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I was delighted to welcome the amendment to this amendment—Amendment No. 11—from my noble friend Lady Campbell of Surbiton. Her suggestion neatly ensures that service users are indeed at the heart of the commission. Amendment No. 11 would ensure an effective link between the proposed service user panel and the commission by requiring the Secretary of State to appoint a member of the commission who is a service user to chair the panel. This mirrors the arrangements made for the Equality and Human Rights Commission’s disability committee, which, as stipulated in the Equality Act, must be chaired by a member of its board. That would give service users more direct influence on the commission and thus enhance people’s confidence in CQC's ability to put patients and carers at the heart of quality assurance. It harnesses the talents of the very people that CQC seeks to help and can improve health and social care outcomes as a result. There is always a danger of the panel merely becoming a talking shop or a body to be consulted after decisions have been taken.

In drafting this amendment, my noble friend Lady Campbell has drawn on her experience of chairing the Social Care Institute for Excellence for five years, where its partner panel is chaired by a trustee, and her experience on the Equality and Human Rights Commission, where she serves as both a commissioner and chair of the disability committee. It is the central seat at the table that ensures the users inform the workings of the commission and see its contribution reflected in its work programme and reports. It protects against any temptation for professionals and practitioners to default back to former ways of working where consultation may be token. The amendment seeks to ensure that service user involvement is enhanced by a strong conduit between the panel and the “top table”, bringing the ideas and knowledge directly into the heart of decision-making and forward planning. I beg to move.

Baroness Wilkins moved, as an amendment to Amendment No. 10, Amendment No. 11:

The noble Baroness said: I strongly support the need for a service user panel for the CQC and for this to be set out as a statutory requirement in Schedule 1.

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Mechanisms for guaranteeing user involvement need to be embedded in the CQC’s governance as well as its functions. Amendment No. 11 would ensure an effective link between the proposed service user panel and the commission by requiring the Secretary of State to appoint a member of the commission who is a service user to chair the panel. Without this direct line of influence to the commission proper, my fear would be that the impact of a service user panel would be diluted and would not see the effective mainstreaming of users’ views and aspirations.

As the noble Baroness, Lady Finlay, pointed out, Parliament was careful to ensure that there was no such risk for the Equality and Human Rights Commission disability committee, which similarly has a direct line into the commission via its chair. User involvement is not just desirable in itself; it leads to better policy-making and improved services. With increasing personalisation on the agenda in both health and social care, it is essential that users are involved at every level of the new organisation. It would be difficult truly to personalise a public service if its regulator had minimal user involvement. I would therefore urge the Minister to accept the case for the provision set out in Amendments Nos. 10 and 11. I beg to move.

4 pm

Earl Howe: My name is attached to Amendment No. 10 and I support everything said a moment ago by the noble Baroness, Lady Finlay. I like the idea of a service user panel because it holds out the prospect of genuine patient and public involvement in the work of the commission. As we debated recently in the local government Bill, and as the noble Lord, Lord Low, effectively stressed the other day, there is an important difference between involvement and consultation. It is the difference between allowing someone to contribute to the shaping of plans from the moment that the initial idea is conceived and allowing a person to comment on those plans only once they are fully formed. The two are not at all the same. Surely, we want a group of people to help and advise the commission from the perspective of the informed service user—people who know what it is like on the ground and who can offer their wisdom to the commission in a measured and reasoned way.

I believe that such a panel would be a force for good. It would be the means by which the commission could assure itself that the interests of service users and carers were properly embedded in the work that it undertakes. Leaping ahead to the next but one group of amendments, it would be the ideal conduit for LINks to feed in their views to the commission in a structured and co-ordinated way.

As the noble Baroness, Lady Finlay, said, there are some good precedents. For instance, there is the Ofcom consumer panel, which I understand works well and is influential. There is also the citizens’ council, set up by NICE, which can make recommendations. Above all, there is the service user reference panel reporting to the Mental Health Act Commission, which in its short existence has undoubtedly proved its value. I would argue that there is no more important sphere for

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service user and carer involvement than the regulation of care provided to individuals detained under the Mental Health Act. In that context, we are dealing with people who have many of their rights taken away and who find themselves with a need to feel empowered as far as reasonably possible and able to influence the way in which they are looked after. Without service user involvement, it would be very easy to imagine a culture developing which failed sufficiently to take that dimension into account.

