Joint Committee On Human Rights Minutes of Evidence

Examination of Witnesses (Questions 420-439)


4 JUNE 2007

  Q420  Lord Judd: Minister, listening to your answers to questions, it comes across to me that perhaps you are a little sceptical as to whether you will have the Health Service you want as Minister if things are happening because the Human Rights Act says they must happen, and that actually you are looking for an all-pervading culture in which the right thing is being done because people believe that is what the Health Service is about. If that is the case, would you not agree that the quality and commitment and leadership, if I may put it this way, from you right down through all the administrators has to be clear all the time that this is a service about compassion, concern and, if I may use the word without being sentimental, love, and not just a service that is delivering something because the Human Rights Act says it must?

  Mr Lewis: I was a child of the sixties so I am happy with the term "love". The point you make is very important. There is no doubt that we have to face up to the reality that staff on the front line do not feel as good as they ought to do about the amazing progress that the NHS has made in recent times and if we do not face up to that and be honest about it then we are going to have continued difficulties. We really do have to look at how we win back the hearts and minds of the people who every day do an amazing job to make people better and care for people in a compassionate and sensitive way because some of them do not feel very good about their jobs. Clearly, part of that is government leading by example but part of it is the quality of leadership and management in individual trusts, in individual social care settings. It seems to me that in the end the only thing that matters about everything I do every day of the week is the interaction between the person providing the service and the person receiving it or their family. Everything else, as I put it, is architecture and wiring and as much of that architecture and wiring as can be hidden the better. If we think of our responsibilities in that way, both as a politician or a minister but also as a leader or a manager in a healthcare or social care setting, in my view we should be far more focused on the quality of that interaction between the person offering the care and support and the person receiving it and everything to do with system change and structural change should be about that ultimate interaction. As I said before, a lot of it is about culture and a lot of it is about skills and training and good management and good leadership. Some of it is also though about those who are using services being aware of their rights, being able to assert those rights and being given a greater level of control than has been the case traditionally in terms of a one-size-fits-all public service offer, "Take it or leave it; here is what we can give you. If it is the Health Service it is free so you have to accept it". Those days are long gone. I agree entirely with the terms "compassion" and "love" but there are also dignity and respect. Compassion and love in the right circumstances are absolutely right but they must not be patronising and if we are talking about people's rights we must remember that many of the people we are talking about, however ill they are and however old they are, still hang on to that desire for maximum dignity and respect. It is always a delicate balance to try and strike. Does the rights agenda add value to patient care and to the way we want people to receive services? I think the answer must be that it does.

  Q421  Lord Judd: If I might say so, Minister, that is a point well made, and I appreciate that, but about four years ago the Audit Commission recommended that all front-line health workers, among others, should receive ongoing human rights training which was integrated with other professional requirements. However, a number of witnesses have told us that this just is not happening. Can you tell us why your department has not implemented effectively this recommendation?

  Mr Lewis: I cannot. What I can say to you is that in terms of the cross-government group that is being chaired by Lord Falconer one of the Department of Health's priorities in terms of reporting to that group is how we are going to ensure that in the future training of staff awareness of human rights legislation is a mainstream part of that. I am not going to sit here today and pretend to you that that is happening as we speak because it clearly is not, but one of our top-line priorities in terms of our responsibilities across government in this area is to come forward with a plan about how we are going to ensure this is taken far more seriously in training. It is not happening at the moment, I agree.

  Q422  Lord Judd: Can you give us an undertaking that it will happen, and if it is going to happen can you also give us an undertaking that in relation to the very crucially important point that the Chairman was making a moment ago about extending it to non-clinical staff this ongoing training, and counselling and advice, will be available to all of them as well?

  Mr Lewis: What I can say is that, as we look to providing a very different kind of service to patients and social care users, if we are going to make a reality of that we have to change the way we look at entry level training into some of these jobs, continual professional development, and that has to apply not just to highly skilled, highly paid clinical staff; it also has to apply to all members of staff, and therefore the logic of that statement is that, going forward, awareness of human rights legislation and its implications should have a much greater priority in terms of the way staff are trained. Can I today give you a cast-iron guarantee for how those words will be put into action? I cannot. We have to look, obviously, at the financial implications and we have to engage in a dialogue with the organisations that are charged on our behalf with being responsible for this training and have a dialogue with them, but certainly that is our intention.

  Q423  Lord Judd: You cannot give us a cast-iron indication in terms of how it is done, the methodology, but there is a difference between saying it should happen and it will happen. Can you tell us it will happen?

  Mr Lewis: I hope it will happen.

  Q424  Chairman: What response did you give to the Audit Commission when they produced their recommendations at the time?

  Mr Lewis: On training?

