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Earl Howe: My Lords, I am very pleased to support these amendments to which I have added my name. The noble Lord, Lord Clement-Jones, and other noble Lords have made a succinct and admirable case for patients' councils. There is very little I can add beyond perhaps underlining one or two key points.

If we believe in a patient-centred health service, then logically we must also believe in the voice of the patient being heard. I am terribly sorry that the Government have seen fit to abandon the concept of the community health council rather than build on it, because community health councils really do provide a means by which the voice of the patient can be heard at the highest level. They also provide a means whereby lay people in an area can reach an informed view on service delivery across a wider canvas than simply this or that acute trust or this particular PCT.

What we have in the Government's proposals is a means whereby lay people will be able to consider the patient's experience, albeit—as the noble Lord, Lord Stoddart, indicated—only in slices, not as a totality. That is not much good to our old friend Mrs Archibald, who is waiting a long time for her operation. The patients forum for Mrs Archibald's primary care trust may well lay the blame on the hospital. The patients forum for the hospital may in good conscience lay the blame on the primary care trust. What use is that to Mrs Archibald? What she needs is one place where all her problems are considered in the round and from where pressure is brought to bear on the system failures that are causing these problems. That place is a patients' council.

In the Government's model, there is absolutely no lay representation for patients above the level of a patients forum. In pointing that out, I am not playing down the significance of the Commission for Patient and Public Involvement in Health; I am sure that the commission is a positive idea and it will have a useful role. However, the commission will not have lay people in it; it will be staffed by paid officials. It is in essence, and I think will be perceived as being, a creature of government.

The commission's job will be to support patients forums, but that is a long way from saying that the commission has to take action when a patients forum brings a particular matter to its notice. It does not have

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to do anything. A patients forum can bring the same matter to the notice of an overview and scrutiny committee of a local authority. However, there is no legal duty for the overview and scrutiny committee to do anything either. I find it very difficult to see this reformulation of patient and public involvement as anything other than a way of weakening the patient's voice rather than assisting it.

The fact is that the overview of health services in an area will be led by staff who are employed by a national organisation which the Department of Health can control. Is that really what we want? The Government are effectively saying that lay involvement is all very well provided it can be muzzled and that lay people are fine as regards monitoring what goes on in an acute hospital, but that is all they can do—monitor. They will have no real power to do anything about whatever may emerge from their monitoring. We need patients' councils to sustain the voice of patients.

The Minister said in Committee that he did not want another statutory tier of patient involvement that usurped the primacy of patients forums. In answer to that I underline the point made by the noble Lord, Lord Clement-Jones. I do not see patients' councils as adding another tier of bureaucracy. I do not see them as altering the key position of patients forums working with and inside NHS trusts. Indeed, I see them as supporting patients forums, not the other way round. The people who serve on patients' councils would be the same people as serve on patients forums.

At the moment the Government propose an array of bureaucratic structures and tasks in a given locality. There would be local networks of the commission and so-called lay reference panels of different patients forums. It would be the job of the staff of the commission to tender, to contract for and to evaluate the independent complaints advocacy services. Why not bring all of those activities and structures together in a patients' council where, using local staff of the commission, they could all be provided much more efficiently? Advocacy would be provided from within patients' councils. Lay reference panels would not be needed at all.

The Government have indicated that they are willing to place a duty on the face of the Bill for patients forums to work together. I have to say that I do not think that that is adequate. Working together is not the same thing as having a lay led organisation that will pull all the threads together from trusts and PCTs and speak up for patients in a particular geographical area, perhaps working across administrative boundaries. That in simple terms is the watchdog function. It is a function we shall lose if the Government have their way.

Finally, as regards visibility, local networks of the commission will be neither visible nor recognisable to the general public. Nor will they be accountable to them. If we look at things that way, I do not think that we can avoid the conclusion that patients' councils are the only sensible solution to the very significant deficiencies inherent in the new arrangements.

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4.30 p.m.

