a wide range of responsibilities. I am very
pleased to be here this morning. It is now almost a year since
I was appointed so I suppose I am pleased that I have come a year
down the line rather than a few weeks down the line, as it were.
Q2 Chairman: The disadvantage of
that is that you now have a track record. Can I also say that,
as we are time-limited, if it is possible to give brief answers
and my colleagues—including the chair—will try to
ask brief questions it would be very helpful for us to cover a
range of areas. Can I start by asking questions about Community
Health Council advocacy issues. As you know, Minister, we produced
a report some time ago on adverse incidents that looked at the
issue of independent advocacy and CHCs and the complaints area.
I am well aware of the fact that you were not involved in the
conception of the new system. There were some quite controversial
debates in Parliament because a lot of people were unhappy about
what was being proposed in some elements of the new system. My
concern is, having followed in great detail the process of legislation
that introduced the new system, the system that is appearing seems
to be somewhat different from what many of us expected with the
assurances that we were given. As I say, you were not involved
in the conception of the system but you have been left, shall
we say, holding the baby. I would like to begin with one or two
questions about that area of your responsibility. I have a quote
here from Lord Hunt when the Lords were examining this legislation.
He says, "I hope I can assure noble Lords that I accept the
point that we should have no intention of abolishing CHCs before
the new arrangements are up and running. We intend there to be
a well-managed transition between the existing system and the
new system." Do you think we are seeing a well-managed transition?
Mr Lammy: Can I say first of all
that if I am holding the baby it is a baby I am very pleased to
be holding because it is a very important baby. When I look across
the range of my portfolio and look at my responsibilities it is
important to me that patients and involving the public is key
right across the portfolio. I look at the direction of travel
that I have inherited from Hazel Blears and I have to say Hazel
Blears dedicated a lot of her time to the patient and public involvement
part of the portfolio; I pay credit to the work she did. I think
she handed me a very coherent, consistent and ambitious programme
that we are now seeing delivered. The first thing, I think, was
beginning to see PALS in our hospitals across the country; we
now have about 96% coverage. Many of you will have gone to your
own individual trusts and hospitals which are doing a great job
of providing patients with advice and access, cutting down complaints.
I heard just this week of one hospital—I think it is in
Kent—where complaints have fallen by 60% because of PALS.
Q3 Chairman: I did not ask about
PALS; I asked about the transition from the CHC to the Patients'
Forum. I have to be specific about this. The area that worries
me is that you gave an answer on 30 October last year, and I quote:
"Community Health Councils will be abolished once the new
system is functioning". You gave an answer to me on 10 December,
and I quote: "We will be working closely with the Commission
to ensure that there is a smooth transition from Committee Health
Councils to Patients' Forums". Quite frankly the information
and evidence that I am getting is that it is anything but a smooth
transition. The whole system appears to be chaotic. I worry about
the way in which people are going to be unrepresented in terms
of their problems with the Health Service for a significant period
of time. My question was about Phillip Hunt's assurance about
this well-managed transition. I ask you specifically: are we seeing
a well-managed transition?
Mr Lammy: I think we are and I
think PALS is key to that and so let us drill down on what are
your concerns.
Q4 Chairman: I will be specific about
what my concerns are. The original intention of the Government,
quite categorically, was to have a period of overlap when both
CHCs and the Patients' Forums were in operation. Instead, what
we are seeing—quite clearly from the evidence we have—is
that there is going to be up to four months when some trusts have
neither CHCs or Patients' Forums, and if your Foundation Trusts
are being established there is going to be an even longer gap
of eight months between the abolition of a local CHC and the establishment
of a local board of governors. Who, in that period, independently
monitors the NHS? I cannot see who is going to do it.
Mr Lammy: I think the first thing
is to look at what CHCs did and then deal with them bit by bit.
PALS is key to that. The CHCs provided patient support. We have
PALS across the country now doing that. The CHCs advised in major
reconfiguration consultation in local areas. For the first time
in this country, since January, we have Overview and Scrutiny
in our local authorities doing that. For the first time we have
the duty to consult across the NHS on major changes. That is happening
now. From September there will be an Independent Complaints Advocacy
Service. The contracts have gone out, charged by the new Commission
for Patient and Public Involvement. That will be happening in
terms of independent complaints advocacy. If someone has a problem
they are able to get advice locally. Then you get to the work
of the Patients' Forums. We have the new Commission. Many people
argued to ensure that that new Commission and the new arrangements
were independent. I have to say that I would be very surprised
if there is anyone in this House is going to challenge the independence
of Sharon Grant and the array of commissioners. They are charged
with this job; we have charged them in this House (there was much
debate about that). They advise me—in looking at the work
that they have to do over the year ahead—that we will see
the business of Patients' Forums taking shape in the autumn and
they hope to see the job complete by the end of the year. In terms
of the other things that CHCs did, Casualty Watch was a big flagship
programme in the sense that many people associate the CHCs with
that. We are in discussions now about the ways in which we can
continue that after the September deadline. We have environment
action teams looking across the board at the environment in our
hospitals—independently as well—and we have the inspectorate.
