Examination of Witness (Questions 20-39)
Thursday 15 May 2003
MR DAVID
LAMMY MP
Q20 John Austin: Whatever the legal
arguments are, were there not ministerial assurances that the
staff of Patients' Forums would be employed directly by the Commission,
and is it not a breach of a ministerial undertaking in the negotiated
human resources strategy to put them in the voluntary sector,
and does it have something to do with cutting costs and lower
salary levels?
Mr Lammy: They are being employed
by the Commission. That has nothing to do with Department of Health;
it is the Commission doing that. They are being employed by the
Commission. If you go through these legal documents about who
is contracting and how it is working, they are being directly
employed by the Commission. We argued for independence. We got
the Commission for Patient and Public Involvement. We have ten
commissioners with an array of experience; we have a great Chair;
we have a good Chief Executive. They have come up with the model;
they are getting on with the business of creating those Patients'
Forums. They are doing that by contracting locally, getting in
local people. They are employing those people. Now, from what
I am hearing, you would like us to be prescriptive about how they
do that. We gave an assurance in Parliament; that is happening.
You may have a view on how it happens, but it is happening.
Q21 Chairman: When you say that this
body will appoint staff, then I assume you mean what you say:
they will appoint staff. They are not doing so. It seems a complete
contradiction of what you said in your own letter of 8 August
last year.
Mr Lammy: I do not see the contradiction.
I really do not. That is what the Commission are doing. At the
moment the Commission are in the business of getting people into
the Patients' Forum. How is that a contradiction in my letter?
I do not see it.
Q22 Chairman: I am a straightforward
simple Yorkshireman.
Mr Lammy: I am a straightforward
Tottenham boy and I do not see it.
Q23 Chairman: When I read "will
appoint" I assume you mean "will appoint" and this
is not happening.
Mr Lammy: As I say, I am a straightforward
Tottenham boy. How do you not see it?
Q24 Chairman: The clear assurance
given—not just by yourself but by other ministers previously—was
that they would appoint and they are not doing. As I say, the
voluntary sector bodies have been given this responsibility. It
is a complete departure from what you clearly gave as an assurance
in a letter to a fellow parliamentarian last August.
Mr Lammy: With respect, I am not
sure it is a complete departure. When a Member of Parliament is
appointing staff for their office they may delegate that to a
senior member already in their office. That does not mean they
are not appointing the member of staff; it means they have delegated
the role. I am responsible for appointments in the NHS; I have
oversight of that but we know we have an independent Commission
set up by Sir William Wells that actually deals with the business
of appointments. The Commission is responsible for appointing
and getting the Patients' Forums. It is doing that by local franchising
because it wants to get the best kind of Patient and Public Involvement
in this country. I have spoken to Sharon Grant and what she wants
to see is disabled people on those Patients' Forums. She wants
to see young people on those Patients' Forums. She wants to see
black and ethnic minority people on those Patients' Forums. She
thinks the way to deliver that is actually to drill down with
those local organisations. I think that is an ambitious system.
I am surprised, in a sense, that there are members that are frustrated
with the process, so caught up in the "how" and want
to set the "how" from here. We have those assurances.
The Commission is getting on with the job of doing it and I encourage
them in that.
Chairman: I have met Sharon Grant, as
you well know. I have known her many, many years and have the
greatest respect for her. What I am concerned about is that in
the process of Parliament agreeing these changes clear assurances
were given—many in writing—which are not being fulfilled.
That is my concern, that we have some rather interesting inconsistencies.
John, did you want to come back in on that?
Q25 John Austin: Clearly we all want
to see the maximum community involvement in the Patients' Forums,
but in terms of their structure and their staffing, one of the
issues which the Government put forward as its rationale for the
abolition of CHCs was that they were patchy, they were inconsistent
in performance, there was no national pattern. Do you think we
are going to have a more consistent performance and a less patchy
one by the way in which Patients' Forum staff are being recruited
and employed?
Mr Lammy: Yes, I do. I do because
for the first time the people of say, my constituency, will not
just be told by me that we have a great CHC community, they are
fantastic, they have standards. The Commission for Patient and
Public Involvement—Sharon Grant and her team—are keen
to ensure that there are standards across the piece to get that
consistency. That will be the first time in the NHS that we have
had standards on patient and public engagement.
