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Lord Darzi of Denham: I am grateful for my noble friend’s intervention. As I have previously said, I am sympathetic to the amendment and certainly to the views behind these amendments. I committed to looking at arrangements for involving patients and service users, their families and carers, with a more flexible approach as I described before. I emphasise that I will come back on Report with amendments that I hope will meet the noble Baroness’s needs.

Baroness Barker: I thank the Minister for his agreement to take this away and consider it. I have a couple of points in response. I agree with the noble Baroness, Lady Meacher, about the power of lay inspection. In my experience, lay inspectors are far less inhibited about saying what they think than professionals. However, I want to correct what may have been a misapprehension: lay inspectors should not merely be confined to inspection of social care services. I remind Members of the Committee that lay people have often uncovered some of the things which were going badly wrong in the health service. There is a key role for lay involvement in that, which is why I chose to use the word “engage” in the amendment; it is perhaps the most important word of all this afternoon.

Why? I have been on the end of some wonderful NHS consultations, and I have been consulted and then watched as professionals wandered off and did something completely different. I had been consulted. I may have been involved. Had they engaged? No; not in the slightest. They already had some ideas that they had come in with.

The important point for us to remember about engagement is that users are not always right. They are not always fully informed. They are not always aware of some of the constraints under which services are, or are not, provided. They can be, and they have an important part to play in making decisions which are informed on that basis. That is why “engagement” is the key word. It is at its most important in mental health, where it is not unknown for service providers and practitioners to develop a sense of their own infallibility and superiority to users over years of dealing with difficult people.

I do not wish to delay our discussions any more, but I hope that when the Minister takes the matter away he will take those points into particular consideration. I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Earl Howe moved Amendment No. 16:

The noble Earl said: I also speak to Amendments Nos. 26 and 64. I make no apology for continuing with the theme of patient and public involvement. We have in the Bill an opportunity to accomplish something really worthwhile: to make an explicit connection between the CQC and the Government’s latest vehicle for patient and public involvement, namely, local involvement networks.

Members of the Committee who took part in the passage of the Local Government and Public Involvement in Health Bill last year will remember that, despite the

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improvements made during its passage through the House of Lords, we were left with a feeling of uncertainty, not to say apprehension, as to whether these new and rather nebulous creatures would really take root and thrive—and, if so, what they would look like.

5 pm

The truth is that no one yet knows what a typical LINk will look like. None, as far as I know, is yet formed. It is of course early days, but it is too soon to tell even approximately what the likely membership profile of a LINk will be. We hope that it will be what Ministers have talked about; that is, a broadly based grouping of individuals and bodies that is able to take an active interest in the delivery of health and social care services in an area, with the necessary energy and commitment to translate that interest into a positive contribution to service quality and service planning.

There are two things in particular that make LINks an ideal point of reference for the commission. First, like the commission, LINks will have the ability to enter and view both health and social care facilities, and to talk to patients and service users. That is, in part, an answer to the point raised, very tellingly, by the noble Lord, Lord Campbell-Savours. The second advantage is that of all the bodies collating the views of patients and the public, LINks are likely to be the most broadly based and, hence, the most representative. The potential for useful feedback from LINks to the commission is enormous.

Members of Committee may recall that when the local government Bill was debated a degree of concern was expressed at the idea of LINks needing to get permission from the appropriate regulator before entering and viewing premises. That fetter on the freedom of LINks was not a popular idea and, I am glad to say, was thought better of. But the idea that no one disputed, because it was eminently sensible, was that the health and social care regulators should work closely with LINks, where possible co-ordinating their respective visits, and that the regulators should stand ready to receive from LINks any information which could be relevant to the exercise of their regulatory functions. Particularly when it comes to healthcare facilities, but not exclusively, the work of LINks and the work of the regulator could be seen as, in some respects, complementary.

