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Lord Clement-Jones: My Lords, I always like to think of this stage of the Bill as the "penalty shoot-out stage"— that is the analogy which seems appropriate in the current circumstances. I believe, like the noble Earl, Lord Howe, that a considerable victory has been achieved by local health campaigners, by ACHCEW and by CHCs in securing from the Government the considerable concessions that the Minister has put forward today.

It is worth reminding ourselves of the status of the proposals at the beginning of this process, some two years ago. The proposals had all the defects outlined by the noble Earl, Lord Howe. There was no national commission or national body at all. There were no proposals for an independent complaints advocacy service. Patients forums were not to be independent, but were to be supported by staff employed by the very trusts that they monitored.

During the passage of the NHS reform Bill, even as it stands, the following improvements have been secured. The independence of patients forums has been protected by channelling their funding through the commission as opposed to the trusts they monitor. Patients forums have been given the power to refer issues of concern to overview and scrutiny committees. They will be able to refer issues of concern to the commission. They will be able to make reports and representations to people and bodies as they see fit rather than being restricted. The range of issues which patients forums will monitor and report upon have been widened. They will also monitor how well NHS bodies involve patients and the public and will make recommendations.

A special role for PCT forums is now being proposed which has the potential to provide the integration for patients forums and the new overview and scrutiny which was previously lacking. Staff will be provided, and will be accountable to PCT forums at the local level rather than there being detached, staff-only groups with no local lines of accountability. I could continue. There have been a significant number of concessions. We have moved some distance since the early days of the first proposals almost two years ago.

There have been almost two years of wrangling, and the fundamentals of what it takes to have an effective patient voice—independent, community-based, with real accountability, integration and real powers—have finally emerged. By taking the approach that the Government tried to take, of imposing a model of patient involvement without involving patient representatives, the Government have, by their own failure to involve, demonstrated how essential proper

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dialogue is. The Secretary of State delivered his initial off-the-cuff diktat in the NHS Plan in July 2000, announcing the abolition of CHCs and their replacement with a string of fragmented talking-shops, each with its own incomprehensible set of initials—PALS, ILAFs, OSCs, etc. We have come some considerable distance.

Yet, ironically, we now know, despite the length of time that it has taken us to get there, as a result of the Wanless report, that the success and probably the survival of the NHS is dependent on,


    "a dramatic improvement in public engagement ... leading to a more effective partnership between the public and the healthcare system".

The report states that accountability is key to this:


    "in devolving greater responsibility to the local level there must be strong arrangements for delivering high accountability",

making the NHS more responsive and ensuring the right balance between centrally set targets and sensitivity to local services. We now have a real chance of achieving that.

I fully support the noble Earl, Lord Howe, in the assurances that he sought. Before giving a final blessing to these proposals, there are further key issues on which the Government need to give assurances. First, as regards independence, given the crucial importance of strong local accountability in terms of the NHS, it is important to evaluate these latest plans for independence, without which there can be no real accountability. If questions are asked by an organisation of the NHS on behalf of patients, the answers will be credible and enhance accountability only if that organisation is, and is seen to be, independent.

There remains a real risk that patients forums will appear to be under the thumb of trust chief executives, who themselves will be under the thumb of the Secretary of State. There is a serious likelihood that patients forums will not be perceived as independent by the public, especially if they have an NHS-type name, an NHS location and a seat on the board of the organisation that they are supposed to be monitoring.

There is a danger in patients forums being based, for instance, in trust premises. Will the Government confirm that they will make use of the existing 184 CHC premises, many of which are in high street locations and have been refurbished in recent years? In London alone, some 2 million has been spent on refurbishing these offices. What will, for instance, the patients forum non-executive director do if his patients forum asks the commission to take legal action against his trust as a last resort when its actions are unlawful? There needs to be some separation.

As regards the name, of course, that is a valuable sign of independence. I know that the Minister is a keen reader of the Health Service Journal. I wonder whether he has seen the suggestion by Dr Richard Taylor in this week's edition. He suggests what I think is a very sensible name for the new forums. After all, let us face it, "PCTPF", if spelt out, would be a very long name. Dr Richard Taylor proposed the term

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"citizens health councils", which seems an admirable suggestion. It should certainly be considered by the Minister.

I turn to continuity. In bringing into existence the new structures, CHC staff and members can provide continuity. I very much hope that the Minister will give an assurance that there will be a fair and open appointments process for both staff and members and that every effort will be made to make use of existing skills and commitment in the new structures.

As for transitional provisions, what will happen to consultations which are ongoing at the date of abolition and to complaints for which assistance is being provided by a CHC at that date?

On configuration, there is the issue of and concern about the lack of coterminosity between overview and scrutiny and the new PCT patients forums. As well as agreeing to "take a lead" on certain issues on behalf of other PCT forums in an area—the model that the Minister outlined—another option would be for patients forums to exercise their overarching functions jointly in relation to, for example, a base for staff to support all the forums and do outreach work; the provision and commissioning of ICAS; and overseeing commissioning and public health issues. This would allow individual PCT forums to get on with the monitoring of individual PCTs' services in the same way that patients forums do for other trusts, a role which might otherwise be diluted by the other functions of PCT forums. It might also help to avoid some of the conflicts of interest that these arrangements will create.