Q26 Chairman: Can I come on to advocacy.
The legislation setting up the changes—Section 19 which
was amended—placed a duty on the secretary of state to,
quote: "Arrange, to such an extent as he considers necessary
to meet all these requirements, for the provision of independent
advocacy services". My understanding was that that would
be according to Hazel Blears on 22 May 2002 where she said, "Every
PCT Patients' Forum will have staff to commission or provide independent
support to help individuals". The picture we have of the
role of the Commission seems to have changed these assurances.
Again, legal advice—which I think you have seen—and
opinion that ACHCEW obtained states: "The Commission has
not been given as one of its functions the management or commissioning
or establishment of advocacy services. Consequently, were it to
do so, it would be acting ultra vires." We are in
a lawyer's world here, but it seems to me to be making a fairly
important point that what was said is not happening.
Mr Lammy: That is not a complaint
that I understand that the Commission share. Independent complaints
advocacy is something which we think is very important. It is
important for all of our constituents that if something should
go wrong in a hospital or in any clinical or health setting and
they want to take action, that they have someone to guide them
and lead them through that process. Patients' Forums and the Commission
will be in a position to do that some time into the future, next
year and beyond. The power exists on the legislation for the Secretary
of State to take on that duty and he has done that. The commissioning
exercise is going out to ensure that we have those ICAS teams
from September in our local areas. There is no inconsistency there.
That is on the face of the legislation and that sits with the
assurances we have, and it is not a complaint I am hearing from
the Commission. I have to say to you—and I say this very
genuinely—that here I am, as a young minister in Parliament,
delighted to see us engaged with patients and the public, really
making my constituents, your constituents, own the NHS, and what
this has come down to—potentially—is legal arguments,
mostly coming from one organisation—ACHCEW—and that
organisation to some extent has a long history and strong feelings
about the old system.
Q27 Chairman: Maybe I am naive, but
when I sit and discuss with ministers my concerns over a policy
change, which is not in anyway properly thought through and anybody
honestly, objectively looking at the process of change, will say
that it has not been properly thought through; it has been the
back of an envelope job and we have simply not looked at the consequences.
When I get assurances I take those assurances on their face value
and when I see what comes through in this process is somewhat
different to the assurances I have been given, that worries me.
Mr Lammy: I say to you that to
the people of Telford and Shrewsbury who have just had their Overview
and Scrutiny Committee make some very real and profound observations
about the reconfiguration of services, it was not a back of an
envelope policy that delivered that. People that are going into
PALS in this country today, tomorrow, next week, getting advice,
bringing down complaints, that is not back of the envelope stuff.
The Commission for Patient Involvement—Sharon Grant and
the 10 commissioners and the work they are engaged in at the moment
in Birmingham—is not back of the envelope work. The Patients'
Forums, as they come about, that is not back of the envelope stuff.
None of it is back of the envelope stuff. All of it is consistent
engagement to ensure that the patients and the public are at the
heart of our system. I say that with the greatest of respect because
I believe it passionately.
Chairman: Having had detailed discussions
with the secretary of state, with various ministers, on the process
of change for Community Health Councils to Patients' Forums, does
it not surprise you that at no time in those discussions—which
went on for a long period of time with a general election in the
middle—did anybody mention the idea that we would have Foundation
Trust hospitals without Patients' Forums? Several of them began
as pilots yesterday. Do you not think that is a bit surprising?
Is it not rather strange? That is why I talk about the back of
an envelope because it seems to me that these ideas are bobbing
up and down all over the place without any degree of consistent
long-term thought as to the direction we are going in.
Q28 Mr Amess: I would like to make
a point as a straightforward eastender and it was really as a
result of the exchange between yourself and Dr Taylor about the
scrutiny committees. Unless my ears deceived me the county of
Essex was mentioned. Essex is a huge county and I think you rather
gave the impression to the Committee that so many of these scrutiny
committees were up and running and doing some really good work
at the moment. I hope you were not including Essex in that because
if that were the case you are wrong. When the Government first
came up with this idea I was invited by Essex—as a member
of the Health Select Committee—to take part in their pilot
run of this. It was very interesting. I gave an appraisal and
Essex County Council members were very, very enthusiastic about
this Scrutiny Committee, they thought it would do a splendid job.
