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Lord Hunt of Kings Heath: My Lords, this brings us back to the happy days when we discussed the setting up of the new arrangements and the abolition of community health councils. I probably delight more in Gothic architecture than the noble Lord, Lord Clement-Jones, and I remain convinced that the proposals and the new structure will produce a greater scale of patient involvement and more effective handling of patient complaints than we ever had from community health councils. The evidence is that, over 30 years, some did excellent work, while others did not. I remain convinced that the establishment of patients' forums and of powers of independent advocacy will lead to a stronger, more user-friendly NHS.
The noble Earl, Lord Howe, and the noble Lord, Lord Clement-Jones, mentioned statements made by Ministers, including me, during the passage of the Act that set up the new arrangements. Those statements were made in good faith. It was my firm intention that the arrangements would be established in the way that I described. I regret that, as it turned out, the arrangements were, unfortunately, not made in time. I apologise to noble Lords for that and accept any responsibility that I must take for that situation. There was no malevolence involved. The task was great, and the commission was slow to get off the ground. I suspect that it spent too much time talking to the
department about money rather than getting on with the job. The commission must also share some responsibility.The question now is how we ensure that the new arrangements are effected as efficiently as possible. I share some of the concerns about the performance of the commission. Reports have reached me from the health service of a certain inflexibility of approach. I regret that. Like the noble Lord, Lord Clement-Jones, I wonder why, for instance, SI 2003/2124 says that the patients' forums "shall have regard to" the advice of the commission. The commission has an important role to play in ensuring and reviewing the performance of each patients' forum, but it is not there to manage the patients' forums. They are not local branches of the commission. It is important that they are seen to be independent. I give notice that I shall return to the matter, if I detect signs that the commission is seeking to have too much influence on the activities of individual patients' forums.
On the question of local network providers, I do not think that the principle is unreasonable. It was a good decision by the commission to recognise that, given the huge number of people to be appointed, using local providers seemed sensible. However, those local providers must have local knowledge. They have a great responsibility to ensure that the people appointed to patients' forums are up to the job. I worry about those who provide the service but are not based in the locality for which the patients' forum is being appointed. I hope that my noble friend might take that message back to the commission.
I have two or three issues to raise. The first is that it was always the intention that patients' forums would appoint one of their number to be a non-executive on the board of NHS trusts. Word reaches me that that has been put into abeyance. I would be grateful if my noble friend could tell me the position on that. I always thought it to be a very important provision that patients' forums would have that direct connection with the board of each NHS trust and primary care trust.
My second question is about foundation trusts. I suspect that the noble Lord, Lord Clement-Jones, for one, will not agree with me. We are discussing legislation that would not require a foundation trust to appoint a patients' forum. Yet word reaches me that the commission, none the less, is insisting that those NHS trusts which are going forward as applicants are establishing patients' forums for those trusts. The noble Lord will no doubt move an amendment on Report to require that but at the moment they are not required to do so. I suggest to the commission that, surely, there is room for some flexibility in relation to the first wave of foundation trusts. Surely they should hold off the appointment of those patients' forums until the matter has been decided by Parliament.
Parliamentary involvement brings me to another issue. In the Bill, the Act and the regulations, there are references to patients' forums, not to patient and public involvement forums. I ask my noble friend: why are these organisations to be called patient and public
involvement forums? That may be a minor point, but as my noble friend knows, I have raised it in relation to the Health and Social Care (Community Health and Standards) Bill where governing bodies are named as governing bodies. Yet my good friends in many applicant foundation trusts have produced consultation documents which refer to them as member councils.Either Parliament is here to determine what happens in the NHS or it is not. If Parliament determines that governing bodies are called governing bodies, it is not for the NHS or the department to suddenly say, "You can use another name". We did not establish patient and public involvement forums; we established patients' forums. My concern is that the commission has ordained that the name should be changed because it considers these local organisations to be branches of the national commission. That is not what the legislation intended. They are not local branches of the commission. The commission has an important role to play in ensuring that patients' forums are given the right advice and information and that they are enabled to do their job properly.