My understanding is that direct involvement by service users in visiting activity in the context of the Mental Health Act Commission has been shown to have considerable benefits. The Government have often said that they are keen on user involvement in the regulatory process and I accept that they are. I therefore hope that they will look constructively at this amendment.

Baroness Knight of Collingtree: I warmly support the two amendments. A moment or two ago, in response to the noble Lord, Lord Lipsey, the Minister read out a mind-boggling list of responsibilities with which the chairman of the new organisation would have to deal. Every single one was very wide and very important. In fact, when he said it, I wondered how on earth any person was going to do that three days a week, but that may be something for the future. I am, however, concerned that, unless the users are clearly harnessed into this work, the commission will not be working on all the information that should be available to it. Surely only the users can know exactly what is going on on the ground. I have seen with my own eyes allegations made by patients about their treatment being totally ignored and put down by the National Health Service people. Unless we ask the users and listen to what they say in the way that the amendments suggest, the people in charge of the commission will not be able to carry out what all of us here hope they will be able to carry out.

Lord Campbell-Savours: I add my support to the amendment. I intend to speak to a number of amendments later but will say just a few words about why I support this one.

I have for various reasons spent a large part of my life in hospital—I will not go into details—but I have seen a lot in hospitals. I am a classic user, having on occasions spent months on end in hospital. My mother is in a nursing home and I try to visit her four times a week. You learn a lot about nursing homes, and she is in a good one, but I visited many nursing homes before I placed her in one. It is inconceivable that people who have that kind of experience are somehow to be loosely represented under the advisory committee arrangements that are set out in the Bill and which were referred to some moments ago.

I hope that the Minister, when he replies, accepts that we, the users, are in a particularly difficult position, because most users have no knowledge of healthcare. Most people in a lifetime—I do not know; I have no empirical evidence for this—probably go nowhere near a hospital; only those of us who are less fortunate end up in hospitals. They start off with very little knowledge

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and go into hospital with very little knowledge. Most people out there have no idea what goes on in nursing homes or care homes; only when they enter them do they begin to learn how things operate. They are confronted by people who are highly skilled and highly articulate and who know the business through and through and know how to answer all the questions. Very often they simply do nothing because they are overwhelmed by the abundance of knowledge that they know they must take on in the event that they wish to make a complaint. There must be far more effective representation of users in the structure that is being created.

Furthermore, as we are in effect consolidating efforts in one organisation, and as has been repeated previously, there may well be an emphasis in the work done on areas that do not necessarily encompass areas of social care that might be my preoccupation. I want to see in the structure that is being created a body of people who can more effectively represent the area that may well become the Cinderella part of its functions.

Baroness Gardner of Parkes: I, too, support the amendment. My experience in the health service and in social care is that people have problems, complaints and unfortunate experiences, but their number one wish is to see that the same thing does not happen to someone else. They are not usually out for compensation; they really just want to see that their experience is not repeated. The user panel would give them the opportunity to see that their feelings and experiences were fed through. This is a very important amendment.

Lord Darzi of Denham: At Second Reading, many noble Lords spoke about the importance of ensuring that patients, people who use social care services and their families and carers are involved in the work of the Care Quality Commission. I hope that I was clear about the importance the Government also attach to that. Many noble Lords have drawn attention to the excellent work of the three current commissions in involving those who use health and adult social care services in their work. I reassure noble Lords that this is something that we are absolutely committed to retaining and carrying forward to the commission.

There is no doubt in my mind that the new commission will be just as user-focused as the current commissions and that it will build on their good work. It is worth remembering that the current bodies are not under any specific legal duty in this regard. The requirement in Clause 2 for the commission to have regard to views expressed by and on behalf of members of the public is therefore a new duty. That will of course include patients and service users and those who represent them, such as LINks. That sets a good foundation for the new commission’s programme of involvement and engagement, which I am sure it will develop.