The Lord Bishop of Hereford: My Lords, I express my warm support for the amendment and my strong agreement with what the noble Earl, Lord Howe, has just said. I ought to declare an indirect interest in that my wife served as a chairman of one community health council and vice-chairman of another and has for some years been a non-executive director of an acute trust. Therefore, she has seen the situation from both sides. I believe that the real point of the patients' council—this has been said already but I want to underline it yet again—is that it is a body which has a broad enough view to co-ordinate and to have a coherent overview of the relationship between the various bodies delivering healthcare. We must think in particular of the primary care trusts and the acute trusts. The shift of responsibility has changed in that relationship. It is one where we must have a body which can relate to both over a much wider area than that of an individual organisation.

I believe that the patients forum, which may be necessary, desirable, effective and good within its narrow limits, has too narrow limits. It will have much too narrow a remit. It will not be able to take an overview and relate its own concerns to those of patients who are being treated by another institution or agency. I believe that patients' councils would have a much greater degree of independence and would be more likely to achieve effective and desirable change. I urge the Minister to accept the amendment. I hope that it will win widespread support from all sides of the House.

Baroness Finlay of Llandaff: My Lords, I strongly support the amendments. I speak as a healthcare professional. I believe that the voice of the patient must have parity with that of the management at all levels. Patients' councils are important in order to establish a route whereby the collective intelligence can be gathered on information that may be supplied through the layers of a patients forum. Patients forums are inexorably linked to trusts and there is always the danger that the patient who is vulnerable cannot really express all his or her concerns. There is also a danger that small trends in one area which may constitute large national trends would be lost if there was not a collective intelligence.

There have been examples of collective intelligence professionally. I refer to the confidential inquiry into maternal deaths and the confidential inquiry into perioperative deaths. Now within trusts there is sentinel event reporting or near miss reporting. It is that collection of many small bits of information co-ordinated and brought together that supplies crucial information as regards a trend. The amendments appear to enable patients to themselves have a collective intelligence to inform their reporting.

Lord Harris of Haringey: My Lords, I was moved by the energetic statements of the noble Lord, Lord Stoddart of Swindon, with regard to the importance of not cosying up to the NHS or the Department of Health. As director of the Association of Community

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Health Councils for a number of years, that was certainly a precept that I sought to follow. Indeed, I have at home a series of copies of denunciations of me by successive Secretaries of State, the most vitriolic of which came from my right honourable friend Frank Dobson during his period as Secretary of State for Health.

However, I am confused by the different points that have been made in the past half hour or so in support of the amendment. For example, the noble Lord, Lord Stoddart, mentioned a diffuse void. I am not sure whether you can have a diffuse void or whether they are necessarily different. However, I am concerned about the extent to which what is proposed here will make the arrangements more rather than less diffuse.

Lord Stoddart of Swindon: My Lords, I did not say diffuse void; I said a diffuse voice.

Lord Harris of Haringey: My Lords, it is possible that I wrote down "voice" but I cannot read it. That explains the situation. In fact, that makes my point all the more telling. If the noble Lord is concerned about a diffuse voice, the danger is that the amendment which he supports creates yet another voice and further diffuses it.

Much has been said in this short debate about giving power to patients. On the various occasions I have contributed to that discussion over the past few months I made the point that the original proposals which emerged from the Government were extremely weak and flawed. What has emerged subsequently is substantially better, but there are still one or two gaps. One of the gaps concerns the need for there to be some system of co-ordination between the different patients forums and the different issues that may arise. The other concerns the need for there to be a focus at area level which is population based as opposed to institution based. My other anxieties concern staffing arrangements. A number of noble Lords alluded to the issue of whether staff of the patients forums will be accountable to the patients forums or to the new Commission for Patient and Public Involvement in Health. There are also concerns with regard to the extent to which the new patient structure will address issues of public health.

In Committee I tabled two amendments which I thought might address those points. I have not tabled them subsequently having listened carefully to my noble friend's assurances. I had hoped that we would have before us today a draft of the regulations which would have enabled us to see exactly how he proposes to meet some of the points that I put forward. Unfortunately, the regulations are not before us. I am conscious that there is an impressive array of support being displayed for the amendment from around your Lordships' House. My limited experience suggests that if noble Lords from both opposition Front Benches and a former distinguished Convenor of the Cross-Bench Peers put their name to an amendment, the chances are that it will be accepted. However, that raises some concern about what will be on the face of the Bill.