  Q425  Chairman: Yes, which was four years ago. Presumably you gave a response to the Commission then. What did you tell them?

  Mr Lewis: We will have to write to you.

  Chairman: What gets me about the points that we have been making all along, particularly in relation to non-clinical staff, the first interface with the Health Service, which is the receptionist or whatever, is that you see in the reception area these signs put up, "Our staff are entitled to be treated with respect". Where is the sign that says, "Our patients are entitled to be treated with respect" as well?

  Q426  Lord Judd: Let me give another example. I recently saw an orthopaedic reception area in a very good hospital where the majority of people waiting in the queue on a Monday morning to register, as it were, were elderly. There was not a single seat for those waiting in the queue. They were on crutches, on sticks, all sorts of things but not a seat. When you had registered there were lots of seats available. It seems to me that it is this sensitivity and imagination that is needed and therefore when we are talking about training it is not about saying, "This is the Human Rights Act. It must be implemented and you must make it part of your work", but about explaining and working with staff as to why the Human Rights Act is important in terms of delivering the quality of service that we all want to see.

  Mr Lewis: Where I think you are being slightly unfair is that the NSF for Older People, which Professor Philp introduced into this country and has begun to make a real difference, was the first time we made some very strong sayings about the way we expected the Health Service to treat older people, and that has begun to trigger significant change. The fact that the Government has made putting dignity and respect at the heart of care services one of its priorities is beginning to affect culture at the local level, so I would only ask you not to use anecdote and individual examples to besmirch the fact that in many parts of the NHS staff would not have allowed the situations that you have described to occur. I think it is really important that we have a sense of balance in this discussion.

  Q427  Chairman: I think that is a fair point, and I made my point about notices somewhat flippantly, but I think it is an important point because of course staff are entitled to be treated with respect and not abused and all the rest of it, but the signs only remind patients of their obligations towards the staff. There is nothing that does it the other way round. Why do the signs not say, for example, "Our staff are entitled to be treated with respect, as are you", and develop the argument that way?

  Mr Lewis: I think we have got a very clear narrative on this. We have to have public services which are run for the benefit not of the producer interest but of the users of those services, and I think the Government has made some progress in terms of reforming public services in that direction. Having said that, we still have a long way to go, and also we cannot deny the fact that it is not contradictory to say that we need to engage differently with front-line staff whilst not compromising on the need for a reform system where users and carers have more control and power. The two are not contradictory objectives, and anybody who has ever run any organisation successfully knows the direct correlation between the satisfaction and the motivation of people on the front line and the quality of the service that the user receives, and somehow we have got ourselves into a mindset where you have to have one or the other. My experience of running organisations when I was in civilian life was that there is a direct correlation between the way you treat your staff and the nature of the service that people who use your services receive.

  Q428  Lord Judd: Absolutely.

  Mr Lewis: The reform and modernisation mantra was important in what it was trying to do but it sometimes missed the point that we should not be choosing between the job satisfaction of people on the front line and the power of those using the services and their families. I will just give you one specific example. My argument about individual budgets for social care is to give far more power and control to users and carers but equally that social workers will once again be able to do the job they came into social work to do, which was to empower and enable people to have control over the services which affect their lives rather than to be form-fillers, box-tickers and administrators, which many of them have become. It is getting that balance right and if you walk into a public service, whether it is a police division or a school or an NHS ward, and the culture is that it is focused around the needs of the staff rather than those people who are using those services, that is a poor reflection on that police division, that NHS ward and that school, which is why when you go into the best schools, the best police divisions, the best hospitals, there are first of all staff who are clearly well motivated, incredibly signed up to a sense of mission, of values, of public service ethos, and as a result of that people who are using those services as pupils, as patients or clients get a better service.

  Q429  Lord Judd: And you would agree that to achieve all this as far as human rights is concerned the drafting, language and content of guidance documents, codes of practice and stipulations about criteria for those working within the service need to be couched in language which both expresses the importance of human rights and the reason for human rights being in them?

  Mr Lewis: I always used to say when I was Education Minister if you are trying to persuade some of the more difficult kids that education matters, you have to make the link and the relevance between what the kids are doing in the classroom and their dreams, aspirations and hopes for their futures. If you are trying to persuade frontline public service professionals of the virtues of human rights, you have to make a correlation between the legislation and what they should want to do in terms of improving the lives of the people they are there to serve. If you do not do that it will just be more guidance and it will be pretty meaningless in terms of transforming either health services or social care services.