It is with that thought in mind that I have tabled Amendment No. 64, which proposes that where the commission issues any sort of a notice to a registered service provider or manager—whether it is a notice granting registration, a warning notice of some sort, or a notice to suspend or vary someone’s registration—it should inform the relevant LINk that it is doing so. In making this suggestion, and in the context of my other amendments, I particularly draw the Minister’s attention to the submission made by the CSCI to the Public Bill Committee in another place where it said in paragraph 43:

Perhaps I could cover just one aspect of this idea. There are some who look at the proposals for the CQC and who regret that the new body, unlike the Healthcare

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Commission, will not have a role in handling complaints. A group of amendments later covers this concern. I have to say that it is probably right to try to do what the Government propose and to make complaints handling, as far as possible, a more locally based process, which is undertaken by the organisation involved, and to have the ombudsman in the background as the second tier back-up.

However, there is no doubt that if we look at the Healthcare Commission’s current role in handling complaints, it gives it a perspective on the quality of healthcare and health services, which is of value and which it would not otherwise have. In particular, it enables it to discern trends with patterns in the matters complained about, which can prove to be informative and useful. If a mechanism could be found for feeding the views and experiences of LINks into the work of the CQC—a service user panel could well be that mechanism—we could hold out the prospect of replicating the wider benefit that currently flows from complaints-handling; namely, the ability to discern patterns or trends in the concerns expressed by service users.

I hope that the Minister will look constructively on these amendments. I beg to move.

Baroness Cumberlege: I support the noble Earl. I start from the premise that the Minister is not responsible for the history of patient and public involvement. As far as he is concerned, the verdict is “not guilty”. It is, however, worth remembering some of the history. It has been quite a sad story. Volunteers who have given so much in the interests of sick and vulnerable people have been pushed around, disbanded, reformed and disempowered.

I return briefly to community health councils, which were so ably led by the noble Lord, Lord Harris of Haringey. They were disbanded because they were too effective. They had real power to refer decisions taken by local health authorities to the Secretary of State. They inspected and reported, carrying out some thorough investigations into how hospitals provided their services. When I chaired the Brighton and Hove Health Authority, we made it our business to work with the local CHC because we recognised that it was a powerful organisation. It was not afraid to make public all our shortcomings. We respected it, and we even commissioned it to undertake surveys and inspections, including of hospital food. As a result, I remember being mortified to read the awful headline in the Evening Argus, “Slug found in hospital lettuce”.

We were taken by surprise when the CHCs were abolished under Alan Milburn’s 2000 NHS plan. There had not been much discussion and there had been little thought about how to fill the void. We then had forums, which had less power. Again, volunteers were pushed around and given a new brief. They related directly to individual trusts, but they proved to be uncomfortable and had to go, as did their overarching body, the Commission for Patient and Public Involvement in Health.

Now we are left with LINks, which are to improve health and social care by promoting and supporting commissioning and scrutinising services. Unlike their

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predecessor forums, they are not connected with a specific service that an individual hospital provides, but they are coterminous with local authorities. There is real merit in this. It is good that LINks relate to both health and social services. If they concentrate on the patient experience—the patient journey, the individual—they can be hugely effective if they are given some power. However, their powers are minimal. They can make reports and recommendations and receive a reply within a set time, but there is no requirement for the body concerned to take any action as a result. They can ask for information and receive a reply—big deal. They can tell an overview and scrutiny committee what they have found, and they can get a response, but again no action is required as a result. There is a danger that unless we build them into this new regulation, they will simply be a talking shop.

In the Our Health, Our Care, Our Say White Paper, we were told that people should have more choice and a louder voice. In my local area, not only is there diminishing choice, but patients and the public have lost their voice. The forums were closed on 31 March and the host—the overarching organisation that is the home to the LINks—will not be appointed until July. Once the host is chosen, it will have to recruit members, who will have to decide what structure they want. They will also have to be CRB-checked, and will be lucky to have any patient or public voice by the autumn at the very earliest. Most likely, they will have it by Christmas.