However, Essex has had some difficulty with the funding that they
have been given from the Government in any number of areas and
they have now written to myself and other Essex Members to say,
"Great, David, we want to do it but where are the resources
coming from?" They have had a very, very disappointing settlement.
To do the job properly—which they want to do and it is a
huge county—they cannot see any pot whatsoever from the
Government which will properly resource this Scrutiny Committee.
They want to do it. They have no argument about it. It is a splendid
idea, but they are asking me to ask the Government where the money
is going to come from.
Mr Lammy: When I used Essex as
an example it was because I think that some work is going on in
West Chelmsford on overview and scrutiny. We were having a debate
about Patient and Public Involvement in this place a few months
ago. I cannot remember the detail of what was raised or how it
came up and I do not want to commit to what work is going on in
Essex because I am not sure whether it was me who raised it at
the time. However, what you will know is that there has been an
increase in allocations across the board, way above inflation:
between 7 and 9% to Primary Care Trusts and the settlement to
local authorities. In any change to the arrangements some lose
out and some gain. I am not aware of what the circumstances are
in Essex. I can certainly endeavour to write to you and lay out
what those circumstances are in terms of the monies that are available.
What I can say is that local authorities wanted for years to be
able to have a greater influence in what was going on in our health
communities, in our constituencies, in our local authorities.
We gave them that power. There are presently Overview and Scrutiny
Panels looking at different aspects of health across the country;
that work is going on. Some local authorities are finding funds.
Patently the work is going on. I looked at the report last week.
Q29 Mr Amess: If you could simply
write to me it would be very helpful. They are very disappointed.
They are in a hell of a difficulty over education, 7.6 million
cuts. They want to do it but they are saying that they cannot
see where this pot is going to come from to properly resource
the committee. They have all sorts of work which they want to
carry out. They understood there were original assurances about
it. They feel the Government has gone back on it, but if that
is not the case please give me the ammunition to argue on your
behalf.
Mr Lammy: I will certainly do
that. Also, a picture has been painted of chaos and breached assurances
and I tried to meet those by saying that there are things going
on and I think you should be proud of them. Then there was the
discussion where Foundation Trusts had not come up and that seemed
to be the nub of the complaint. I think again that that is a difference
of view about how the Patient and Public Involvement should look
in our individual Trusts.
Q30 Chairman: All I am concerned
about—my grievance, if you wish—is that I have been
in Parliament 16 years and I do not recall a situation where a
new structure was actually abolished before it had been introduced.
It just indicates to me that somebody is not thinking very clearly.
Mr Lammy: That might be one analysis,
but another analysis is that you have a three star Trust in a
constituency and everyone in the constituency knows that it is
never really engaged with the patient and public; it does not
really listen to their views; it does not really get into their
communities. Actually, despite the fact that it is a good hospital
it has not been able to bear down on the health and inequalities
that still exist in that community, the fact that there are different
rates of death from cancer because it is an ethnically diverse
constituency; the fact that diabetes is affecting the population
in different ways; the fact that it still has a high instance
of cervical cancer or whatever. It has not been able to bear down
on that because the patient and the public have not been in the
heart of the system. For the first time we have been able to deliver
that because we have said that those Trusts should have Patients'
Forums. In the meantime it may be that some of those Trusts become
Foundation hospitals and put patients and the public at the centre
of those Trusts in a different way because, for the first time,
my constituents, your constituents, Julie's constituents, Richard's
constituents can actually sit on the board and see what is going
on. That is not confusion. That is a different example of local
democracy at work.
Q31 Chairman: The point that I was
making—which I do not think you have understood—is
that I would have expected it to be appropriate—in discussions
directly with ministers about the issue of Patients' Forums and
public involvement—to have floated in the public arena the
fact that these new Patients' Forums would not be—despite
the assurances I was being given—applied to a number of
hospitals.
Mr Lammy: They do apply because
they will be in Primary Care Trusts.
Q32 Chairman: No, they do not.
Mr Lammy: The Primary Care Trusts
Forums have a key role.
Q33 Chairman: I was given assurance
that every hospital would have a Patients' Forum.
Mr Lammy: Let me just set it out.