I get very concerned when the commission takes it upon itself to change wording that is in the legislation and seeks to over-manage what those patients' forums do. I do not hold my noble friend responsible for that at all. We set up the commission as an independent body; it is right that they should be independent. My goodness—the commission has a responsibility, too, to Parliament, to act in the way that Parliament intended and ordained.
8.2 p.m.
Baroness Masham of Ilton: My Lords, I should like to thank the noble Earl, Lord Howe, for giving your Lordships the chance to hear about the progress of setting up patients' forums and for his interesting speech. With the demolishing of community health councils, several of your Lordships, including myself, were concerned that there would not be an independent voice for patients and the public. Community health councils have closed down or are closing down before, it seems, the forums are set up and in place.
With the fragmentation and confusion to the public while the many different professional bodies are sorting themselves out, the patients' voice, which was supported by the CHCs, seems to be left in limbo. Because he has been a director of social services, I am sure that the noble Lord, Lord Warner, the Minister replying, will understand how confused and vulnerable patients or their relatives need support and information.
I hope that the noble Lord will give us some assurances today that suitable patient support bodies will be set up. CHCs were able to delay the closure of hospitals—in a way, rather like the House of Lords—giving the Government a chance to think again. CHCs could give the Secretary of State for Health a chance to listen to the public and think again. Will there be any body which will be able to do that now? What functions are the patients' forums to have?
It was of great concern to read this week about the epileptic children in Leicestershire. There seemed to be no mechanism for patients and health workers to get any satisfaction about the deplorable situation which was going on around them. No one seemed to want to listen. The Minister will no doubt say that he cannot comment on an individual case, but there were more than 600 young lives being damaged, having been given unnecessary drugs.
The noble Earl, Lord Howe, is to be congratulated on bringing up this matter. What is to be the membership and procedure of the patients' forums? Will they really represent patients? What will happen to all the information gathered over the years by CHCs? Is it to go into a bin? I should like to ask the Minister: why will foundation hospitals not need to have a forum? While other health bodies and hospitals will have them, will that not add to the present confusion? Are dentists to have forums?
I hope that the Minister will be able to take up the challenge and put in place a satisfactory, supportive and independent body which has time to help patients and advise managers on the needs of their communities. The present forums, as stated in the statutory instruments, do not seem satisfactory, as stated by your Lordships tonight. The criticism of CHCs was that they did not have enough teeth: these forums seem to have none.
8.6 p.m.
Lord Harris of Haringey: My Lords, I should declare an interest as a former director of the Association of Community Health Councils. However, on this occasion I have not had the benefit of sight of the interesting review and survey carried out by the association. None the less, that will not stop me commenting on the regulations.
I am grateful to the noble Earl, Lord Howe, for his commitment not to divide the House on these regulations because we must get on with establishing patients' forums. If the Prayer were to succeed, the consequence would be even more confusion, even more of a hiatus and even more of a gap than might otherwise be the case. Nevertheless, it is valuable to have an opportunity to discuss and debate some of the rather interesting issues that appear to be in the regulations.
I speak as someone who is not a lawyer, something of which I am inordinately proud. As a lay person, it seems that there are a number of issues in the regulations that it would be helpful for the Minister to clarify.