Mr David Lammy, the new Minister, was kind enough to write to my honourable friend Dr Evan Harris setting out some of the assurances which my honourable friend sought on the new amendments. In his letter, the Minister said that there is a duty on NHS bodies to consult OSCs on substantial variations and developments. As I understand it, however, that is dependent on regulations being made to define what those services are. I certainly have not had any draft regulations. I should therefore be grateful if, in his reply, the Minister will clarify the status and ambit of those regulations.

Ministers have been uncharacteristically coy in discussing what resources will be available for the new patient and public involvement structure. We are continuously told that we must await the outcome of the spending review. However, we have been waiting two years for these sets of proposals. Ministers must have an idea of the resources that will be required. How do we know that the resources allocated will be sufficient to fulfil the many and complex functions of the patients forums and the OSCs and so on? Having agreed these proposals in the other place and in this House, it would be extremely galling to find that the resources were not available to implement the model with which we were prepared to live.

There is a similarly vague approach to the funding of PALS. Some trusts are not establishing them at all this year for lack of funds. We certainly do not wish that to be mirrored in the funding for PCT patients forums.

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My final point is on the abolition of the Association of Community Health Councils for England and Wales. The Minister has given assurances that CHCs themselves will not be abolished until the new system is up and running, but it would be helpful if he could give an assurance on the future of ACHCEW itself. Will he confirm that ACHCEW will not be abolished ahead of CHC abolition? He might wish to argue that, once the new Commission for Patient and Public Involvement in Health has been appointed, there is no need for another national body. Clearly, however, ACHCEW needs to exist to represent and provide services to CHCs as long as they are in existence.

In many ways, we would have preferred to retain CHCs and the clarity of the structure of patients councils proposed in the original amendments. However, we believe that we have come as close as we possibly can to the model which we on these Benches proposed originally. Like the noble Earl, Lord Howe, we believe that, with the right assurance, this is a satisfactory and workable model. We will not stand in the way of the amendments proposed by the Government. I very much look forward to hearing the Minister's reply, and I thank him in advance for the flexibility displayed in this part of the Bill.

6.30 p.m.

Lord Harris of Haringey: My Lords, the noble Lord, Lord Clement-Jones, described this as the "penalty shoot-out stage" of legislation, but given that we will probably have no Divisions at all, I suspect that it is more like the golden goal. I think it was Harold Wilson who said that a week in politics is a long time, but it is now 98 weeks, I think, since the Government first said they wished to do away with CHCs. However, the proposals had been made before. The noble Lord, Lord Jenkin of Roding—who spoke earlier but has left the Chamber—made similar proposals 20 years earlier. They were strongly opposed, however, and ultimately dropped.

What is interesting about the process of the past 98 weeks is the extent to which the Government have shifted their position and listened to concerns about the original, cack-handed set of proposals. I am pleased that the Government have listened to the arguments which I advanced in the House on patients forums attached to PCTs. It is essential that the one-stop shop—which is what I think we are creating—should be seen as locality based rather than institution based. I am also pleased that we have had various assurances on the independence of both the membership and the staffing arrangements of patients forums. The Minister's comments today have reinforced that point.

An added bonus in the later arrangements is the way in which the advocacy arrangements have been much more clearly integrated into the new structure. I believe that the current proposals offer clarity at local level. Previously, there was no clarity over how individual members of the public would relate to the structure. The structure is now undeniably coherent.

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Given that neither clarity nor coherence was at all visible in earlier representations, that is clearly substantial progress.

It would be helpful, however, if my noble friend the Minister could give more indication of the resource levels that the Government think appropriate to make the new structure effective. It is possible, for example, that one isolated staff member from the Commission for Patient and Public Involvement in Health could wind up in a room dealing with individual patients forums for PCT areas. Such a structure would clearly not work and would represent less investment in the structure than is made now. What resource levels are envisaged? What resources do the Government think necessary to make the structure work? I appreciate that we are still awaiting the outcome of the spending review, but some guidance on the point would be very helpful.

Another matter that should have been dealt with in our many discussions—perhaps it was but I missed it—is a reassurance that patients forums will elect their own officers, such as their chairs and vice-chairs. It would be useful if my noble friend the Minister could confirm that those officials will be elected and not appointed by the commission. It would also be helpful if he could clarify at what stage the commission will be put in place, patients forums properly established and the appointments process started. We should like some idea of the timetable and how it relates to the winding down of CHCs and the association, which are currently withering on the vine, given that both staff and members are looking to the future and moving elsewhere. I hope that my noble friend can give some indication on those points.

I hope that all Members of your Lordships' House will agree that we now have a system which will act robustly in the interests of the public and patients. The Government have demonstrated a clear desire to listen to the arguments put forward on all sides of the House and outside Parliament.


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