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Lord Hunt of Kings Heath: My Lords, it has been a wide-ranging debate which has taken us back to some of the substantive discussions on Second Reading in terms of the future of patient and public involvement in the National Health Service. Like my noble friend Lady Pitkeathley, I have had a long-standing interest and experience in patient and public involvement. I have always made it clear to your Lordships that the tests of the Government's proposals are whether at the end of the day they will be more effective in improving patient and public involvement and NHS sensitivity to the needs of patients than the current arrangements. I have no doubt that the arrangements we set before noble Lords will lead to a more effective engagement with the public than we have at present.

The noble Baroness, Lady Carnegy, said that the problem with our proposals was that they took a "big tent" approach. I disagree. The problem with community health councils is that they were a big tent approach. Within CHCs they were meant to encompass a range of functions. Often they did so inadequately. They were patchy in what they achieved. At the end of the day, I say to the noble Lord, Lord Stoddart, that the proof of the pudding is in the eating. Twenty-seven years after the establishment of CHCs, can we say hand on heart that we believe that their impact has been to turn the NHS into a patient and public orientated service? The answer is, no: that has not happened. That is why we think it better to separate the functions that CHCs have traditionally been given and ensure that they are organised in a much more professional and effective way—hence the establishment of PALs (patient advocacy and liaison services) within NHS trusts to deal with problems as they arise; in other words, to nip them in the bud. We also have the establishment of patients forums, independent advocacy services, as well as the overview and scrutiny committees of local government.

The noble Baroness, Lady Masham, asked for independence. That is what these arrangements are about. For example, patients forums are independent. Indeed, by its very name, independent advocacy is independent. Overview and scrutiny committees and the committees of local authorities are independent of the NHS.

Going beyond the range of measures that we now propose, we come to the issue of the co-ordination of the work of patients forums. I accept that patients' councils are one way by which one could co-ordinate the work of forums, but, in my view, they are not the best answer. Patients' councils risk undermining the key plank of our proposals; namely, the establishment of patients forums. There is a very real risk in this respect. Unlike community health councils, patients forums will be operative in those areas where patients are actually being treated within NHS trusts. That is the point where patients need help and support. It is

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there that the wide spectrum of patients' views needs to be brought to bear on clinicians, and on those who take a leadership role.

If our patient/public involvement initiatives are to make a real difference, it will be in the improved quality of every-day patient experience. That is why patients forums, based within each NHS trust, are the essential foundations of our proposals. Patient journeys cross organisational boundaries; indeed, they have always done so, and they always will. Patients forums will need to work together. That is why we propose that the national commission will provide the support to give the necessary flexibility at the local level. We do need a flexible approach. It is because different patient journeys cross different organisational boundaries that the required flexible approach is embraced within our proposals.

The risk with the proposed patients' council is that its function would go much wider than merely facilitating co-ordination. It would be a statutory body—another tier. The risk is that it would take to itself a role of speaking on behalf of patients forums and of supplanting their primacy. As my noble friend Lord Harris pointed out, under the proposals put forward by the noble Lord, Lord Clement-Jones, my strategic health authority covering Birmingham and the Black Country would have but one patient council for a huge population area. How can that possibly be concerned with getting closer to the views of patients?

I argue for subsidiarity as opposed to a centralist approach, which I believe would be almost inevitable if formal statutory patients' councils were established. The noble Earl, Lord Howe, said that there was no risk in that respect. However, he then recited a whole list of responsibilities for patients' councils. It is clear that they would become the primary patients' organisation within the proposed new structure. The last thing we should want is to have such councils tying up resources and people, acting in an inappropriate representational role, and taking the main focus of attention away from the direct patient experience at the NHS trust level.

However, that does not mean to say that co-operation between patients forums is unimportant. The Commission for Patient and Public Involvement in Health has already been given the function of providing assistance to patients forums, as well as facilitating the co-ordination of their activities. But I am not unsympathetic to the points raised about trying to flesh out further details about how that co-ordination may work. Having listened to the debate in Committee, and having had useful discussions with several noble Lords, the Government have decided to go further on the basis that the patients' councils option is not pursued.

We would plan to make explicit on the face of the Bill a requirement on patients forums to come together on a regular basis in a structured format, along the lines of standing conferences. That mechanism would mean that all the forums within an area would bring their views, findings, themes and trends into one place where consideration could be given to sharing views

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and co-ordinating the work of different forums. That process would ensure a mechanism that was inclusive and one that would be open to all forum members. It would not be a matter of giving an extra status to any forum, or any forum member. Similarly, it would not involve an extra statutory bureaucratic tier.

At the same time, we are prepared to place a requirement on the commission—again, on the face of the Bill—to take account of the views of patients forums in deciding its work plan. In that way, we can be sure that the commission and its work are being explicitly influenced by local patients forums, which, in itself, would encourage the working together of those forums. The commission will already have a very clear and comprehensive view of patients' experiences across an area, but the requirement for forums to come together, and the fact that the commission will take this into account, will ensure that important degree of accountability—but without shackling its work unnecessarily.