In SI 2123 on membership and procedure, for example, Regulation 2(4)(b) on membership seems to suggest that the commission may decide that all kinds of other bodies might be represented on the patients' forum. That could be very helpful, but it would be interesting to be given some sense of what Ministers have in mind here. It is self-evident that local authorities or parish councils within the area of a PCT are bodies that represent members of the public. Perhaps they might have a representative on the
forum. It could even be argued that Members of Parliament represent the people in the area and therefore might be allowed to send a member of their staff to become a member of the patients' forum. That is an interesting concept, but I am not sure whether it is quite what was in mind. Local neighbourhood watch schemes may even seek representation. What exactly does this part of the regulations intend to achieve?I turn to Regulation 10(5). The noble Lord, Lord Clement-Jones, drew attention to some of the issues surrounding meetings and proceedings. However, this regulation provides that the only meetings which must be held in public are those dealing with the items set out in paragraph (4). The much-maligned community health councils were subject to access to information provisions and there was a presumption that all meetings would take place in public. Given that such a body is considering the services being provided for local people, it is an important provision. I am not sure what is to be gained by allowing this potential restriction.
Regulation 8(1) and (2) address the central questions of funding and resources. I would welcome a clear statement from the Minister that Regulation 8(2) would apply even if staff are associated with supporting a patients' forum only on a part-time basis. Do they then come under the direction of the members? What will define the point at which they would stop being under the direction of the members and under the direction of someone else?
Regulation 2 of Statutory Instrument 2124 covers functions. I suspect that those lawyers drafting these regulations may have raised a number of issues which they did not intend—or perhaps they did intend to do so, in which case the aim may have been to make the job of the new patients' forums almost impossible to complete. Regulation 2(2), for example, states:
- "Where an NHS trust provides services under arrangements made by more than one Primary Care Trust, the Patients' Forums established . . . shall co-operate".
Regulation 3(1)(a) is excellent stuff, giving the PCT patients' forum the most impressive powers of entry and inspection. If I read it correctly, where it states,
- "any body mentioned in paragraph 3",
A similar point arises in respect of Regulation 5(1) on information. Subject to Regulation 6, which covers not disclosing personal information about individuals, it seems that any of the bodies referred to in Regulation 5(3) must produce for the patients' forum any information,
- "which appears to the Patients' Forum to be necessary".
However, the fundamental issue that must be addressed, and to which no doubt my noble friend on the Front Bench will respond, is that there are some real weaknesses in what is actually happening. The point has already been made about the commission's decision to contract out some of the staffing and administrative arrangements. I thought that the real strength behind establishing the Commission for Patient and Public Involvement is that it would enable common standards to be set, along with a common set of procedures and common arrangements across the country. That was a strength and would mark how these new arrangements would be better than those for the CHCs, but that has been thrown away. I would be interested in the Minister's views on that, and whether he thinks it is working well in the light of experience so far.
I turn to the question raised by the noble Lord, Lord Clement-Jones, and my noble friend Lord Hunt of Kings Heath. Both noble Lords are suspicious about the phrase "will have regard" to the points made by the commission. I am rather more sanguine about this because it seems to be precisely the role that the commission should play. Again, however, I would be interested to know the Minister's views about how that will apply and whether it is about achieving common standards and enabling common information from patients' forums in relation to their work to be made available.
My final point comes back to the question of funding. When the Bill passed through the House it was quite clear that what was being proposed could be a better system than previously existed, but it would always have been naive to assume that it could have been achieved on the same level of funding as CHCs or even on an enhanced level of funding. The messages I am getting from all around the country is that an attempt is being made to do this on the cheap. I will be interested to hear from the Minister, not so much about the costs of winding up and start up but about the real, expected resources that will be available for
patients' forums in the future and, again, my noble friend's judgment of whether they will be sufficient to enable the patients' forums to do the job that the House and the public expect them to do.8.15 p.m.
Lord Warner: My Lords, I am grateful to the noble Earl for giving the House an opportunity to debate this issue. After listening to the speeches, I have a slight sense of being someone who has blundered into a reunion party without having paid his dues. I shall do my best to earn my entrance fee. I was quite touched by the suggestion of the noble Lord, Lord Clement-Jones, that I might have something of the night about me.
