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Lord Clement-Jones: My Lords, I rise briefly to support Amendment No. 32 and to speak to Amendment No. 33 tabled in my name. As the noble Earl, Lord Howe, indicated, it seems strange that the patients forums would be required in certain circumstances, if the Bill were unamended, to carry out the functions of PALS.

The Minister was not particularly clear in Committee on this matter. The amendment is designed to substitute oversight and provision of independent advocacy services via patients forums. But the specific purpose of Amendment No. 33 is designed to elicit from the Minister a clearer reply than he gave in Committee.

It seems strange for the patients forums to be carrying out the duties of PALS. It would blur the functions of the forums. The PALS are effectively part of the acute trusts and the patients forums have entirely different functions. Perhaps the Minister could elucidate that rather more clearly in his reply on this occasion.

Lord Hunt of Kings Heath: My Lords, the functions of patients forums are specific. It is explicit within those functions that forums put forward the views of patients, in particular those who use the services of the relevant trust.

While I understand what the noble Earl, Lord Howe, is saying, to extend the remit of the forums to represent the interest of the public rather misses the point of our proposals. To say that we have a representative role on behalf of what would be a large section of the community being served by each patients forum, would be untenable and unlikely to be realised in effective action on behalf of those patients forums.

If we look at the performance of community health councils—we may talk about that in a few moments—we see there have been big problems where community health councils have sought to speak on behalf of the whole community. Community health councils do not have the legitimacy or the credibility to do so; nor could patients forums take on that wider public representational role.

The aim of patients forums is to enable patients' views to be put forward. It is recognised that patients' views on an issue may differ. If a patients forum is charged with representing those patients' interests, it implies that the forum will have to make a judgment as to what those interests are; that is, that the forum members know what is best for the entire body of patients served by the NHS trust with which the patients forum is associated.

Patients' views differ. It is the job of the forum to represent all those views to enable trusts and primary care trusts to take account of that range of views when making decisions. Our objective with this system is to increase opportunities for patients and the public to have a say, to have greater influence and to make real

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changes, but also accepting that patients will often have a wide spectrum of views. On that basis I resist the wording of the noble Earl.

In looking at Amendment No. 33 we see that the effect is twofold. The first is to remove from the Bill Clause 15(2)(e), which is what would be used to give forums the power to be able to take over the operation of a patient advice and liaison service in prescribed circumstances. The second effect is to give forums the specific role of monitoring and reviewing independent advocacy services and to make reports and recommendations about them.

I do not accept, as the noble Earl suggested, that the clause as presently drafted impacts upon the independence of patients forums. Indeed, I argue entirely the opposite. The fact that it has that role is an expression both of the ability the patient forum will have at local level and its very independence. I accept that the circumstances in which that would occur—a PAL service being taken over by a patients forum—would be rare. It is an important service to patients and their families and it is surely only right and proper that in those rare cases where the forum feels that the trust is failing to provide an adequate service, the patients forum should be able to do something about it.

I am sorry that I disappointed the noble Lord, Lord Clement-Jones, in Committee on this matter. Perhaps I can try again to reassure him. How would the provision work if a patients forum was dissatisfied with the work of a PAL service in a trust for which it was responsible. We envisage a grievance type of process. If a forum is concerned about the quality of PALS, it would normally report that to the board of the trust or primary care trust. If there was no improvement, it would report again, copying its report to the strategic health authority. If again there was no improvement, the forum would report the matter to the Secretary of State.

The Secretary of State would then need to make a decision about what action should be taken. He could choose to direct the trust to take action. He might also decide that the forum should take over responsibilities for the PALS service. If the latter were the case, the forum would make arrangements for the provision of the PALS, such as arranging for another trust's PALS to take over the service but with the forum retaining responsibility for it; or a voluntary sector organisation might take over the PALS but report to the forum.

