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Baroness Cumberlege: I strongly support my noble friend's amendments. There is a feeling, which I am sure the Minister will seek to dismiss eloquently, that the proposals now tabled have not been very well thought through, and that one structure has been piled upon another to resolve any problem that exists. I have tried really hard to get through this issue. Your Lordships will know that I am a slow learner. I have looked at the whole issue from a patient's point of view. I am not looking at the matter from the point of view of a community health council, but from that of a patient, a complainant, someone seeking redress.

I have called my patient Mrs Archibald. Mrs Archibald, aged 80, suffers a stroke one night. Her relatives contact her GP who refuses to come out. They dial 999 for an ambulance. There is a long delay before the ambulance arrives. On arrival at the hospital Mrs Archibald is left on a trolley in the A & E department for three hours before being seen by a doctor. She spends a further 14 hours before being sent to a surgical ward. That is because the medical wards are full and there is no dedicated stroke unit. Her stay in hospital is three weeks longer than necessary as no suitable place can be found to meet her very dependent needs. On leaving hospital she is inappropriately assessed. She is sent to a residential home instead of a nursing home which she requires.

That short vignette raises six associated policy issues: first, the access to a GP out-of-hours; secondly, the response times of the ambulance service; thirdly, the performance standards in the A & E department;

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fourthly, stroke care; fifthly, delayed discharge; and, sixthly, quality and multi-disciplinary continuing care assessment.

As is so often the case with complainants, Mrs Archibald's daughter is keen that no other patient should endure what her mother has suffered. She wishes to prevent that happening by making a complaint. She has heard of the PALS system, but since this case arose at night none was on duty. The Minister would agree that even if they had been on duty, it is doubtful whether they would have been able to persuade a GP to turn out at night. The ambulance trust PALS and the PALS in the hospital would have had a problem to expedite the ambulance or to overcome the shortage of beds that night.

In this case three patients' forums have a policy remit: the PCT forum, the ambulance trust forum, and the hospital trust forum. Mrs Archibald's daughter goes to the patients' council with her complaint. The council "anonymises" the details and sends the complaint to the three chairs of the three forums. Each chair is a non-executive director of the corresponding trust. Each forum discusses a section of the complaint relevant to that trust and asks the respective chair to raise the issue at the next trust board meeting.

The chair of the hospital forum is reluctant because it has recently had a great deal of bad press over its A & E service. The trust chair has instructed all the non-executives to try and promote a positive image. The forum non-executive agrees to raise the issue in the private part of the meeting after the press and the public have been excluded. However, that means that he cannot report back to the relatives as he has a duty to keep the discussion confidential.

The PCT forum's non-executive raises the issue of GP out-of-hours services. Although, through the health authority, the board can influence the generality of out-of-hours services, it cannot influence the services a GP directly provides because he is an independent contractor. There is no patient's representative on the health authority to raise the policy issue.

The ambulance forum non-executive raises the issue of response times. The board agrees that it needs more money from the commissioning bodies to improve these times, but it does not know if it will be forthcoming and "unbadged". There is no forum where discussions on delayed discharges and multi-disciplinary assessment can be raised.

Mrs Archibald's daughter is advised to raise these policy issues with a local authority scrutiny committee. She could also write to the PCT forum concerning the NHS element of the multi-disciplinary assessment. The scrutiny committee discusses the delayed discharge and agrees that it is very unfortunate that the council's cabinet decided to cut the social services budget. It will make a report to that effect. It does not have time to consider the issue of multi-disciplinary assessment as its work programme is over-committed.

The relatives are thoroughly dissatisfied, but they have no redress against the scrutiny committee for its refusal to consider these matters, although, of course,

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I suspect that they will vote against their local council in the next election. In the meantime, the exhausted daughter is becoming increasingly concerned about the council's residential home and the inappropriate care given to her mother. She seeks out the independent advocacy service provided by the patients' council. The advocate is employed by the local authority, either directly or through the patients' council. The advocate is clearly nervous about giving even informal advice about the local authority issue as his contract is held by the local authority. In addition, he has no remit over the care sector. The complaint process continues for 18 months and the relatives finally give up.