In terms of having suitable mechanisms for enabling ongoing involvement and commentary on its work, we had sought to establish such a mechanism

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through the requirement in Schedule 1 to appoint an advisory committee, to whose advice the commission will have to have regard. The noble Baroness, Lady Finlay, along with the noble Earl, Lord Howe, has in Amendment No. 10 made the case for a more specific requirement to have a separate advisory committee comprised solely of patients, service users and their families and carers, to be known as the service user panel.

The noble Baroness, Lady Wilkins, has proposed a further addition to Amendment No. 10, through Amendment No. 11, which would require the commission to appoint one of its members who is or who has recently been a user of health or social care services to chair the service user panel. There is no doubt in my mind that direct experience of services would be very valuable in informing the way in which the commission carries out its work. However, I expressed my concerns when we discussed Amendments Nos. 6 and 9 about seeking to specify what kind of background members of the commission should have. I therefore do not think that we should be prescriptive about this in the Bill.

As a general point, I emphasise the importance of flexibility in engaging with users and carers. Innovation is key and, as I have mentioned, the Healthcare Commission, the CSCI and the Mental Health Act Commission all engage well with users, using a variety of methods of engagement and involvement. However, I recognise the importance that noble Lords have placed on the CQC having appropriate user involvement and engagement, as very eloquently described by my noble friend. I will, therefore, undertake to consider how we could strengthen the current arrangements for ensuring that the commission has strong public, patient, service user and carer involvement in its work, while maintaining a flexible approach, with a view to reporting back at a later stage of the Bill’s passage. Given that reassurance, I hope that noble Lords will feel able to withdraw the amendment.

Baroness Finlay of Llandaff: I—

The Deputy Chairman of Committees: Amendment No. 11?

Baroness Wilkins: I understood that the noble Baroness, Lady Finlay, had moved both amendments, which is why I am confused that you called me to speak to Amendment No. 11.

The Deputy Chairman of Committees: Amendment No. 11 was an amendment to Amendment No. 10, which you wish to withdraw.

Amendment No. 11, as an amendment to Amendment No. 10, by leave, withdrawn.

4.15 pm

Baroness Finlay of Llandaff: I would like to address the Minister’s response to both amendments. I am most grateful for the wide support that both these amendments received from the Committee. My concern is that if we are to be user focused, we must have the

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user at the heart of the process, particularly because, as the noble Lord, Lord Campbell-Savours, so eloquently pointed out, there will be a broad range of types of inspections from very large hospitals down to nursing homes, small units and social care providers who are very disparate. A one-size-fits-all approach cannot be taken. I greatly appreciate the Minister’s assurance that he will undertake to strengthen the current arrangements as laid out, and because of that assurance, I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Schedule 1 agreed to.

Clause 2 [The Commission’s functions]:

[Amendments Nos. 12 to 14 not moved.]

Baroness Barker moved Amendment No. 15:

“(a) the need to engage with service users and members of the public through appropriate mechanisms and channels, about activities to which the functions relate,(b) the views and experiences of service users and members of the public in relation to such activities,”

The noble Baroness said: This afternoon we will debate groups of amendments that follow a theme. The theme for this amendment was to some extent set in the previous debate. My understanding was that in the previous group of amendments the Committee was considering the role of users in the governance of the commission. I believe that is important. Governance is about setting strategy and direction, not about management. However, the amendments in this group and in subsequent groups are about operational matters, which are also important.

I live in a part of London where there are two large hospitals that people who need acute care go to. For some services, probably for most services, people can elect to go to one or the other. As we all know, probably the most elective of elective services is maternity services. I live in an area where there are women who will not set foot in one hospital and swear by the other one, but on the other side of where I live there are women who make the reverse judgment. I have no doubt that if one goes to the mothers and toddlers groups round where I live there are raging debates about the benefits or otherwise of those two hospitals, the basis of which is probably highly subjective. What members of the general public who are not engaged and have no need of those services think is probably based on nothing more than the opinion of the person to whom they last spoke. However, the opinions of users are very different and are formed on a wholly different basis.