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The amendment is slightly strange. A number of noble Lords have expressed concern about the danger of diffuse arrangements. The first paragraph of the amendment states that the Secretary of State shall establish a body in each area covered by an overview and scrutiny committee. The third paragraph proposes that in addition the Secretary of State may create other patients' councils in other areas. That is not instead of the patients' councils for each overview and scrutiny committee but as well as, thereby making the provision even more diffuse. There may be a misprint in the second paragraph which is incoherent. It states:

    "Each Council shall comprise from among members".

I assume that that is just a mistake.

The first paragraph establishes a body known as a patients' council in each area for which an overview and scrutiny committee has been established. Some noble Lords suggest that it will be close to the public. I do not understand how it can be closer to the public than areas represented by a patients forum representing a PCT area which is likely to be much closer to the public. Others have talked about an overarching view. In some areas the area covered by an overview and scrutiny committee will be a long way from the public. It will probably relate to a county council area which covers perhaps 2 million people and is remote from local communities, issues and concerns.

In London it is the converse. There will be a patients forum for each PCT, covering the area of a London borough. If the amendment were passed, there would also be a patients' council for the same geographical area. That seems a recipe for enormous confusion for the public. I suspect that it is a flaw in the drafting and that the noble Lord, Lord Clement-Jones, did not intend that.

The proposals produce a bureaucratic response to the problems identified. I have suggested that the local area covered by a PCT and the patients forum established for that area should have the co-ordinating function. It should bring together the various areas within it. I have yet to hear arguments which satisfy me that that is not the best way to address the issue.

I am amazed at subsection (4)(d) of the amendment. It proposes that one of the tasks of the new patients' councils will be to advise a series of bodies about anything,

    "which would or might affect (whether directly or not) the health of those members of the public"

in respect of those services. The provision does not relate only to health service bodies. It is clearly intended to address the question of public health. But it provides for,

    "other public bodies, and . . . others providing services to the public or a section of the public".

Presumably it will be the duty of the patients' councils to advise transport undertakings on the safety of the railway system because that may potentially affect the health of people who may or may not use it. The patients' councils will be required to give advice to the supermarket chains about the quality of the food that

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they provide because that may affect the health of people, and to small shopkeepers, and so on. The provision is extraordinarily widely drafted. The noble Lord, Lord Clement-Jones, will no doubt suggest that it can be tidied up. But there has to be clarity about what we seek to achieve.

Noble Lords have suggested conflicting aims. Some say that because the patients forums will be close to specific trusts they cannot be the champions of the patients. Yet others say that the strength of the patients' councils is that they will be drawn from the patients forums. The same people will be sitting on the patients forums as are on the patients' councils. That does not make sense. One cannot have it both ways. Like, I am sure, the noble Earl, Lord Howe, I have sought assurances from the Minister on the independence of the patients forums. If the patients forums are genuinely independent, there can be no problem about creating a patients' council. If one is not satisfied that they are independent, the patients' council is not the solution because the patients' councils are drawn from the patients forums.

The noble Lord, Lord Peyton, expressed concern about the death by a thousand visits. The proposals create yet another statutory body with, presumably, powers to visit, to have reports, and to require responses involving extra rounds of visits. I do not believe that the amendment meets the purposes that noble Lords seek to achieve. Simpler and less bureaucratic solutions could create a focus on a specific locality and population and address questions of public health without the all-embracing, blunderbuss approach to every conceivable issue which may arise. With appropriate guarantees from Ministers, bodies could be independent of the NHS and adequately serviced by the arrangements for the new national commission.

4.45 p.m.

Lord Rea: My Lords, I have added my name to those putting forward the amendment in order to demonstrate to my noble friend the breadth of support the provision has not only from the Opposition Benches in this House but also from among the large segment of government supporters, particularly in another place. As the noble Lord, Lord Clement-Jones, pointed out, the amendment is identical to that moved by David Hinchliffe, the chair of the Select Committee in another place. It also has wide support among the health profession.

Like the noble Lord, Lord Weatherill, I shall not argue again the case for patients' councils which many noble Lords have argued eloquently. However, unless my noble friend puts forward a proposal which goes a long way towards embodying the principles outlined in the amendment, he is likely to provoke a Division which he is likely to lose. I await with some anxiety the noble Lord's suggestions. Perhaps some of the suggestions just put forward by my noble friend may act as a basis for them. However, the proposals will

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have to be quite radical for me to support the Government and oppose the amendment in the Lobbies.

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