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(a) the functions of that Patients' Forum are to be taken to include those functions, but
(b) the Patients' Forum may not make any arrangements with itself under this section."

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    (6) In this section—


"carer" and "patient" have the same meaning as in section 15,
"independent advocacy services" means services provided under section 19A of the 1977 Act (independent advocacy services),
"relevant overview and scrutiny committee" has the same meaning as in section 15."
16JPage 24, line 5, at end insert—


    "( ) The regulations must also secure that the members of a Patients' Forum established for a Primary Care Trust also include—


(a) at least one member of the Patients' Forum established for each NHS trust all or most of whose hospitals, establishments and facilities are situated in the area of the Primary Care Trust and
(b) if it appears to the Commission for Patient and Public Involvement in Health that there is a body which represents members of the public in the Primary Care Trust's area in matters relating to their health, at least one person who is a member or representative of that body (or, if there is more than one such body, of any of those bodies)."
16KPage 24, line 20, at end insert "(in addition to its function of appointing members of Patients' Forums)"
16LPage 24, line 34, after "providing" insert "staff to Patients, Forums established for Primary Care Trusts, and advice and"
16MPage 24, line 42 leave out "and"
16NPage 24, line 42, at end insert ", and making recommendations to them about how to improve their performance against those standards"

16OPage 24, line 43, leave out paragraph (g)
16PPage 25, line 10, at end insert—


    "( ) It is also the function of the Commission—


(a) to review the annual reports of Patients, Forums made under section 17, and
(b) to make, to the Secretary of State or to such other persons or bodies as the Commission thinks fit such reports or recommendations as the Commission thinks fit concerning any matters arising from those annual reports."
16QPage 25, line 11, leave out subsection (5)
16RPage 25, line 37, leave out subsection (12)

Lord Hunt of Kings Heath: My Lords, I beg to move that the House do not insist on their Amendments Nos. 6 to 16 to which the Commons have disagreed and do agree with the Commons in their Amendments Nos. 16A to 16R in lieu thereof.

We are coming to the end of what has been a long and interesting journey to strengthen patient and public involvement in the health service. From the NHS Plan, published in July 2000, through to the Health and Social Care Act 2001 and now to the Bill, we have reached a position that I can truly describe as one that is as good as it gets.

My ministerial colleagues and I—and our officials—have been in discussion with many stakeholders during the past year and a half to ensure that we develop the best possible set of arrangements. At the end of the day, that has been an extremely constructive process. Although we have not agreed with all of the views expressed to us, all have played a part in fine-tuning the system that we now put before your Lordships.

13 Jun 2002 : Column 420

Patients councils were, I think, the turning point. The patients council amendments voted into the Bill last month were not welcomed by the Government because of our concern that they would add another tier to the arrangements that we proposed. But the Government always said that much of the purpose of patients councils fits with our view of a strong and comprehensive public and patient involvement system. We have attempted to ensure that the system builds on the strengths of patients councils without weakening the overall structure.

The effect of Amendments Nos. 16A to 16R is to give to primary care trust patients forums the functions that we had previously envisaged for the local offices of the Commission for Patient and Public Involvement in Health. Essentially, that means that the commission will appoint staff to every primary care trust forum in England. On a day to day basis, the staff of the forum will of course be accountable to the members of the primary care trust forum.

That will ensure that a robust process is in place for the work of the staff to be informed by local people and that there is real accountability to local people. It will then be the job of the primary care trust forum to promote the involvement of the local community—in particular, disadvantaged patients and typically excluded groups—in local decision-making processes, and to promote the views of people in their area to local decision-makers and in particular to their local overview and scrutiny committee.

In addition—and this where the key strengths of patients councils have been picked up—the staff of the PCT forums will be able both to provide and to commission advocacy support. As commissioners, primary care trust forums will also be able to commission additional support as local needs determine—for example, specialist services such as bi-lingual advocacy. The intention is to enable primary care trust forums to be the core providers of independent advocacy services but to retain the flexibility to ensure a comprehensive service that fits local needs.