In the mean time, local people are fighting to retain maternity services and a major reconfiguration is taking place across two counties in the Brighton and Hove City Council area with no formal system for patient and public involvement. So it is not really surprising that we have marches and protests in our towns and villages and that the local population is losing faith in the NHS. It is widely recognised throughout health and social care that user involvement is a mark of best practice. Indeed, the Healthcare Commission actively monitors the requirement of providers to engage with their users. In many parts of the country, the return will be a blank sheet because patient and public involvement no longer exists. Those of us in the commercial world know that if we do not actively seek the views of our customers or clients, we lose them and we are in danger of calling in the receiver. How much more important is it to have the views of the discerning public when receiving a service delivered by a near monopoly?

Amendments Nos. 16, 26 and 64 and those of other noble Lords seek to make it crystal clear that LINks are an integral part of the commission's work. A regulator who is not engaged with patients and the public will have a reduced understanding of the impact the work is having. It will miss the eyes and the ears of perceptive lay people, people who can sense immediately when something is wrong. For those of us who, in the course of our careers or through family responsibilities, as illustrated by the noble Lord, Lord Campbell-Savours, visit residential homes and geriatric wards, it is the smell of a place, as he said, which is the immediate indicator of quality.

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One cannot appreciate that from a written report. Seeing and smelling is worth a million words.

Angela Coulter, chief executive of the Picker Institute, in an interview in the Royal College of General Practitioners’ March edition of the college’s news, said:

So we know that user involvement is effective and, in the context of what we are debating this afternoon, we also know that it can lead to better regulation. I am hopeful that the LINk system is effective—after all, statutorily it is all we have. I am delighted to hear the Minister say that he will look at this, so through amendments we should ensure that it is involved with the regulatory process.

I was very encouraged to hear the noble Baroness, Lady Barker, and the noble Lord, Lord Lipsey, in a previous debate talk about engagement. However, I agree with my noble friend Lord Howe: I like the word “involvement”. I believe Nelson Mandela said that if you tell people, they will forget; if you show people, they will not remember; if you involve people, they will understand. We are seeking the opportunity to deepen the understanding of the new regulator by involving LINks. I know that the Minister has a tremendous track record in involving people in the Next Stage review and I am delighted that he will think about the points that have been made this afternoon and that he will return with an amendment on Report. For me, that is no surprise.

Lord Harris of Haringey: I support the amendments tabled by the noble Earl, Lord Howe, and the noble Baroness, Lady Cumberlege, and I want to speak to Amendments Nos. 17 and 21A that I have tabled. Like the noble Earl and the noble Baroness, my objective in moving these amendments is to help to save the Government’s reputation. I am sure that that is an objective shared, maybe in one small element, by our two colleagues who have spoken. The history referred to by the noble Baroness of, first, the abolition of the community health councils and then the abolition of public and patient involvement forums is not a happy one. It is for that reason that great thought needs to be given to how LINks are to develop and how they are to be involved in the quality process in which the Bill is so important.

5.15 pm

We start from considerable concerns about how LINks will operate. We cannot tell because it is still too early, although the patients’ forums have already disappeared, but we know that they will not provide a consistent pattern of involvement and scrutiny across the country because they will not be related to each other in the way they are established. Each local authority area will find a host body. There is no

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guarantee that those host bodies will be the same or will be connected to organise the LINks, and there will be no clarity about what the expectations are intended to be for those LINks. There has deliberately, and perhaps rightly, been vagueness about who are to be the members of LINks. There has similarly been a feeling that it is right and proper that in every part of the country LINks should determine how they should operate in the interests of best reflecting the needs of a particular locality. The consequence is that there will be even more of a patchwork quilt of local involvement than there was under community health councils or public and patient involvement forums because there will be no mechanism whereby they can be drawn together.

