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23 July 2007 : Column 577

She added:

Her worry about LINks, as presently imagined, was that,

She continued that she was worried that this focused on a process rather than on refining an outcome.

4.30 pm

I already had real concerns about all this, as did many members of forums who have contacted me separately and together in the past few weeks. But my concerns have been strengthened considerably during the past week. The Minister kindly sent all of us involved in the Second Reading debate the drafts of two guidance documents for the establishment of LINks. The first was the model contract specification and the second was a document that sets out,

I am grateful to the Minister for sending us this material, but the second document made me almost lose the will to live. It is, indeed, all about process—what it will be like—including a rather offensive list of what it will not be like. The document states:

and so on. That list is, rather, a suggestion that forums have not lived up to expectations and that they are somewhat like these theoretical groups that LINks are not to be.

The real clue lies in the statement that the detail of the powers of LINks will be provided in the future regulations that the Government intend to consult on in the autumn. There is no clarity, just the suggestion that,

We are then told:

according to local circumstances. There follows a series of diagrams from early adopters—Kensington and Chelsea, and Durham. While I could understand Kensington and Chelsea’s simple membership diagram and begin to comprehend its more complicated model of how it would work with no central hub membership, the Durham model left me wholly baffled. In each case, the text tells us that the models are under development. I am not surprised. This way of thinking

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is absurd. The first decision must be about the objectives, powers and duties of LINks. What are they to do? What must they do? What can they do? Only then should this discussion of process even begin.

This has seemed to me to show that the Department of Health is more concerned with process in this area than outcome and is more concerned with breaking down the present structure of patient forums than developing them and creating a smooth transition into LINks. It is not concerned about creating a huge cadre of disaffected volunteers, who will look at all this and ask, quite sensibly, what it really means. For those reasons and many others, I strongly support this group of amendments.

Lord Low of Dalston: I, too, support this group of amendments, particularly Amendment No. 238LF. I received an e-mail about the Bill at the weekend, which pointed out that as things stand, since local involvement networks have no independent legal personality, their members could be personally liable for their actions, even though they are discharging statutory functions. This contrasts sharply with the present position whereby patients’ forums are legal entities.

Amendment No. 238LF changes the definition of a LINk in Clause 223(2) from a person carrying on the activities specified in Clause 222(2) to,

Clause 222(1). The amendment, therefore, would change LINks from groups of persons coalescing around a particular function or set of functions to a corporate legal entity. I submit that this is a much more satisfactory situation for the members of these local involvement networks and I believe, therefore, that this constitutes an ungainsayable argument for inserting Amendment No. 238LF into the Bill.

Baroness Howe of Idlicote: I, too, would like to support the making of a LINk, if we are to have LINks in the way that has been suggested by the noble Earl, Lord Howe, and re-emphasised by my noble friend Lord Low. What really concerns us is that we have no real conception of what the future holds. The noble Baroness, Lady Neuberger, has spelt it out extremely well.

I have to admit that I have another worry. It seems extraordinary that this Bill has been going on for so long now in the background without coming to Parliament. The Commission for Patient and Public Involvement in Health has been extended about nine times since it began. That is a fairly extraordinary figure. We have heard from some of the earlier doctors that very good work has been going on with more or less the same members as exist in the forum. I find it really rather upsetting that, even if the time has come to say goodbye finally to the Commission for Patient and Public Involvement in Health, nobody has thanked it for the work that it has done. Considering it was set up and abolished almost at once, it was a pretty disturbing commission to have been in charge of and to have been on the staff of. I would like the Minister to take this opportunity to say something rather more positive than we have heard so far.



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There are obviously reasons for moving in this direction, particularly on the social care side, as I understand it, which cannot so easily be joined with the health side. I believe that the health side is rather bossy and dominant. It will take some persuading that we will have a sufficiently strong social care side for them to be on a par and in partnership; many other Bills put through by the Government rightly aimed to achieve partnerships at all social levels. I just wanted to say that, by way of a background to my concerns. I did not take part at Second Reading because of other commitments later in the day but I was there for most of the time and I have followed, as far as I can, what has been going on since.

Baroness Masham of Ilton: The House of Commons Select Committee on Health called LINks woolly. What Members of this House have said today bears out what they felt. Members of health forums have been treated very badly. These are volunteers. They need support, not putting down. Will members of LINks be treated any better? We need good public involvement in health. I hope that the Minister will comment on that.

Baroness Howarth of Breckland: I want to ask one or two questions. I apologise for not being able to take part on Second Reading. I, too, am bemused about this but could not have put the position more eruditely than did the noble Earl, Lord Howe; it is always a joy to listen to him but this afternoon was a particular joy.

My questions are about how ordinary people who will become part of LINks—or at least those whom the Government hope will become part of LINks—will understand what they are engaging in. I say that having talked to some ordinary folk who regretted the loss of their community health councils, but continued stalwartly to join patient forums—I declare an interest as a rather distant member of the St Thomas’s forum—and would like to continue to work in these areas. They do not understand two things, the first of which is about governance. How do these strange bodies, which are so ill defined, fit into the total governance structure of the health service? Do they have any power? Are they just sounding boards? What is their value? How will they be appreciated and understood? How will you get that message to ordinary people to maintain their interest?