When we look at the wording of the Bill, it is important to state quite frankly that the Government are way behind the times. By not putting the views of users first, at the heart and above and beyond the views of the general public, they are way behind the thinking, particularly in the field of social care. Why is that? It is, at least in part, because of a point that I referred to at Second Reading, which is that people who need social care have very few rights in law. I suspect that by the time we are through with this

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legislation the only right that they will be left with will be the right to have information. They are certainly not going to have a right to have services. Particularly in the field of social care, the right of people to be involved at a very high level in decision-making about their personal care and about the management and strategy of services overall has gone on apace, and social care is way in advance of what happens in health. While what is in the Bill at the moment may be a giant leap forward for the NHS, it represents a massive leap backwards for social care. I am afraid that that is not acceptable.

Why is this important? Apart from anything else, the diversity of users is important. People who use mental health services have vastly different experiences and needs from people who intermittently use some low-level social care services. Their views are wholly different from people who go through major acute trauma and receive high-level surgical services. There is also a distinction to be drawn between the needs of people with learning disabilities and, for example, older people. That is not a fashionable thing to say at the moment, not least because much of the underlying policy on development of social care services comes from the learning disability field.

There is a range of different views to be taken into account. It is important that we should not be prescriptive in this legislation about how the commission should go about the business of user involvement. Indeed, I suspect that it would be misguided if we thought that if we were prescriptive about the involvement of any particular body the legislation we ended up writing would be relevant for more than two years—that is the average length of NHS and social care reorganisation. That is why my amendments are in some ways quite unspecific. They do not make suggestions about involving specific bodies, but simply say that there must be mechanisms that ensure that there is engagement with users and the public.

In Amendment No. 108, I again pick the point made by myself and the noble Baroness, Lady Howarth, in our discussions last week about the fact that we remain convinced that a director of adult services must work within the commission to ensure that adult social care has the proper prominence it will need. That is why we have suggested in Amendment No. 108 that it is a duty to have that part of the commission’s work included in its annual report.

If I were in the shoes of the noble Lord, Lord Darzi, I imagine that I would say that this is otiose. It has taken 40 years for user involvement to become an expectation in social care in any meaningful sense. However, it is not easy and certainly not cheap; it is a deliberate and expensive process. There remains a fear among many that, if it is not backed up in statute, it may simply become a passing phase and, when times get hard, become a luxury which hard-pressed professionals can simply dump. That is why it needs to be in legislation—although I accept that, in stating that it needs to happen, we cannot be overly prescriptive about how it happens. That is the basis of my amendment. I beg to move.

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The Deputy Chairman of Committees: I advise the Committee that if the amendment is agreed to, I cannot call Amendment No. 16 because of pre-emption.

Baroness Meacher: I rise to speak to Amendment No. 27, which is complementary to Amendments Nos. 10 and 11, but goes a little further in placing a duty on the commission to involve service users, including their families and carers, in exercising its functions. The amendment makes it clear that the term “involve” encompasses the need to provide information about the exercise of its functions and to consult and involve service users, families and carers in the inspection of registered service providers. Although I accept the point made by the noble Baroness, Lady Barker, that we should not be too specific in the Bill, there are certain functions of the commission where it is so essential to involve service users that there is a strong case for being specific. The only other point in this amendment is that users should be involved in the process of special reviews. Again, I do not think that that will be done properly unless users are involved.

The amendment is supported by the Royal College of Psychiatrists, the National Consumer Council, Which? and the Picker Institute. My motivation in tabling it lies in my experience of working very closely with users, families and carers in East London. The health service has for years paid lip service to user involvement. We had community health councils and PPIs, but I cannot recollect anything really different occurring because of consultation with those bodies. Only very recently have we on the front line taken this seriously. We are finding that the real involvement of service users is the fastest and most efficient way to find out what we are doing wrong and how to put it right. I have never known things coming so clearly through to board level about our problems and what we are doing to put them right as is happening now. At last, this is apparently a part of government thinking across wider areas of government policy and I am delighted to hear that. Things will improve faster than we imagine because of that commitment. Yet the Health and Social Care Bill makes no explicit reference, as I am sure other Members of the Committee will point out, to service users, their families and carers.

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