I accept that the patients forums themselves would not physically provide the patient advocacy and liaison service, but they would be in the driving seat for ensuring that such a service is provided. When a trust is not doing the right thing in terms of running a proper PALS, surely it is a very important lever in the armoury of the patients forum that it is able to take such action.

In the second part of the amendment, the responsibility for commissioning the independent complaints and arbitration service is to be one of the key functions of the commission. It will commission such independent advocacy services only from providers that meet standards set by the commission.

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I believe that that process will ensure that this service is available, that it meets a certain standard, that it provides an effective monitoring system and that it avoids unnecessary duplication. Given the likely range of the independent arbitration service—which is likely to go wider than an individual trust or primary care trust—in practical terms it is best commissioned by the commission at a national level. But of course, in so doing, it will be informed by the experience of patients forums, which can be fed into the commission so that it is well aware of any problems that might be arising.

Amendment No. 55 is consequent on Amendment No. 33. We believe that engagement with the wider public and representation of their views, particularly in relation to overview and scrutiny committees of local authorities, will be with the local commission. The commission will, in the course of its activities, develop a clear picture of the entirety of patient experiences across a whole area. The commission will support and facilitate forum activity, and in so doing will build up a wider view of the patient's journey. As with independent arbitration, the experiences of patients forums would be an important influence on the commission in being able to make those representations. But both in terms of the workload of local commissions and in enabling a commission to get a clearer perspective of a patient's pathway across organisational boundaries, I believe that that particular responsibility is best left with the commission.

Earl Howe: My Lords, I am grateful to the Minister for that reply, although I am disappointed by it. At present, community health councils have a legitimate role in representing the voice of patients and the public. In the strict sense they have a legitimate role in doing so because the law empowers them to engage in such activity.

The Minister is effectively saying that a patients forum should not be allowed to make representations at all. The forums are, as it were, to be silent witnesses—except, and very importantly, in the context of their ability to refer a matter to the local overview and scrutiny committee.

I believe that that is retrograde. The fact is that CHCs can, and do, speak up for patients—sometimes very vocally. I should have thought that it would be entirely healthy for a patients forum to have the ability to make representations in that sense.

Lord Hunt of Kings Heath: My Lords, I am grateful to the noble Earl for giving way. This is an important point. Will he accept, in reference to Clause 15(2), that the role of a patients forum in monitoring and reviewing the operation of services, obtaining the views of patients and their carers and reporting on those views to the trust is a powerful set of responsibilities on patients forums? It is better to have focused responsibilities such as those, rather than suggesting that a patients forum could represent the interest of all the people who were served by a particular trust.

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3.15 p.m.

Earl Howe: My Lords, I agree that it is a powerful set of responsibilities, but the powers conferred on a patients forum are minimal. All the forums are allowed to do is to monitor and express their opinion to the trust. They cannot do anything further than that.

I agree that that is a job that needs to be done. I am glad that there will be an independent body within the trust to do that. However, the wings of patients forums will be clipped; they will not have the ability to fly outside a trust and tell the world what they have found and express their views more widely.

The issue of the independence of a patients forum is an important one. I feel that a patients forum should be independent from its own trust in the fullest sense. People value community health councils because they are independent of the operations of health trusts. The same independence should apply in the case of patients forums.

The explanation given by the Minister of how the process of patients forums taking over trust functions would work—a matter to which he referred in Committee (at col. 561 of the Official Report)—demonstrates that these ideas have not been fully thought through. The Minister referred only to PALS. But if the clause is meant to refer only to PALS, I do not understand why it is not specific.

There is a danger not only of patients forums being allocated inappropriate responsibilities which they may be ill equipped to deliver, but also of patients forums giving undue attention to monitoring PALS, because they have that power, at the expense of the trusts' main services to patients, which are the things that matter most.

I shall read the Minister's remarks carefully. I do not believe that he has given me much comfort, if any, but I shall reserve the possibility of bringing these matters back at Third Reading. I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

[Amendment No. 33 not moved.]

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