Secondly, because of all this, I do not really understand what the objective is for the new groups. That may be my lack because I was not able to engage in Second Reading or listen to all of it, although I read a certain amount. I understood the community health councils; the Government may not have liked what some of those groups did in terms of challenging issues in the health service. I have begun to understand—just about—what the patient forums were doing. I cannot understand what LINks are going to do. I am afraid that, even after listening very carefully to the noble Earl, Lord Howe, who usually illuminates me, I still do not understand—probably because he does not know either—what the organisations, bodies or people will do. I would be grateful for clarification from the Minister. A great deal depends on this in relation to local involvement, particularly, as my noble friend Lady

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Howe said, if we are to try to engage people in understanding LINks in relation to social care, with which I have a strong connection. It would be a great help if local communities could understand LINks. If they cannot understand the structures, they will never understand the services.

The Parliamentary Under-Secretary of State, Department for Communities and Local Government (Baroness Andrews): I am tempted to welcome this new cast to Part 14 of the Bill. We have had a splendid time so far but we have an even better time in prospect.

I am challenged by the “enigma code” version of the Bill proposed by the noble Earl. I am happy to do what I can to decrypt the Bill. I hope to inspire noble Lords to have confidence in where we are and why we are there. We give additional information in the hope of clarifying and supporting people’s understanding. Given what has been said, it might be useful if I give a bit of background about why we have come up with this formulation.

The amendments explore our changes and why we made them, the relation between the host and the LINk and the form and function of what is planned. Those issues go to the heart of what we are trying to do. I understand what noble Lords are saying about the absence of a statement of objectives at the front of the Bill. We have that debate over and over again in the House; we had it recently on mental health.

4.45 pm

I refer noble Lords to the Minister’s foreword to Creating an Effective LINk, a draft document which has been circulated. It can be summed up very simply: the establishment of local involvement networks gives communities the chance to influence all health and social care services. Whether they are run by councils or the NHS, LINks will give citizens the chance to have their say in a much wider range of ways, which I will come to discuss later. It may be, for example, by investigation or commissioning reports that will be put together by a much wider range of participants than has ever been possible before, because of the extension to social care. It may be through the “enter and view” function, which is very clear in the Bill. It could be by gathering voices to exert greater influence on a particular decision in the local health service.

Part 14 is not a convenient afterthought; it is brought forward from a genuine conviction that there must be better and less exclusive and forbidding ways for people to exert influence over health and social care in all areas of communities and to become more involved in what matters most to them. The substance of Part 14 is to put forward those more extensive and inclusive ways of involving the widest range of people to influence and improve healthcare. This debate has a long history; noble Lords around the Chamber will have engaged in it.

I know that change is not comfortable; neither is acknowledging that what served once has been overtaken by different imperatives, but that is part of the debate that we are having. The first thing that I want to say, particularly to the noble Baronesses, Lady Masham and Lady Howe, is that I thank those who have served on patients’ forums for their work. The Minister thanks them in the foreword to the document; they have been

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thanked in different ways. Without their expertise and commitment, which have been built up and demonstrated, we would have a far worse health service. They have performed an extremely important function, so much so that we are determined that that expertise will not be lost, devalued or wasted. As I explained, as we go through the amendments, we want passionately to build on the best of what has been achieved and, indeed, to extend it.

It is important to stress that these requirements are in this Bill because they belong here. First, their new role in local government will go far beyond the notion of a traditional delivery service, taking local authorities to the threshold of a new role in which they will shape the whole local environment—the place in which people live, work and thrive. In terms of health, that is expressed first in the new duty that we propose for local authorities to put in place an independent structure to empower local people. Secondly, the Bill will enable services to work together in ways that have eluded us so far, closing gaps between social care and health in the design and delivery of services. Thirdly, the Bill breaks new ground in healthcare by finding a way to involve local people in providing services that go far beyond the interrogation of institutions, which is what the patients’ forum specialised in. They therefore go beyond the expertise of a small and dedicated group. The Bill goes into the wider community, across the entire patient journey and the experiences people have as part of that long journey.

I know that noble Lords are asking, “Why this Bill?” and “Why now?”. In the past five years, the landscape of healthcare has changed, and it continues to change. The institutions have changed; foundation trusts and primary care trusts have changed; the configuration of PCTs and the patterns of provision have changed. Healthcare is offered in different ways and places. Priorities have changed; people have changed. Patients have become far more used to choice and far more used to being heard. System regulation has become more sophisticated. We have the wherewithal, capacity and vision to join up services. The health service role of overview and scrutiny committees has changed. I could go on.

Just as the system for health and social care has changed, the opportunities must change so that local people can shape the services that they experience. I am not saying that patients’ forums failed, but the context and demands on services changed and the remit of the patients’ forums was narrow: they covered only health; they focused on institutions; they were very inflexible; and they were inextricably linked in legislation with the Commission for Patient and Public Involvement in Health. That was determined centrally, so what they did and how they were made up, supported and funded was all set out in legislation. That is why we have come forward with a proposal which, I believe, provides the security of a legal framework and guarantees that an independent organisation—a host—will have a way of collecting and amplifying the voices of people who might otherwise not be heard.