Before responding to the points raised by noble Lords, perhaps I may start by paying tribute to the staff and members of CHCs for all that they have contributed over the years to protect and promote the interests of patients. None has done so more than my noble friend Lord Harris, who made a typically robust contribution. He will not be surprised to hear that I shall not be able to answer all his detailed questions tonight, but where I do not pick up on points I shall reply to him. I was grateful for his statesmanlike approach in encouraging us to think about the future rather than dwell too much on the past.
I recognise that the noble Earl, Lord Howe, and the noble Lord, Lord Clement-Jones, have made great contributions in trying to improve the arrangements we have in place for patients. I am grateful that I have been found personally not guilty and for the fair-minded tone of many of the noble Earl's comments.
I accept that he and others have reservations about the process by which we have reached the present position. But we have a new structure in place which comprises 570 patient and public involvement forums—we can discuss later whether that is the right title—serviced by 68 local network providers. We are reliably assured by the strategic health authorities that patient advice liaison services now cover 98 per cent of NHS trusts and PCTs. There is a new regional independent complaints advocacy service offering support across the whole of England to those who wish to complain. It may well be that an easier road to reform could have been taken, but we are where we are and it is important that we look to the future as well as thinking about what went on in the past.
I have listened to the comments made about the commission. We should recognise that a huge effort has been made in the past 10 months by the Commission for Patient and Public Involvement in Health and others to put the new arrangements in place and that there are some good early signs as well as problems. We have to give these new arrangements a chance to flourish. Certainly having been a change manager in the public sector in a number of areas, I fully recognise that transition is never easy. In the transitions in which I have been involved, I have observed that there is a tendency to don rose-tinted glasses about the past and to be suspicious about the future. I am not making accusations, but there is a tendency somehow to see the past as a little better than it might have been.
A number of noble Lords referred to the issue of money. I do not have detailed evidence of the cost of the transition. What I can say—I hope that noble Lords will find this reassuring—is that the money spent on patient and public involvement last year was around £23 million and we are expecting to spend a little more than £35 million this year. So a penny-pinching approach is not being adopted in this area. I acknowledge that that does not deal totally with the issue of whether in the past people would have spent the extra money in this particular way, but we are certainly not doing this on a wing and a prayer. We are certainly putting in resources to make it work effectively.
Noble Lords have raised a number of issues with which I shall attempt to deal. I would like to deal head-on with the idea and the setting up of local network providers. While acknowledging that this was not the Government's original idea, it is possible to see the commission as having been rather creative and innovative. It is also possible to see this as a genuine effort to work with and involve the voluntary and community sectors more effectively. Given my background, I have a lot of sympathy with that approach.
Our job in the department—I do not want to distance it from the commission—is to ensure that the commission carries out its functions within the scope of the legislation. The local network providers' approach does this, even though it is probably not the approach people would have thought would emerge when this was being discussed at an earlier stage. It is different from the Government's original thought that the commission would employ staff locally, but we have to respect its independence. It has produced an alternative approach of achieving its main goal, and we have to give that a chance to work before we rush to criticise.
It is worth bearing in mind that in a 10-month period the commission has managed to get in place this series of networks by awarding 140 contracts by 1st September. That is a very considerable achievement. Network providers will undoubtedly work differently from the staff support arrangements that were provided to CHCs. But not all CHC arrangements were universally popular. There were some great success stories but there were some areas where things did not work quite as well, and we must bear that in mind.
Staff of the local network providers may support more than one forum. That does not mean that the forums will be in any way less supported than CHCs have been; the approach can encourage forums to work with other forums where they share a network adviser, something that people were concerned about in the debate. They can work to promote the sharing of ideas between forums. There will be local network providers which have an overview about groups of forums and the way in which they are working.
