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Baroness Northover: What the noble Lord has said bears out the point. This was a nationally established commission which we all agree did not work. We therefore need to learn from that costly experience to try to move on and to work out a way in which you can have local healthwatch organisations as the local eyes and ears, feeding through to HealthWatch England, a national organisation. We are at the moment looking at how that national organisation should be sited. Everyone has said that the relationship between the national organisation and local organisations did not work previously. We are seeking here to make that relationship work much better. I can see another noble Lord is about to hop up.

Lord Warner: The Minister will be pleased that it will be the noble Lord who pulls his punches, as my noble friend said earlier. I wish to pursue this issue of how much money the Government think they need to spend on funding HealthWatch England. This is the real issue: say, for example, it has £10 million-I do not know what figure is being considered, but there will be a sum of money. It seems to be agreed that there ought to be some kind of national body. I do not altogether understand the Minister's argument that we got it wrong in the past, because we fully accept that we got it wrong. However, it does not follow from that there should not be a national public body called HealthWatch England. The Government seem to accept that. The argument is over whether you should place that body in the Care Quality Commission. I can see that one might argue that costs could be reduced by doing that, but we first need to know what the Government are prepared to spend on this body, and then we can discuss the best way of spending that money in terms of independence.

Baroness Northover: Perhaps I may come on to the points that I was going to make regarding why we are making our proposals in light of the experience of the national organisation that did not work brilliantly. They address some of the issues that the noble Baroness, Lady Pitkeathley, raised and are implicit in the points made by the noble Lords, Lord Warner and Lord Harris, and others about the independence and status of the new organisation.

I cited what happened with the previous national organisation, and the point about where we are placing HealthWatch England is that it is an attempt to ensure that it is in a strong position to influence the regulator, the CQC, rather than sitting off to one side and not necessarily being listened to. A lot of concern has been expressed about how that relationship would work, but I point noble Lords towards the other side of the issue. If HealthWatch England is sitting there alongside the CQC, with local healthwatch feeding into HealthWatch England, what better way to make sure that you flag up to the regulator concerns from local areas. Noble Lords should try to look at the issue from that point of view, as opposed to seeing the CQC as somehow silencing HealthWatch England. It is vital that the views of patients and other service users are taken on board by the CQC and that it does not close its ears and eyes to what is happening.



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Lord Warner: I am still struggling. I am sorry to keep interrupting the noble Baroness, but let me give her an example. Could HealthWatch England, as a sub-committee of the CQC, run a national campaign against what is being done by that regulator on an issue such as feeding elderly people in hospital?

Baroness Northover: HealthWatch England has a statutory obligation to represent the position of patients and, if it is concerned about the feeding of patients, yes, it indeed has the right to set its agenda, to campaign on that and to argue that this must be checked on and brought up to a much better standard. As my noble friend Lady Cumberlege said, we have throughout the NHS and through its recent and long-term history, problems and challenges in meeting basic standards of care and attention. All of us know that, whatever party we come from. The previous Government did not get this right; we are seeking to move forward, and we need to ensure that we consider these questions fundamentally and address why these problems continue to arise. They have been intractable; we will continue to address them; I welcome noble Lords' contributions on that.

4.15 pm

Lord Harris of Haringey: The noble Baroness made a very important point just now. She said explicitly that HealthWatch England could and should be a campaigning organisation, although it would be a sub-committee of the CQC. This is irrespective of the debate about where it is located. I think that the principle of creating a national patient organisation as a campaigning organisation on behalf of patients is extremely important. I am very grateful to the noble Baroness for making that commitment on behalf of the Government.

Baroness Northover: HealthWatch England will represent the voice of the patients. It will publish on that; it will advise on that; to take up a point raised under one of the earlier amendments, it will no doubt make recommendations within the areas of its advice. It has the obligation to make those recommendations to various organisations within the NHS. Various organisations, including the CQC, have the responsibility to respond to that. All those obligations will flag up problems, so I do not see that I have made a startling admission. I would have thought that the noble Lord, Lord Harris, would know that transparency-publishing information-was the best way forward.

However, I agree with many noble Lords that this has been rather a patchy area. We have to try to give greater strength to these organisations both locally and nationally. Much of that is not based on their structures, because all sorts of structures have been tried, but we are trying to take them further forward.

Lord Warner: I just want to pursue the issue of the campaign, because it is very important. Currently, there has been a very effective campaign about literacy run by the Evening Standard. That has attracted lots of voluntary money to run it and led to some interesting changes and the Government supporting it. To be

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absolutely clear, I ask: are we saying that a sub-committee of the regulator-the Care Quality Commission-could run a campaign on the feeding of elderly people in the National Health Service in association with a national newspaper and criticise the Government strongly, implicitly, about the way that they are running the NHS in that area? If the Minister, on behalf of the Government, is saying that yes, it can, I start to get more convinced about the Government's commitment to independence of the sub-committee of the CQC.

Baroness Northover: As I said, HealthWatch England will need to look at what works well and what works not so well right across the country, gathering the information from local healthwatch. It will flag up things which, no doubt, will be uncomfortable at all levels of the NHS and the Government. Noble Lords would not expect change to be driven in any other way. If things are unsatisfactory locally, as fed by local healthwatch to HealthWatch England, if it is doing its job it will obviously flag up areas where change is required.