Let us set out how democracy, how patients and the public are
right in the heart of the system in a way that they have never
been before. They are on the governing body of the Foundation
Trusts—
Q34 Chairman: The point I was making
is that I feel it would have been reasonable to expect ministers—in
discussion with members of the governing party who were concerned
about the process of abolishing Community Health Councils—not
to have mislead us over the fact that these Patients' Forums would
not be attached to each hospital trust. Presumably at that stage
somebody in government somewhere was thinking about Foundation
status and not having Patients' Forums.
Mr Lammy: I suspect that in the
discussions you had—and I was not there—that your
arguments were put passionately—because I know you put your
arguments very passionately—and were heard and actually
the system we have ended up with is more democracy. What I was
listing there was more democracy. We now have patients and the
public in the Foundation Trusts on the governing body. We will
have patients and the public in the Patients' Forums in all Trusts.
We have patients and public involved at the local authority level
because of Overview and Scrutiny. I suspect that your arguments
were heard. You take a view that on top of those three layers
of democracy there should be another Patients' Forum and Trust—a
fourth layer—within the individual Trust.
Q35 Chairman: Do not assume my views.
My views are very radical and probably very different to what
you are assuming.
Mr Lammy: That has been the mainstream
view, why is there not a Patients' Forum, and what I am saying
to you is that it is because of the governing body and the other
layers alongside and above and beneath it.
Q36 Dr Taylor: Going on with Foundation
Trusts and the lack of Patients' Forums, I think our concerns—and
we do understand the mechanisms and we do understand the wider
involvement of the public—are that the members of the management
board, the lay people—because they are non-executive directors
of that organisation—will not be as independent as people
on an actual Patients' Forum. That is the first worry. The second
worry is that as they are not connected to the Commission for
Patient and Public Involvement in Health it will cause a large
blind spot for that Commission. You will not have had time to
read it yet so I am going to read the recommendation we made in
our report on Foundation Trusts and then I will ask you for some
off the cuff comments on that. We said: "We recommend that
in the absence of its own Patient and Public Involvement Forum,
a Foundation Trust's patient non-executive directors should have
access to support and training from the CPPIH. Such non-executive
directors should be a part of the CPPIH in the same way as non-executive
directors appointed to Foundation Trust management boards as representatives
from PCT Patients' Forums." So we are trying to see if you
would consider involving these people much more with the CPPIH
for training and for support and back-up, and to try to give back
some of their independence.
Mr Lammy: Can I just deal with
the first point you raise, and that is that somehow by being on
the board you give up your independence? Can I say, with the greatest
respect, you were independent, running as a candidate for Kidderminster
before you came into this place, but you were still independent
within this place. I suspect that independence is something that
you can retain and you have demonstrated that.
Q37 Dr Taylor: May I come back on
that?
Mr Lammy: Just next door in Committee
at the moment Foundation Trusts and the whole issues around Foundation
Trusts is with this House. In terms of a parliamentary process
it has moved from the Government to being with the House; these
things are debated and discussed and things are tweaked and changed
sometimes, and I am sure that your views are well heard and the
views that came across during deliberations as well.
Q38 Dr Taylor: I went through at
least two interviews for becoming a non-executive director. Strange
to say, I got through the interviews but I was never chosen. It
was made quite clear at those interviews that a non-executive
director was meant to act within the consensus of that body, even
if he disagreed with it. That appears to me to be the weakness
of non-executive directors on Foundation Trusts, that they will
be expected to act within the consensus even if they disagree
with it.
Mr Lammy: Can I just say two things
on what is actually a very serious point. The first thing is that
I suspect that Foundation Trusts, in examining how they are going
to demonstrate that they are properly engaged with the role of
patients and the public on their board, will be wanting to do
a job of work with the Commission for Patient and Public Involvement.
I think that the Secretary of State is clear on that as well.
I also know that Sir William Wells at the NHS Appointments Commission—and
I think he would not mind me saying this—is rabid about
the business of ensuring that non-executive directors sitting
on boards are informed and are there to get that local voice across
and training is one of the things he is looking at. I am sure
we will be coming back with ideas in that area as well.
Q39 Dr Taylor: Can I take it from
what you have said that we have your assurance that local ICAS
services will be operational from 1 September.
Mr Lammy: Yes.
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