The inspectorate across the NHS is a new one. I do not see a picture
of chaos across the country. What I see is more patient and public
involvement than we have ever had before.
Q5 Chairman: Let me come on to one
example of many that I could bring forward about concerns at a
local level. This comes from the ICAS organisation in Norwich
and is a letter I received yesterday from one of the people working
there. I quote: "No Community Health Council staff will be
able to deal with complainants after 31 May 2003. The proposed
scheme after this time is to send complainants self-help packs
to the new enquirer. However, today I have had an enquiry from
a gentleman with learning difficulties who informed me that the
pack would be useless to him as he does not have the capabilities
to understand the content of the pack." She goes on to say:
"There are no local non-specialist independent advocacy services
to pass these patients on to. This is a common problem nationwide.
PALS is not authorised to deal with complaints. ICAS agencies
have been offered no exit strategies. For example, what do I do
with my database of highly confidential information?" This
is somebody on the front line who clearly does not have any reassurance
from government that some of these pretty difficult issues—and
she lists a whole series of cases anonymously that she is dealing
with at the moment—are just going to be left in limbo.
Mr Lammy: You will know when you
look right across the country, when you look at the 1.2 million
people involved in the NHS, that you will always be able to find
examples of things happening locally.
Q6 Chairman: I have numerous examples;
I only picked one because I cannot read them all out.
Mr Lammy: Let me tell you the
examples of the good things that are going on, if I may. I saw
a report from an Overview and Scrutiny Committee on the reconfiguration
of the hospitals in Telford and Shrewsbury. It was an excellent
report. I saw an excellent PALS both in my capacity as a minister
when I was up at the Addenbrooke in Cambridge and also visiting
a friend who was at Guys and St Thomas' just a couple of weeks
ago. We have put in place a transition team with CHC people on
it, with department officials, with the Commission, to ensure
that there is the smoothest of transition in terms of the independent
complaints advice that people need moving into September. We are
at the beginning of May; the handover is in September. The Commission
has begun its tendering exercise. I intend to have faith in the
Commission as it begins on that journey. They started off in January;
we are now five months into their life. The Commission has met
twice. They are doing their best to get on top of this and to
see that transition take place.
Q7 Chairman: I was intimately involved
in dialogue with your predecessors—and Mr Denham, who was
initially involved in this—and my real problem with what
has come through is that the system is very different from the
assurances that I was receiving, detailed assurances, several
in writing, several in parliamentary answers from other ministers.
One of the things I mentioned last week on the foundation debate
is that we have had all these promises about Patients' Forums
at every hospital and we have actually abolished the proposed
Patients' Forums for Foundation Trust applicants before they have
even been introduced. Whatever the relative pros and cons of the
new model of Patient and Public Involvement Forums, the elected
boards of governors proposed the Foundation Trusts simultaneously,
establishing two different systems for this process at the same
time, and this does seem to indicate some degree of confusion
in the thinking of the Department. In the discussions that I had
not very long ago over the abolition of CHCs, why was it that
nobody mentioned the thinking about local governance of Foundation
hospitals? Surely that was highly relevant to the discussions
we were having about CHCs and ICAS and attempting to engage the
patients more closely than has previously been the case.
Mr Lammy: You are asking a number
of issues there. The first thing is that we, in the Department—and
I think the Commission for Patient and Public Involvement is keen
on this as well—do not want to get fixated on the past nor
on the simple fixture of a CHC. This cannot be just about the
institution; it has to be about people and the public. As a Labour
politician representing one of the poorest constituencies in the
country I want to ensure that the business of being involved in
the NHS is not just the occupation of a few people in an office;
it is in the life blood off my community and my population. I
believe that the system we are putting in place will deliver that.
It will deliver that because, for the first time, we have a national
body responsible. We have the independence in that national body
that you and others argued for. As a back-bencher the first meeting
I ever had in a ministerial office was also with John Denham on
this very issue. Many of us argued passionately to ensure that
we had patient and public right at the centre of the NHS. We have
the Commission responsible for this and what I am not going to
start doing—indeed I cannot because the Commons and the
legislation that has passed through Parliament does not allow
me to, quite rightly—is interfering with the independence
of that Commission. That is the first thing. The second thing
is that we have put in place the system now of independent complaints
advocacy services which will take place in September to represent
people if they have a problem. We have PALS in our hospitals.
People are going to them as we speak and will go to them tomorrow
and the day after. We have overview and scrutiny going on in our
local councils which have never been going on before. That is
not a picture of chaos; that is a picture of the patient and the
public involved in the NHS in a way they have never been involved
before. You can be fixated on the old system but the old system
did not deliver that.
