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Lord Harris of Haringey: I make one final point on a slightly separate issue. My noble friend said that he did not think it was possible at this stage to have a robust performance management system for patients' forums. I have some sympathy with that view. However, can we be clear that he accepts the principle that the performance management of patients' forums and, for that matter, patients' councils, must be independent of the local health service? If that is not

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the case a successful patients' forum and a successful patients' council may well be considered to be the one that gives the quietest life to local health service managers. However, it might well be argued that a more effective patients' forum or patients' council would sometimes give local health service managers a difficult time.

Lord Hunt of Kings Heath: I understand the point that my noble friend makes. That is why I emphasised the support that should be given to patients' councils and patients' forums when they are established to ensure that they do their job properly and to ensure that there is exchange of good practice between different parts of the country to enable them to draw on the best practice available.

Baroness Masham of Ilton: The Minister, who is an expert, sounded rather confused just now as to who to approach. I just wonder how on earth the poor patients will be able to find a way through the network.

5.45 p.m.

Lord Hunt of Kings Heath: I am sorry that the noble Baroness thinks that I sounded confused. The matter is very straightforward. If you go into a hospital and there is a problem in the outpatients department, you will have immediate access to the patient advocacy and liaison service within the relevant trust. I hope that that will sort out the problem there and then. However--

Baroness Cumberlege: Even at night?

Lord Hunt of Kings Heath: Of course, we shall have to make arrangements to ensure that there is access to patient advocacy and liaison services. That is an issue and a challenge to which every trust will have to face up. If that does not work out, or if an individual does not want to use PALS because he or she feels that it is more appropriate to make a formal complaint, the system will operate as now. He or she will make a complaint and that will be dealt with through the formal process. At the moment if someone seeks assistance, he or she can approach the community health council. In the future if someone seeks assistance to make a complaint, he or she can approach the independent advocacy service. As I say, I believe that the matter is straightforward. The individual will be given more leverage and power than he or she has had hitherto.

Lord Clement-Jones: This has been an extremely useful and important debate, as was demonstrated by the fact that so many Members of the Committee took part in it. The more Members of the Committee gave examples and teased out situations where certain provisions might come into effect, the more the doubts in my mind (which were already considerable) grew. Certainly those who have spoken have been sceptical about those provisions, to say the least.

The amendments tabled by the noble Earl, Lord Howe, and myself seek to join up the disjointed. I believe that the story of Mrs Archibald will live on

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in folk memory. It illustrated the situation well. The noble Lord, Lord Harris of Haringey, valiantly tried to illustrate that the CHCs did not have the help and assistance that it appears that some of the new services to be established under the Bill will have. The budget of the CHCs is something in the order of £20 million at present. The budget required by the new services may be over £100 million. That is outrageous. How effective could they have been if they had had the necessary powers? Will Hutton's commission on the health service--it was sponsored partly by ACHCEW--concluded that CHCs had inadequate powers.

There is not a great deal between us in terms of agreeing an effective outcome but there is a great difference between us in terms of mechanics. I fully accept that the amendments are rather a la carte, but we have given the Minister a chance to select out of that a la carte menu the provisions that he might consider attractive or at least those which fit in with his general approach. I suggest to the noble Lord, Lord Harris of Haringey, that the table d'hote will come later if we are permitted a Report stage.

However, I am disappointed in the Minister's response. He said that we were debating a matter of principle. I disagree. As I made absolutely clear, we are debating the details of the powers and the joining-up of the different bodies. The Minister showed no willingness to effect more joining-up than has been evident heretofore. The Minister is aware of the need to be as public and patient friendly as possible and as public and patient oriented as possible--there are all kinds of different ways of saying the same thing. I am sure that we agree with that. We want more powerful public involvement in the NHS. However, we do not believe that that will be achieved at present. The Minister went into enormous detail over PALS. That demonstrates some of the difficulties. We had to clarify whether that was to be the normal way of proceeding with independent advocacy. Will patients' councils deal with that on a usual basis or an exceptional basis?

The noble Lord, Lord Harris of Haringey, teased out some interesting answers from the Minister to the effect that the Government do not appear to know at the moment how the system will work. However, if the system really hung together, the Government would know how it worked. Patients' councils should be able to plug into the complaints system.

Lord Hunt of Kings Heath: I do not have a blueprint for saying what proportion of independent advocacy services might be run by patients' councils in the future or might be run by other voluntary organisations as decisions have to be made as to what circumstances suit every locality. That is the responsibility of the Secretary of State. In fulfilling that responsibility he will seek the views of local patients' councils. Surely that comprises the taking account of local circumstances for which the Committee has asked.

The Earl of Listowel: I hope that the noble Lord, Lord Clement-Jones, will forgive me for interrupting

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him. However, what if a mother who does not speak English wishes to access the independent advocacy service? She tries to call NHS Direct but there is not an Urdu speaker to hand. Under the old system she would be able to go to the CHC--the shop front--with her child who perhaps can speak English and gain access to whatever service she needs. How will her need be met under the new system?

Lord Hunt of Kings Heath: It is interesting to note that the noble Earl assumes that in those circumstances every CHC in the country will be instantly accessible and able to respond to those demands. I think that that is most unlikely. With the availability of NHS Direct, and efficient, independent advocacy services, where the views of the patients' councils expressed to the Secretary of State that certain services need to be included are taken into account, one is more likely to have a mechanism for responding to those demands than at present.

The Earl of Listowel: I am sorry to persevere. Perhaps I have not understood the Minister correctly. It seems to me easier for a person to go to an office, perhaps with someone who can speak the English language, than for him to contact a disembodied person at the end of a telephone line in order to gain access to a service. However, perhaps I misunderstood the Minister.

Lord Hunt of Kings Heath: I think that there are four CHCs in Birmingham. Does the noble Earl seriously suggest that it is easier to find those offices, in a city of about a million people, than to have direct access to NHS Direct and then contact with an independent advocacy service?

The Earl of Listowel: I thank the Minister. I shall consider what he says. I am sure that we shall have an opportunity to discuss the issue later.

Lord Clement-Jones: In many respects, that illustrates clearly the total difference between the mindset of those who tabled the amendments on this part of the Bill and that of the Minister and his colleagues in the Department of Health. To me, local decision making involves local decision making: a patients' council has the ability to determine the kind of independent advocacy services it wishes to run, sub-contract, commission and so on. To the Minister, it is the Secretary of State, with perhaps some consultation with the patients' council. That is decentralisation. It is extraordinary.

Lord Hunt of Kings Heath: I do not wish to prolong this debate. I am sure that we could carry on all night on these issues. The point is this. At present, support for the public in making complaint is too variable and patchy. Therefore, the Secretary of State needs to take the power to ensure that a consistent, high quality, independent advocacy service is available throughout the National Health Service. However, in doing so, he

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will take account of the views of local organisations, including patients' councils. Surely that is a sensible approach which involves the best of both worlds.

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