Noble Lords will agree that this is a monolithic labyrinthine system compared with our present system--a one-stop shop, locally-based, accessible and known to the local community, with statutory powers. The Government are proposing three sets of PALS, three different forums, a patients' council, a local authority scrutiny committee and an independent advocacy service.

At the moment, Mrs Archibald's daughter could deal with one body which is able to handle all aspects of the problem except the quality of care in the residential home. That is an issue that needs to be addressed, and has not been addressed in the Bill. Within CHCs lines of accountability are very clear. In these proposals there is an inbuilt conflict of interest between the non-executive appointees to the trust board and their loyalties to the forum. Even the Institute of Directors questions how corporate responsibility can work with this half-baked system. Furthermore, as Elizabeth Manero is quoted as saying in this week's Health Service Journal, the independent advocacy service, if commissioned by local authorities as suggested in the Bill, ensures a conflict of interest between representing users of joint health and local authority services.

CHCs have been seriously unpopular with the Secretary of State, but were lavishly praised by the Prime Minister. When the CHCs celebrated their 25th anniversary the Prime Minister's agent wrote:

    "Tony would certainly like to add his congratulations to the work the CHCs have done over the last 25 years and wishes them every success in the future".

Those are odd words to choose when signing a death warrant.

And the Secretary of State continues to plot that death sentence. The truth is that the CHCs hold the truth-- how it really is--and the Government cannot bear the criticism.

As Donna Covey, the director of ACHEW, in an article by Anthony Browne, the health editor of the Observer, said:

    "Getting rid of the CHCs will not get rid of the problems for the NHS, but it might make them more difficult to detect".

She is right. In all public services we need a regulator, an independent scrutineer to detect the problems. It is right that they should carry out surveys of trolley waits, waiting times for out-patients' appointments, dirty kitchens and so on, but the big picture is often gleaned from the individual complaint.

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It was complaints to the CHC which brought to light events at the Bristol Royal Infirmary, the Alder Hey Children's Hospital, and the situation of Mr Rodney Ledwood, Harold Shipman and others. An article in The Times headed "Complaint by patient uncovered list scandal". which appeared last Saturday, stated:

    "A telephone call from one disgruntled patient led ... investigators to discover the waiting list scandal at Stoke Mandeville Hospital. The patient was fed up at hearing official claims that only a handful of patients nationally were waiting longer than 18 months for treatment".

That is the point. Every government are prone to exaggeration of their achievements. Claims are made and when probed turn out to be somewhat fragile. A complainant needs the confidence that there is an independent body which will not only take up his complaint but will piece complaints together to build a big picture.

Finally, it is surprising that the General Medical Council, the BMA and other professional bodies have been championing the retention of CHCs. One might think that they were an irritant to such bodies. That is not so. They recognise that CHCs, with their coherent and comprehensive role, are a safeguard to maintaining quality in clinical care locally and, with the establishment of a national body to which we shall come later in the debate, nationally, in providing the big picture.

I strongly support the amendments put forward by my noble friend. They aim to bring the system together in order to be coherent, to be more joined up and to give patients a chance to understand the complaints system and to have confidence that it will be really effective.

Lord Weatherill: I support what the noble Baroness, Lady Cumberlege, said about the amendments proposed by the noble Earl, Lord Howe. As the Committee may know, I represented the Borough of Croydon for many years and I have been urged by Croydon Council to participate in this debate. I shall do so briefly because I am not the kind of expert in these matters that the noble Baroness is.

What has been said is absolutely right. The amendments would give continuity to the present system, in contrast to what the noble Baroness said about the various other bodies that would be involved if the Government have their way in this matter. Croydon Council recently passed a unanimous resolution. My contribution will be to read it to the Committee. It states:

    "This Council is proud of the way that the Croydon Community Health Council provides a strong and independent voice for the people of Croydon on NHS matters and is proud of the way that the CHC carries out its functions as the local watchdog. This Council judges that the involvement of an independent watchdog role is essential in helping the Council undertake its proposed new responsibility for scrutiny of the NHS and in adding cohesion to, and commanding public confidence in, other initiatives proposed in the NHS Plan. This Council encourages the Healthy Croydon partnership to include the expertise of the present CHC in developing a future model of health scrutiny and patient advocacy in Croydon".

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I suspect that that resolution, if not passed by other councils, will be equally strongly felt by them. It is in that spirit that I warmly support this group of amendments.

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