I detected, once or twice, a kind of enthusiasm for a traditional public sector committee structure, and a feeling that something was not quite right in these
arrangements. It is fair to say that we do not necessarily want all patients' forums to work like old-style committees, with a rather static secretariat support. We want them to be flexible; we want them to use modern technology to generate and sustain interest.We have been rather programmed—rather institutionalised—when it comes to always having a chair, but we think that should be left to local forums. I am sure that the noble Lord, Lord Clement-Jones, does not like me even implying that he might be a bit fuddy-duddy about this, but we want to leave this to local decision-making. From time to time I am accused of being one of the great centralisers, but we are trying to devolve responsibility down to the local level. The local network providers can provide services by making more use of telephone and Internet services and disseminating good practice information. I mention these points to show that there is another approach and another point of view.
Let me turn to the specific points raised. On one-stop shops, local providers will provide support to PCT forums to carry out this role. There has been no change of heart; the commission is committed to one-stop shops. Rome was not built in a day, we have not got there yet, but there is no backtracking on that issue, as I understand it.
Why do patients forums have to have regard to commission directions? One criticism made of CHCs was that there was unevenness of standards across the country. That provides for the commission to ensure that standards are adhered to and there is greater consistency across the country—consistent with a fair degree of local devolution. One wants to be able to ensure that most parts of the country receive a consistently good and supportive service.
My noble friend Lord Hunt became very concerned about whether the commission has changed the name agreed by Parliament. One can argue that there is something rather respectable about patient and public involvement. The commission has used its own title in effect to brand that work. I am not versed in the background to the issue. I do not promise to change things, but I shall reconsider the matter so that I, at least, understand it. I shall return to the issue of how I might communicate with noble Lords after the debate.
The policy on patients forum members as NEDs has not been changed. We are agreeing a timescale and will amend membership later next year. The regional offices are trying to ensure that local network providers cover adequately the country as a whole, which raised some concern.
I share the views of the noble Baroness, Lady Masham, on vulnerable people. I cannot comment on the tragedy of epilepsy that she raised, although I can understand her concerns.
A question was raised about why there was no mention of prisons in the regulations. There is no need for that; from next April, healthcare in prisons will begin to be commissioned by primary care trusts and, as such, will be a service that can be monitored and
reviewed by patients forums. There is no bar to entry. Arrangements will have to be agreed with the Prison Service on the way in which prisons are entered, but there is no intention to exclude prisons in any way.The primary legislation does not give rights of entry to patients forums in respect of care provided in the private sector, but we recognise that, increasingly, care is provided outside NHS settings. We shall be issuing directions to primary care trusts requiring contracts that they have with the independent sector to cover arrangements for dealing with patients forums.
Some noble Lords expressed concern about whether PALS have adequate coverage. As I said earlier, we are assured that 98 per cent coverage of PALS is in place.
Much concern was expressed about whether the Independent Complaints Advocacy Service was answering the phone adequately and properly. Such services are often difficult in the early days. However, our understanding is that, although the service was very busy in the early days, things are working much better now. Demand has stabilised and the phones are being answered reasonably. However, I shall check again on that to reassure noble Lords.
I do not want to go over future ground. We shall come back to patients forums and foundation trusts in the debates on the Bill, and I have given a commitment to consider again some of the issues on those matters. The debate has been useful, and I am grateful to noble Lords for their contributions. I have not been able to respond to all the points that were made, but I shall write to noble Lords about many of the points I was unable to deal with in detail.
We have a new structure in place, and it is important that it should be allowed to work effectively to improve patient and public involvement in the NHS. I am sure that the commission will heed the concerns and criticisms voiced by noble Lords. Without in any way wishing to sound as if I were reverting to a traditional centralism, I shall ensure that the commission is aware of the concerns that have been expressed. I will want to seek some reassurances from it on some points that noble Lords have raised.
Given the work that the House has done in this sphere, I think it fair that noble Lords should know and be confident about how we are moving forward. However, I hope that we can avoid rushing to judgment on how well the new arrangements will work. The commission knows that it will be judged by results, and we have to give it time to demonstrate those results. I hope that we do not dwell too much on the past. I think that we can put that past behind us. We need to give these new arrangements a chance to show their worth and what they can do. With that reassurance, I hope that we can successfully move forward.
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