It will also be the responsibility of the primary care trust forum to act as a kind of one-stop shop for local people, providing them with advice and information about how they can get involved locally and how to make a complaint. The amendment is drafted in a way that enables the primary care trust forum to provide advice and information about making complaints about the services provided and practices and policies adopted by the NHS. They will also be responsible locally for monitoring the arrangements that local NHS bodies have in place to fulfil their duty to involve and make arrangements to consult the public about changes to services. We intend that duty to come into effect later this year.

We have also amended the composition of primary care trust patients forums. They will now include members of local interest groups that represent the public on issues that affect their health. An example may be a residents group concerned about the erection of a local mobile phone mast. They will also include a

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member of the NHS trust forums in their area so that there is an in-built mechanism for forums to share ideas and agree areas of mutual concern.

It is extremely significant that we are placing all of those responsibilities with the primary care trust patients forum. That means that we have shifted the power base of the new system for patient and public involvement to local communities. We will be removing the middle layer of our original proposals—the local office of the commission. However, we recognise that there needs to be a way for forums to come together across an agreed area. We have therefore strengthened the provisions in the Bill about the circumstances in which forums should work together. Those will be made explicit in secondary legislation.

I know that concern has been expressed about forums duplicating effort and resources. We intend to involve stakeholders fully in the development of the working arrangements for forums. We will encourage partnership arrangements to be developed whereby one primary care trust forum takes a lead on a specific issue; for example, the commissioning of specialist services that covers several primary care trusts, or the provision of independent advocacy services. Another example might be a primary care trust forum taking the lead in collecting and analysing the data relating to a specific cross-boundary scrutiny exercise being undertaken by a social service authority overview and scrutiny committee.

The important issue to stress is that those arrangements will need to be developed through effective communication and will result from the continuous development of partnership working right across the system. At national level, the commission will perform the critical role of developing best practice and providing resource material on how to ensure that effective practices and outcomes are achieved. It is important to remember that patients forums are independent bodies. I stress that to your Lordships. It will be up to forum members to decide the exact nature of their collaboration. The regulations to be prescribed will provide the structure for that collaboration and it will be vital that we test out real-life scenarios in the formulation of those regulations.

We are also amending the provisions that apply to both primary care trust and National Health Service trust patients forums. We are making it explicit in the Bill that patients forums will not only have a role in monitoring and reviewing services that a trust provides but will also be able to identify gaps in service provision and make reports and recommendations to trusts about them. Trusts will have to publish forum recommendations in their annual patients' prospectus, together with the action that they are to take as a result, further ensuring that forums have real influence.

We have also made explicit the width of the powers for forums to be able to refer matters not just to overview and scrutiny committees, as previous amendments provided, but also to the commission and indeed to any other person or body that the forums

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themselves deem appropriate. So we have taken away some of the functions envisaged for the commission at national level that would have been carried out in its local offices. We have also strengthened the functions that it will carry out at a national level.

On top of its job of setting and monitoring quality standards for all patients forums and providers of independent complaints advocacy, the commission will now also be able to make recommendations to them about how to improve their performance—a point that my noble friend Lord Harris has consistently raised during the passage not only of the Bill but of the Health and Social Care Act 2001. The important thing is that that will ensure that, wherever they are, the public and the NHS can be assured of consistently high standards for patients forums and providers of independent advocacy.

We have listened to parliamentarians and to stakeholders—in particular to the Association of Community Health Councils for England and Wales and community health councils—in relation to the often-cited need for a "casualty watch" exercise. My view, and that of the Government, is that the key thing about the commission's responsibility is that it should be able to undertake national reviews of patient experience data on issues that appear to it to be of national concern. That may include waiting in accident and emergency departments.