  Q430  Earl of Onslow: Minister, there is going to be a merger between the Health Care Commission and the Commission for Social Care, or so it says here, in the fourth session of this Parliament (2008-09), taking effect. It seems to me that if you are going to do that you therefore have to have standards relating to quality care that should be equal for both hospitals and care homes which can then be set within a human rights framework. The framework then is used to reverse the coin, which is what the Chairman said, and what you said, with which I completely agree, is the attitude of how people are led and guided, et cetera. Would you agree that it would be a good idea to have the same set of standards for both sorts of people?

  Mr Lewis: I think we are going to have a merged regulator, an integrated complaints process, and this is a massive opportunity to ensure that we have common standards. The answer to your question is that I do think in the next two or three years we will have a major opportunity to achieve synergy between the NHS and social care. We are doing it with regulation, we are doing it with complaints, and it seems to me that mainstreaming human rights in that context there is a real opportunity to do that.

  Q431  Earl of Onslow: You talked earlier on about the Berlin Wall between social care and healthcare and I can quite understand that. When I was last in hospital there was a chap who had been there for three weeks and they could not discharge him because there was nowhere for him to go, so one understands this. Are these problems going to be overcome? I have put a note down here on your comment on staff. With the increasing age of people and people living much longer, the proportion of the elderly to the young is getting much higher. We were told certainly in Sweden and Denmark that with the wages it is very hard to find healthcare workers. All of these things make your job much more difficult. How does that fit in with the standards being the same for both people to address the problems there?

  Mr Lewis: We used to have an annual winter crisis in this country—

  Q432  Chairman: GPs shortening their work lists.

  Mr Lewis: It might be something to do with the loads of extra resources this Government chose to put in and it might be to do with the fact that the relationships between the local authorities and the NHS at local level are much better than they were. The point I am making is we have made a lot of progress. On bed-blocking, the Committee has received a lot of information about delayed discharges and readmission. Certainly we need to reflect on some of the readmission information but overall there has been a massive improvement and central to that improvement has been the relationship between NHS and local government. I have said recently, quite stridently, that in every local community we need to move away from a woolly notion of partnership to true integration between the NHS, local government and the voluntary sector in terms of the health and wellbeing of older people. Whether it starts with somebody beginning to deteriorate in their home, becoming lonely and isolated, and if we do not intervene at that stage they deteriorate and end up having health problems that they do not need to have, or whether it is intermediate care or acute care, we need all of the innovation and resources that exist within the local NHS, and it is not just about the money that is spent through the adult social care budget, it is culture, lifelong learning, older people using computers, housing, the whole range of services that local government either commissions or provides. We definitely need to shift towards a far more holistic approach. Local Area Agreements are beginning to make a difference in that respect in terms of local government and health service at a local level. A more integrated approach to the commissioning of services is going to make a difference. In too many areas we still do have this Berlin Wall. Some of it is about legislation that we are doing our best to change and some of it is about professional prejudices and organisational culture, which frankly takes longer to change. You raised the question of staffing and those issues. Political parties of all persuasions are going to have to face the public square on with a debate about the consequences of demographic change in terms of the responsibilities of the State vis-a"-vis the responsibilities of families and the citizens. At the moment there is a group of charities that have got together to look at this in the context of social care. In my view the NHS will always be free at the point of need irrespective of ability to pay funded through general taxation as long as my party is in Government. Social care has always been different from that, it has always been means-tested. In my view it always will be means-tested and, indeed, the demographics make that even more likely. The question is what is a fair and sustainable funding system in the context of these rising pressures and growing expectations out there that will create the kind of system that is fair and sustainable. Also, if there are going to be a large number of self-funders in terms of social care, does the State have responsibility for those who self-fund—this goes back to some of the discussion we had earlier—as well as for those who are offered public funding. I think that for self-funders, whilst always being a reality in terms of social care, we certainly have a duty of protection from exploitation from abuse and at the moment what is happening out there for lots of people is if you are not receiving public funding you are more or less being left to get on with it yourself. I think any review of the way that the system as a whole works has got to address that. If I can be controversial, if we are going to have this nonsense where GPs are suggesting that if people want out-of-hours and weekend cover then people should be made to pay for it, if you look at the contracts that GPs now have, as far as I am concerned that is completely unacceptable and it will not wash with the vast majority of people in this country. GPs should be providing, or facilitating if they do not want to provide it, appropriate weekend and out-of-hours care and the fact that some of them are now suggesting the only way that ought to be done is that patients should be charged for it is disgraceful in my view.

  Q433  Chairman: I think that is helpful. One point on staffing issues that came out of our visit was this: with the way that healthcare has been reformed and people are treated more closely to their community, and even in the home, the net result is those who are occupying hospital beds are a lot sicker than they used to be, a lot frailer than they used to be, and that produces additional demands on staff which makes it that much harder for them to deal with the things that we were talking about in terms of decent standards. Basically you have got the same number of nurses dealing with the same number of patients but the demands of those patients are a lot higher than they used to be in the past. Would you like to comment on that?