The noble Baroness has been kind enough to refer to my period as director of the Association of Community Health Councils, and I have obviously taken an interest in all this. One of the distinctive features of community health councils, through the national association of which I was director for a period, and the public and patient involvement forums was the existence of a national body that was able to assist them and support them in the work that they were doing, certainly as far as CHCs were concerned, was involved in raising standards in the work that they did and was also able to draw out general lessons about the issues being identified around the country. If the LINk process is to work, there needs to be statutory recognition of the role that it is to play.

Following Second Reading, my noble friend Lord Darzi was kind enough to write to pick up points about LINks. He wrote, quite correctly, that,

He also wrote that the Government,

That would be a fine argument to deploy if it was being suggested that the sole mechanism for listening to local views or to the views of users of services or their families was to be the LINks, but that is not what is being proposed by any of these amendments. They are simply suggesting that the bodies that have been given a statutory role by Parliament should have a statutory role in respect of this commission. That is not to say that the views that will be expressed by other representative groups or local groups will have no value; it is simply saying that that statutory role and the fact that they are resourced by public money, because they will be through local authorities, should give them a particular right to be listened to. If LINks are not explicitly referred to, it is likely that people will pick and choose which voice they wish to listen to. That will always be the case, but if there is no expectation that they will listen to the voice that has a statutory basis and is supported by public money, we are in danger of wasting that public money and the statutory status that has been conferred on LINks. That is why it is very important that LINks are

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referred to explicitly in the proposals for the Care Quality Commission, which is the purpose of Amendment No. 17.

Amendment No. 21A is in two parts. First, it aims to place a responsibility on the Care Quality Commission to ensure that on an annual basis the lessons drawn out from the work of LINks around the country are pulled together and considered. That is important because the issues highlighted in different places in different ways by different LINks may demonstrate a pattern, which should inform the plans and intentions of the CQC in its future work. At the moment, there is no mechanism whereby that will happen. There is no national structure for LINks, which relate to individual local authorities and to the service providers in their patch. There is no way in which those lessons will be drawn out. It is extremely important that those matters are dealt with.

For example, in this Committee, we will at various times consider amendments about the quality of food in hospitals, which I know is a concern of many organisations. When I was director of the Association of Community Health Councils, something like 12 to 14 years ago we published a report, Hungry in Hospital?, which highlighted, from the experience of individual community health councils around the country, the problems that particularly the elderly and many other vulnerable patients were having in the way in which food was served to them.

Those messages were pulled together from individual reports and organisations, for which there will be no mechanism at the moment. That is why something which will place an obligation on someone—I would suggest that the Care Quality Commission is the best place to do that—to pull those lessons out will be extremely important. If it is to be the Care Quality Commission, the expectation would be that that would help to inform its planning.

The second element of Amendment No. 21A is to consider the effectiveness in each local authority area of the arrangements under that section. I assume that my noble friend Lord Darzi will have absolutely no problem with that amendment, because when my noble friend wrote to me he said:

He goes on to say:

I am not clear how that will happen, but he is saying that that will be the case. He continues:

He is saying that, by the nature of the local area agreements and the monitoring role that the Care Quality Commission will have, one of the requirements will be to look at the effectiveness of local engagement.



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This is a job that the Care Quality Commission will be doing anyway. Therefore, to make it explicit to report on the effectiveness of the local area agreements seems to be something to which there can be no possible objection from my noble friend. It is a job that the CQC will do anyway. For the sake of transparency and clarity, and the importance that public money is used effectively to engage local citizens, local users of service and their families, it seems very sensible that this obligation should be placed on the Care Quality Commission.

Baroness Wilkins: I strongly support the case made by my noble friend, the noble Earl, Lord Howe, and the noble Baroness, Lady Cumberlege. I have added my name in support of this group of amendments, which all set out the relationship between the CQC and local involvement networks. As I said at Second Reading, I would expect the CQC to play a strong role in supporting the changes concerning user involvement and joint-needs assessment to be ushered in by the Local Government and Public Involvement in Health Act, and in monitoring the effectiveness of these new arrangements.


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