Q8 Chairman: I am accused of being
some kind of dinosaur; I am not. I am quite happy to see change
but I want a logical change.
Mr Lammy: Can I move on to the
issue you raise of Foundations Trusts?
Chairman: John, would you like to come
in now?
Q9 John Austin: I understand what
you say about the independence of the Commission, but ministers
gave assurances which the Chairman has referred to, and now it
seems that the Government is saying that that is not a matter
for them any more because they have established an independent
Commission. Then the Commission says that they are not bound by
assurances that ministers gave.
Mr Lammy: Those assurances are
very important, but please can I have some further clarification
from you on what you see those assurances as and how you see them
not being met?
Q10 John Austin: You mentioned the
Transition Advisory Board and yet the model which has been chosen
by the Commission for Patients' Forums was not a subject of consultation
through the Transition Advisory Board. Why not?
Mr Lammy: We did not prescribe
in the legislation what the model for the Commission should be,
did we? We did not do that.
Q11 John Austin: But there was going
to be continuity and there was going to be consultation.
Mr Lammy: There is continuity,
but I have to say that it is rather like the House of Commons
leading through the legislation to create Ofsted—which we
did a few years ago—and then wanting to prescribe how Ofsted
inspects and does its job in our schools. We cannot on the one
hand argue for an independent body that is responsible for patient
and public involvement and then prescribe its Commissioners how
they should deliver that. I think the model they have come up
with is very exciting. It is for them to determine how they do
that and then they report to Parliament.
Q12 John Austin: But it becomes a
very different model from what we were presented with in Parliament.
Let us take another example. You stressed in a letter to Lord
Ponsonby the importance of the one-stop shop. Now it appears that
the Commission is not committed to the provision of a one-stop
shop. Many of us think that one of the very positive things about
CHCs was its high profile in the high street and was, effectively,
a one-stop shop. Now it seems that the Commission is not committed
to that model which you said was important in your letter last
August.
Mr Lammy: It depends on how you
perceive that one-stop shop to be and there will be discussions
about and differences of view now doubt going on in the Commission,
going on in the Department, going on in health communities around
the country of what that should look like. Different areas will
have different requirements. Paying all due respect to CHCs—I
know because I was here during much of the discussion on CHCs—there
were also members who said that there were many people in their
constituencies who did not know that the CHC was there on the
high street. I do not want to paint a rosy picture of this golden
past when, in fact, what we are into is—I believe—a
very positive agenda of public and patient engagement across the
NHS and, indeed, the resource that goes with that.
Q13 John Austin: Do you think it
is important for there to be—and I quote—"a one-stop
shop for local people providing advice and information to them
about how they can get involved locally and how to make a complaint".
That is a quotation from your letter to Lord Ponsonby.
Mr Lammy: Yes, and I believe that
the Patients' Forums, when they come into being, the local network
providers that will support those Patients' Forums will achieve
that.
Q14 Dr Taylor: Minister, I absolutely
agree with you that it is a very positive agenda for greater patient
involvement and I am absolutely delighted about that. However,
I am still desperately worried about continuity. You say there
is continuity but when you think that CHCs are going very soon
and Patients' Forums are going to require something like 10,000
members to be recruited before they can get off the ground, there
has got to be a gap. You say that PALS has a 96% coverage. I cannot
help doubting that figure, certainly from my local experience
where PALS are literally not in existence in Worcestershire because
of various problems. I would like you to accept that somehow there
has got to be a gap and how that is going to be covered when Patients'
Forums have to appoint 10,000 people before they can function.
Mr Lammy: That is why, in a sense,
I come back to fundamentals. There will be a transition period.
I am afraid transitions exist in all walks of life. They exist
when you leave a job and go to a new one; when you leave one school
and go to another one. Transition periods happen; we see them
as normal people in daily life. The question is, is that transition—that
gap that people are talking about—some black void or hole
into which our constituents are going to fall in September?
Q15 Dr Taylor: Yes, I think it is.
Mr Lammy: I feel very sorry then
for the people of Wyre Forest because that is not the case. You
think it is a gap, let me fill it with some things I believe your
constituents have. On 1 September, were there to be some kind
of reconfiguration in Wyre Forest they would have an Overview
and Scrutiny Committee in the local authority that will be able
to look at that. The Overview and Scrutiny Committee can look
at any issue it wants and report back. The local authority can
have a much bigger nexus with what is going on in the NHS in Wyre
Forest than it had before, certainly than under the CHC. Will
patients be supported? They should be supported through PALS and
if there is a problem in Wyre Forest please let me know; it is
something I am happy to look into. They should have—tenders
will have gone out from your local area to us—an Independent
Complaints Advocacy Service. I do not know what the figure was
that went down to Wyre Forest of the 23 million we were spending
on CHCs, but I can tell your constituents that they will see three-fold
that amount of money spent on patient and public involvement.