We propose an amendment to the commission's functions to provide for it to carry out a systematic review of the data contained in forums' annual reports and, on the basis of them, to identify what key issues warrant a national review. We wish the commission to facilitate the co-ordination of forum activity on a specific theme and then to make reports to the Secretary of State and any other person or body on the outcomes of such a review.

To summarise, in every NHS trust and primary care trust there will be a patient advice and liaison service ensuring that concerns are dealt with before they become a serious problem. There will also be a patients forum ensuring that locally the public have a vehicle to express their views about matters relating to health and that this will monitor and review local services. In every primary care trust forum there will be staff who will commission or provide independent support to help individuals to make a complaint, work to empower their local population to express their views about health issues that matter to them, and provide a one-stop service by providing advice and information to the public about public involvement and complaints processes.

Nationally, the Commission for Patient and Public Involvement in Health will set quality standards for the work of patients forums and independent advocacy, and performance manage them in relation to those standards. The commission will submit reports to the Secretary of State on how the whole patient and public involvement system is working. Alongside that we have the vital and important role of local authority overview and scrutiny committees.

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I have always said that, ultimately, the test of these proposals is whether they will work more effectively; whether they will give individual patients more clout than they have at the moment. I have no hesitation whatever in saying that the proposals before your Lordships' House today will do that. They have been enhanced and improved by our debates and I commend them to the House.

Moved, that the House do not insist on their Amendments Nos. 6 to 16 to which the Commons have disagreed and do agree with the Commons in their Amendments Nos. 16A to 16R in lieu thereof.—(Lord Hunt of Kings Heath.)

6.15 p.m.

Earl Howe: My Lords, this is the end of a long road. The destination we have reached is perhaps not the one that either the Minister or I expected we would arrive at when we started out on the Bill—or, indeed, the one that we anticipated before the last general election when we debated the earlier proposals set out in the Health and Social Care Bill.

We have before us an organisational structure for patient and public involvement that, happily, bears little relation to the one which the Government put before us only a few months ago. Those first proposals were, in my view, so very deficient, so very much weaker than the system that they purported to improve upon, that I had no hesitation in resisting them. We believed—and still do believe—that the Government were wrong to abandon so readily the model of community health councils. I make no apology at all for the position that we on these Benches took in arguing for their retention and reform.

Nevertheless, we are where we are, and I must now acknowledge that the Government have moved a considerable distance. The deficiencies and weaknesses that we identified in their original proposals were ones that we attempted to address in the amendments that were carried in your Lordships' House, creating patients councils.

It is worth reminding ourselves of what the original Bill gave us. It gave us a fragmented structure of patient representation, without a real voice, without proper independence and with a narrow remit and focus. It made no attempt to replicate the one-stop shop; it made no attempt to allow for a lay overview of the NHS in a geographic area; it created a national commission, but one with hardly any responsibility for real patient issues, only for issues relating to processes and structures. For my part, in the absence of CHCs, I should dearly have liked to have seen patients' councils become a reality because they have the potential for rectifying the vast majority of the failings that I have enumerated. I believe that the Government's objections to them are overdone and, in large measure, illusory.

Nevertheless, this House asked the other place to think again, and the other place has done so—not simply by deleting our amendments but by inserting others in their place. The new amendments to which the Minister has spoken address a great many of the

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key points of principle that were previously at issue between us. I am delighted by that. I do not believe that having secured those points of principle it would be constructive for the House to cling doggedly to the concept of patients' councils and insist on our previous amendments.

This is not a debate about achieving the best structures; it is a debate about how we can enable patients and the public to have their views listened to and represented within the NHS. Any alternative to patients' councils needs to be judged against four key benchmarks: the level of independence enjoyed by the new bodies; their degree of integration; the extent to which they are community led and accountable; and whether they have a real measure of power.

The Government's new model, which is light years away from their first one, can probably be made to work satisfactorily. It is less elegant than CHCs or patients' councils—it will certainly be more expensive—but, importantly, the key principles for which we have been consistently pressing are there.