  Mr Lewis: Having spent, through personal circumstances, quite a bit of time on an acute NHS ward with a relative not that long ago, the challenges for staff of dealing with a ward full of older people, some of whom have Alzheimer's and dementia, these are challenges that the system has never been asked to face before, these are new questions that are being asked of staff, so essentially we have to recognise that the demands being placed on frontline staff and on the system are of a very different nature and that means every element of the system needs to change to reflect that. You do need specialist skills in dealing with people with dementia and Alzheimer's. You do need to understand what it feels like to be a husband or a wife of somebody who out of the blue develops a condition like that and you see before your very eyes the deterioration of the person that you love. You need to understand what that means and how that feels. In a more clinical sense, on a daily basis almost there are massive scientific and medical advances being made in terms of the treatments that are available to people and that raises other implications; the role of NICE, for example. At the end of the day it is okay being rational about these discussions but in the end if your loved one basically has an illness which is threatening their life and you believe there is a drug out there on the market that may just—may just—conceivably save that person's life, you will do everything you can to fight and argue for that person to have access to that drug. Having said that, the Government is charged with, and has to make through NICE in terms of the legislative framework that we have established, having to make judgments about the relative benefits of new drugs that come on to the market and the impact that they really do make on particular conditions. I think what I am trying to say to the Committee is that the world is changing rapidly, both in terms of scientific advances and demographics, and we should not forget changing public expectations as well, what we expect from public services. The consequences of all of that change mean that we cannot afford to stand still. We have got to continue to advance, to make progress and to change the way that public services are offered. I believe in personalisation. I do believe that public services need to be reconfigured increasingly around the needs of individuals and family units, that we have to move away from a one-size-fits-all approach. I also believe that can mean very different things in the health service, in social care, in other local government services. I also firmly believe that to achieve personalised public services you have got to win the hearts and the minds of the people on the frontline.

  Q434  Lord Judd: Do you agree that on admission to a hospital or a care home it should always be carefully explained to all patients and residents that a hospital or a home is committed to ensuring that their right to be treated with dignity, respect, equality and fairness is fulfilled and that they should have no hesitation whatsoever in raising any issues or complaints in this respect and that, indeed, they should be told in this interview, this meeting, how they should set about doing that? Would you agree that would be a good systematic approach?

  Mr Lewis: This is about being moved from a hospital into a care home, is that the scenario you are referring to, or not?

  Earl of Onslow: On admission to hospitals and care homes.

  Q435  Chairman: On admission, not transfer.

  Mr Lewis: Admission to either a hospital or a care home?

  Q436  Lord Judd: Both, I said.

  Mr Lewis: I think best practice as we talk about personalisation of public services would be an understanding that if you walk through that door and you are going to receive support or treatment either of a significant nature or on a long-term basis, as a basic there should be a discussion with you about rights and responsibilities.

  Q437  Lord Judd: And that it should not just be left to a document that is given to you?

  Mr Lewis: Ideally, no. If we are talking about really personalising public services, about a completely different approach, then I think that conversation should take place.

  Q438  Lord Judd: You said that there is going to be a merger of the complaints system in the future, but what we have identified is a flaw in the complaints system in care homes whereby the Social Care Inspectorate refers residents and their relatives back to their care provider, the very people against whom the complaint is being made. Witnesses have told us, not surprisingly, that this can have a chilling effect on people's ability to make complaints about poor standards and, indeed, there are cases where residents have been evicted after they have tried to make a complaint. Will you ensure that it is the standards set by the Healthcare Commission which prevail after the merger?

  Mr Lewis: No, I cannot guarantee that will be the case. All of that has got to be considered when we talk about a streamlined complaints process for both health and social care. I agree entirely with your analysis that at the moment if it is a complaint about the NHS you have the right to go to the Healthcare Commission ultimately if it is an individual matter, but if it is a matter about social care the complaint begins and ends, if you like, with, I assume, in most cases it would be the local authority or it might be the care home provider. I suspect that somebody with an individual complaint which is linked to maladministration can then go to the Ombudsman if they remain dissatisfied with the outcome of the investigation. I agree there are two different systems and part of what we have got to decide in terms of merging the systems is where the ultimate right of appeal goes in relation to individual complaints, but we have not made that decision yet.

  Q439  Lord Judd: Would you agree that there is a flaw at the moment that must be put right and you will see that it is put right?

  Mr Lewis: We have to look at what is the most effective way of ensuring people, first of all, feel able to complain, secondly, feel that their complaint is taken seriously and, third of all, that there is an element of independence and objectivity about the system.

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