I do not see that as a gaping hole into which your constituents
are going to fall. I suspect it is because you are wedded to the
old that you are not prepared to accept the work the Commission
is doing; you are trying to avoid the work going on in terms of
overview and scrutiny; you do not want to see the fact that the
tenders have gone out and ICAS will be up by 1 September. You
are not looking at the actual picture as it really is on the ground.
Am I saying it is perfect? No, I am not, because frankly it would
be ridiculous for any minister to suggest that in a new system
with any transition that you are going to have absolute perfection.
But will we get to that in the NHS? Yes, I do think we will.
Q16 Dr Taylor: We are all delighted
to have Overview and Scrutiny Committees because it is a huge
move forward to involve locally elected people in scrutiny of
the Health Service. I put in a written question at the beginning
of April asking how many local authorities have a Health Overview
and Scrutiny Committee working and on 8 April you replied that
the Department did not know; the information was not available.
You are saying now that a lot of Overview and Scrutiny Committees
are working. The actual paper from the Health Development Agency,
Local Government Scrutiny of Health, does just list 18 case studies
of Overview and Scrutiny Committees that are attempting to work
out how to work. Certainly, again in Worcestershire, it has not
even begun to work as yet. I am slightly puzzled as to how you
are so confident that they are going to take place when, so far
as I am aware, a lot of them are only at the trial stage at the
moment.
Mr Lammy: When I was in committee
on the regulations on this there were Opposition Members talking
about what their Overview and Scrutiny Committees were doing in
their area. There are Overview and Scrutiny Committees in this
country which have done reports on reconfigurations and I saw
one last week on Telford and Shrewsbury. They have done reports
on or they are looking into child obesity; they are looking into
diabetes services; they are looking into cancer services; they
are looking into children's services. They are doing that, as
we speak, in local authorities across the country. You will know,
because of the nature of the democracy we have in this country,
that councillors and political outlooks—and what councillors
see as important in their particular areas—vary. It varies
across the country. Issues come and go across the country. What
is important to Haringey Council and Tottenham—I know we
have an Overview and Scrutiny Committee—and the issues they
want to look at currently might be different to what a local shire
county is looking at in Essex or Cambridgeshire. But that work
is going on; it is definitely happening; it is happening all around
the country.
Q17 Dr Taylor: Going back to ICAS,
the ICAS pilots in Worcestershire actually end at the end of August
and nobody knows how they are going to carry on after the pilot
stops. Is there an arrangement?
Mr Lammy: I thought that that
was the arrangement that I outlined. The arrangement is that we
are undergoing a tendering exercise to ensure that ICAS is up
and running in September across the country. We have gone out
to local providers and looked at who wants to provide those independent
advocacy services. I issued a press release on this a short while
ago. It may be a matter of communication and I am happy to get
that to you if you have not heard about it.
Q18 Chairman: You asked me to be
specific about one or two concerns. Can I press you specifically
on two areas, one on Patients' Forums and on ICAS, picking up
to some extent where Richard left off. On the staffing of Patients'
Forums I am making the point that what has been envisaged does
not appear to be happening and commitments that have been given
do not appear to have been followed through. The Lord Ponsonby
letter—I think it is probably the same letter that John
referred to a moment or two ago—from yourself to Lord Ponsonby
on 8 August last year said: "The Commission for Patient and
Public Involvement will appoint staff to every PCT Forum in England".
You said "appoint staff" in your letter. What appears
to be happening is that the voluntary sector bodies are being
given this responsibility. You are probably aware of the legal
opinion of ACHCEW. They are concerned that what is happening is
in breach of the actual legislation that states specifically that
the functions of the Commission are about providing staff to Patients'
Forums. In essence, their legal opinion says that it will amount
to an unlawful delegation of functions. That is a pretty serious
allegation. They go on to say, "It is not in order for the
secretary of state to delegate responsibilities to the Commission
without legislative permission". To me that seems a very
specific and very serious allegation about the manner in which
this process of change is being handled. Presumably you have a
different legal opinion on this.
Mr Lammy: I do not just have a
different legal opinion. You know I was a lawyer before I came
into this business.
Q19 Chairman: I am very conscious
of that.
Mr Lammy: We all know that you
can get legal opinions from all sorts of lawyers who will come
up with different things. The Commission's legal opinion—Sharon
Grant's legal opinion—is different to that one and, indeed,
so is the Department's. I think that what the Commission has come
up with is an ambitious and exciting programme; it is one I want
to support them in. What they are seeking to do is to work with
what is already on the ground in our local areas to provide and
come up with those Patients' Forums. I think that is a good thing;
it is a constructive thing. It is the right direction to travel.
In a sense it meets with the obligations under the legislation
as framed.
| 