Having said that, and having made the boast that I understand these new proposals, there are a number of questions that I should be grateful if the Minister could answer. Some are of considerable importance for the way in which the new structures will work.

The first relates to the Commission for Patient and Public Involvement and its power to appoint members of patients forums. How long does the Minister estimate it will take to appoint the 7,500 or so members of patients forums? It will be a lengthy process. How much will the process of appointment cost? The Secretary of State retains a power of direction over the commission. Can the Minister give an indication of the kind of directions that are likely to be issued by the Secretary of State? I hope that he will not mind if I say that the ability of the Department of Health to influence the way in which the commission performance manages patient and public involvement at ground level should be controlled—and controlled in a way such as to avoid direct interference or, indeed, gagging.

As to the statutory powers of the commission to initiate legal action where that is appropriate, will the commission definitely have the locus to take legal action, if it needs to, on local issues referred to it by patients forums?

I am delighted that patients forums will now have a power of referral to the commission. Can the Minister comment on the status of the patients forum non-executive director on a trust board where, let us suppose, a legal action is initiated against that trust by the commission? The director would find himself or herself with an immediate conflict of interests. How is that to be dealt with?

Another conflict would arise with confidential business. A patients forum non-executive director would not be able to report back to the patients forum on business that was confidential. CHC members who attend trust boards have the right to disclose confidential information obtained as speaking observers where the public interest favours disclosure.

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Am I correct in thinking that under these new arrangements this safety valve in terms of accountability will cease? The whole notion of patients forum non-executive directors raises, to my mind, quite serious difficulties relating to corporate responsibility and governance.

The government amendments extend the remit of patients forums to cover the whole range of health services, not only those being delivered by the trust. I welcome that. Can the Minister confirm that patients forums will now be a one-stop shop on all points of concern to the public and not only complaints? Does subsection (1)(b) of the proposed new clause in Amendment No. 16I provide a one-stop shop for any general concerns that the public might have—for example, on policy issues or contested reconfigurations, and not simply for complaints about local services?

I welcome the new power of patients forums to make representations and referrals as they think fit to whomsoever they think fit about matters arising in the course of their functions. Will the Minister confirm that patients forums will be able to make referrals on health inequalities as well as on straightforward service issues?

I note in passing that there is no obligation on any body, including the Secretary of State or an overview and scrutiny committee, to respond to a referral made to it. Can the Minister give any reassurance on that lacuna? I am sure that he recognises that accountability is a two-way street and that he wishes to see the process deliver such accountability.

Finally, perhaps I may ask the Minister about foundation trusts within the NHS. We are given to understand that foundation trusts may not be NHS trusts within the terms of the Bill. In view of that, what arrangements will they have for patient and public involvement, and how will this be performance managed to ensure consistency and equity?

The Secretary of State has been quoted as saying that he is looking at the potential for the direct election of patient representatives, implying that the system now under discussion will not necessarily apply to foundation trusts. How will their accountability to patients be guaranteed if they are outside the complex system of patient and public involvement that the Government are now setting up?

None of the changes made to the Bill will mean anything unless it is adequately resourced. Without an indication of the level of staffing and other resources, it is impossible to judge how robust the proposals really are. If the Minister cannot give an indication of that kind today, I hope that he can at least give an assurance that this point will be borne closely in mind during the current funding review.

It is probably right that we do not let this occasion pass without a mention of our old friend Mrs Archibald. In the absence of my noble friend Lady Cumberlege, who was the creator of this useful and ubiquitous lady, I believe we can say that Mrs Archibald will be better served by the revised

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arrangements for patient involvement than she would have been under the original Bill. They are clearer, and certainly less confusing, but most importantly they have the potential, if set up correctly, to be joined up. If that is a victory for this House—as I believe it is—it is also right for me to express my thanks to the Minister for his part in bringing these changes about. He has listened to our concerns, and the Bill is much the better for it.


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