Examination of Witnesses (Questions 420-439)
MR IVAN
LEWIS MP, MR
DAVID BEHAN,
AND MR
SURINDER SHARMA
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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