At all levels of the system we have built in accountability between the local authority and the host in terms of the contract—the host is the servant

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of LINks, much as officials serve Ministers—and between LINks themselves and the wider community. I am sure that we will explore that in due course.

For very good reason, we have not put in the Bill details about the form that a LINk might take, although its functions are set out clearly in Clause 222. We have not included those details because that ties in with the culture of the change that we are trying to make and because in the consultation that preceded the Bill it was made clear that local people wanted to decide the form of the organisation and to determine the scope of the network and its membership and governance arrangements.

Amendments Nos. 238KBB, 238KCA and 238LF would put a duty on the local authority to establish a LINk directly rather than through the procurement of a host. Having set out the context, I hope that the Committee will recognise that I appreciate the sentiment behind that aim and the fact that noble Lords are searching for an explanation of this structure. I also fully appreciate the difficulties that can be brought about by a lack of detail in the Bill. Many Bills are icebergs: all the interesting stuff is underneath and the legislation has to be interpreted in different ways. I can see the attraction of putting in a definition of an organisation with legal substance and form; apart from anything else, it would seem to give noble Lords a degree of security that a tangible organisation would emerge. However, I stress that, in not doing that, we are not being perverse; we propose that a LINk should be created as a result of a contractual arrangement not so as to weaken, lessen the impact of or sideline a LINk and not because we think that it is a better philosophical model. Above all, we are taking this approach because, given the new relationship between a local authority and a local area, we need a means of ensuring that the LINk is separate from the local authority.

A fundamental premise of patient and public involvement is that arrangements must be independent. I can understand the desire to simplify arrangements by cutting out the need for a host, but the host will perform a critical function: it will support independence. Without that arm’s-length body holding the budget, facilitating the early stages of forming the network—I shall come later to the point raised by the noble Baroness, Lady Howarth—and enabling LINk members to generate a common agenda and distinguish priorities, the LINk might become no more than a reflection of or extension of the local authority. These amendments would reverse that principle by creating a LINk which, I fear, could become a creature of a local authority. That is why we are trying to build in independence.

Perhaps I may write to the noble Lord, Lord Low, on his question about the limited liability company. That was an interesting point, but I cannot answer it from the Dispatch Box.

The noble Earl, Lord Howe, asked why there was not more substance, with more detail about form and functions, in the Bill. The noble Baroness, Lady Neuberger, said that it is all about process. I hope that I have set out the reasons why the objectives are clear. The process is there to deliver objectives, and we are doing this to expand opportunities for people to have a

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greater say over their health and care. I was asked why, for example, we cannot substitute the word “functions” for “activities” in the Bill. They are described as activities because they allow a LINk to have some discretion, whereas “functions” suggests that they would be mandatory. We refer to people in the Bill, rather than to LINks themselves, because LINks are collections of people—collectives, in a way. A LINk has no set definition; we will talk about that in a moment. The legislation does not describe what LINks should do, because we want them to make their own judgments about what is more important for their areas.

In framing the legislation, we have tried to reflect the need for flexibility and autonomy. I understand the frustration, but this is a better way forward. The noble Baroness, Lady Neuberger, referred to two of the three diagrams at the back of the report; one is definitely more complicated than the other, but that has been a local choice. Sometimes democracy is complicated and diverse; indeed, I can tell the noble Baroness, Lady Masham, that it is sometimes very worrying. Yet if we give people the power to choose what to prioritise, they will come up with some hard choices that will challenge the local health and care services.

There are different models in development. One LINk could have a host that provides all the staffing and support that we could think of, while another may say, “No, just hold our funds. We want to employ our own staff”, and it will be able to do that. In either case, the network of participants will decide. One reason for this determination is that we did not want to repeat past mistakes. Over the past few years, officials at the DoH have received countless requests for clarification about the legislation surrounding PPI forums—whether they can do this or that. Usually, the answer has been no because the legislation has not allowed them to. We wanted to avoid that so, for now, abstract and enigmatic though it may be, we are providing the chance for LINks to be created in ways that are relevant to people and places.

I will briefly flesh out the bones before I finish. LINks will create coherent arrangements for governance, more likely comprising a small group of people and user organisations as their heart and soul. LINks will have a clear identity, with known contact points. Once it is contracted, the host will first map out who is liable to want to join in the area—some local authorities have already begun that process. As well as the usual organisations, such as self-help groups and so on, there could be youth organisations, for example, because there are issues regarding youth health. LINks will be able to relate directly to NHS and social care organisations and to enter and view premises. Noble Lords will see that in Clause 225. LINks will be able to request information, to make reports and recommendations, and to receive a response. Critically, they will be able to refer matters of concern to the relevant overview and scrutiny committee. These important powers and functions are clearly laid out, and we think that they score highly on those grounds.


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