I turn to the issue of a one-stop shop. Wherever local people may be, I agree that it will be important for them to have a single access point into the patient/public involvement system. Clearly, it will be possible to access this through PALS, through independent complaints and advocacy services, through patients forums, through the overview and scrutiny committees of local government, and through the staff of the local commission; and, indeed, through many other sources of information, not least in the NHS. However, in response to some of the points raised, we shall ensure that the commission provides a central access point through its network at the local level. Again, we shall make it an explicit function of the commission to provide information and guidance to local people wanting to complain, to have their say, or to know what is happening locally on matters that affect their health.

We have in mind a single point of contact, as suggested by my noble friend Lady Pitkeathley, by telephone, by electronic media, so that it will be possible through one contact not only to access all the local mechanisms for patient involvement and information but also to provide information about key developments in the local health service. We would plan to bring forward the necessary amendments on Third Reading.

I have no doubt about the sincerity of all noble Lords who have spoken on these matters. I believe that we all want better public and patient engagement within the NHS. I agree with the noble Lord, Lord Stoddart: we do not want the patient to be a "supplicant" at the table of the NHS. We want the NHS to serve patients in the most effective and sensitive way possible. We have not done this well in the past; indeed, we must do better. If we do not better serve the public, they will walk away from the NHS. It is as simple as that. I should point out to the noble Lord, Lord Peyton, that it is in the interest of the Government, as much as anyone else, to have powerful patient engagement.

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All that we have said about the NHS, and all the plans that we have made, are predicated on a more responsive National Health Service. We will not have a responsive NHS unless we have strong patient involvement.

My view of the amendments starts and finishes with an analysis of which approach is more likely to lead to strong patient involvement. Which approach is more likely to secure the responsive NHS that all noble Lords want? I am convinced that the patients forums route is right. The impact on each trust of having within its midst wholly independent patients forums will be enormous. Please do not inhibit and undermine those forums by placing on top of them remote patients' councils, which will at best detract from the primacy of patients forums and at worst become a bureaucratic and unnecessary encumbrance that is remote from the day-to-day experience of patients.

Patients forums must work together; that is not in doubt. That is why we have listened carefully to the arguments and are prepared to table amendments at Third Reading to reinforce that co-operation if the patients' councils amendments are not pressed.

We will of course be determined to ensure that the model that we finally reach will be the best model for co-operation. It will operate on the basis of equal partnership in relation to patients forums and it will be grounded in the day-to-day experience of NHS patients. I do not believe that patients' councils would add to that one iota. The risk is that they would considerably detract from those arrangements.

5 p.m.

Lord Clement-Jones: My Lords, I thank all noble Lords for their contributions to this debate and the Minister in particular for his powerful speech.

It is clear that the overwhelming opinion of the House is in favour of patients' councils. I was interested that several times in his reply, the Minister used the word "risk". He said that the approach risks undermining the world of patients and public involvement, as designed by the Government. The irony is that the Government accepted amendments involving patients' councils in a Bill before the previous general election, and they did so gladly. They did so by way of a compromise with one of their own Back-Benchers—the chairman of the Select Committee on Health. What has changed in nine months? Very little.

The Minister and his ministerial colleagues have had some time—probably one year—to consider the matter. I am afraid that although his reply was well considered, he and his colleagues have come up with roughly four or five additional sticking plasters for what was already a very complicated solution. The Government have added to the Bill a duty to oblige patients' forums to work together. Very useful. A standing conference has been suggested and a telephone line. Well, that is a very useful contribution! Most noble Lords who listened to the Minister's speech will mull over whether all of those rather minor additions to the Bill could be fulfilled through patients' councils.

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I was interested to hear the robust contribution of the noble Lord, Lord Harris—it is always good to hear him in full flow. The answer to his suggestion is that, in essence, patients' councils are a bottom-up solution to patient and public involvement. The networks of the national commission, which are a Government creation—they are effectively the creature of the Secretary of State—are a top-down solution. That is the key difference between patients' councils and the Government's proposals.

Many noble Lords would like to return to the status quo in relation to community health councils. I do not believe that the Government have properly taken into account the fact that this proposal is a compromise that was put forward by many voluntary organisations and by the CHCs themselves through their national organisation. We advance it in a genuinely constructive way—in the belief that it is the best way forward, rather than an attempt to fight past battles. I do not believe that the Government are giving as much credit as they should to supporters of patients' councils.

Why go for a solution of sticking plasters and string when we could have a solution that is a powerful and well-constructed way forward? There is a considerable philosophical difference between the Government and those on these Benches, the Opposition Benches, many on the Cross Benches and, indeed, many on the Government's Benches. I would like to test the opinion of the House.

5.5 p.m.

On Question, Whether the said amendment (No. 40) shall be agreed to?

Their Lordships divided: Contents, 227; Not-Contents, 136.


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