Lord Warner: I am not talking about flagging up; I am talking about a campaign. A campaign means that you take action, using the media, to put serious pressure on the Government in relation to their record in running the NHS for elderly people. I am not saying that that should happen; I am trying to understand what power this body would have as a sub-committee of the regulator, which is the point that we are discussing.

Baroness Cumberlege: Does the noble Lord, Lord Warner, agree that much depends on the membership of this body and whether it is independent? I am not sure why people call it a sub-committee. In the Bill it is called a committee. I have chaired the top board in organisations and I know that you get very close to some of those committees-you listen to them. If an organisation is totally independent and it goes left field, making a whole lot of noise, you just dismiss it and say, "Oh, they're always making problems". The opportunities are far greater if part and parcel of what it does is informing you of what is going on. I honestly think that you will listen much more carefully to people whom you meet in the corridor, in the chambers or wherever the debates are going on.

I take the point made by the noble Baroness, Lady Emerton. The Care Quality Commission does not always say that everything is dreadful. The Healthcare Commission used to say, "This bit's good; this bit needs addressing". I can see that this committee-not sub-committee-of the Care Quality Commission will serve a very useful purpose. It could put enormous pressure on the Care Quality Commission really to understand what is going on and it would not just be an irritant that is offside.

Baroness Northover: I thank my noble friend Lady Cumberlege for that and I agree with her very much. We all wish, and have all sought, to drive up quality in the NHS. That is so often difficult to achieve but this is one of the means by which we hope to make that

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happen. No doubt some people will be made to feel uncomfortable by what the committee reports and says, and I hope that that will be the case.

Baroness Pitkeathley: Perhaps the noble Baroness can take that a little further. For example, could HealthWatch, in the position envisaged for it by the Government as a committee of the CQC, join with a national campaigning charity-I am thinking of something such as National Voices-to put pressure on the CQC itself about how it was reporting patient outcomes?

Baroness Northover: I am sure that it could. If it felt that it was not managing to persuade the CQC or some other part of the NHS to do what it considered to be in the best interests of patients, then I am sure it would go to greater lengths to ensure that it got its message across. It is very important that we have a louder patient voice within the NHS, and this is one means of seeking to achieve that.

I return to some of the amendments that noble Lords have flagged up. This is a very important debate. I think we agree on where we wish to head and what we are seeking to achieve, but I hear noble Lords' concerns about whether this is the right way of going about it. Noble Lords talk about an independent organisation and so on but that route was tried. This is another route for trying to make sure that there is a body close to an organisation which itself must have a major role in driving up quality. The synergies there are very important.

The question was raised of how local healthwatch is going to influence HealthWatch England. I heard what the noble Lord, Lord Harris, said about elections to HealthWatch England from local healthwatch. Clearly, as my noble friend Lady Cumberlege said, a great deal will depend on who is on these organisations nationally and locally, and it will be necessary to ensure that they are as strong as possible. The Secretary of State will determine how the membership is comprised through regulations and we will be discussing with a wide range of stakeholders the contents of those regulations. I can confirm that we will discuss the suggestions put forward by noble Lords. We had from the noble Lord, Lord Harris, an emphasis on election and a concern about that route from the noble Baroness, Lady Pitkeathley. Both noble Lords might wish to feed in to how those regulations are taken forward so that we can best comprise HealthWatch England and local healthwatch.

Lord Harris of Haringey: Can the Minister indicate the timetable for consultation on the content of those regulations? Those of us who wish to see an election process in the Bill will need to know sooner rather than later whether that is the way in which the Government's thinking is going. When is that consultation going to take place and when is it likely to conclude?

Baroness Northover: In the meeting that I was in yesterday with NALM this was an issue. The noble Lord, Lord Harris, is probably aware of that. No? That was one of the issues-perhaps the noble Lord,

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Lord Warner, referred to it-that did come up. The consultation will be early next year. Given that we are almost in next year, that is pretty soon.

The noble Lord, Lord Harris, wanted to make sure that HealthWatch England's annual report was shared with local healthwatch. While we do not feel that that is a matter for the Bill, the annual report must be published. It is important that that information is made widely available. I am sure that the noble Lord's suggestion will be noted by HealthWatch England and local healthwatch as the information between the two must go back and forth, in both directions.

Lord Harris of Haringey: The Bill does not refer just to the annual report. It refers to all reports.

Baroness Northover: It is clearly important that the information goes back and forth between the local and national organisations.

If HealthWatch England were significantly failing in its duties, the Secretary of State has powers to intervene. An amendment addressed whether the Secretary of State should consult local healthwatch. This was on the assumption that HealthWatch England was in effect failing local healthwatch. While the Secretary of State should not be bound into a rigid consultation-something else entirely could be in question here-we would fully expect him to seek the views of others where appropriate in coming to a decision to intervene. I hope that that will reassure noble Lords.

My noble friend Lady Jolly talked about local healthwatch needing to look widely at all groups of patients, including those with rare diseases and so on. She is right. We will be coming on to other amendments where we look at this a bit more. LINks and its predecessors recognise that they have not had as wide a coverage as they would like or been as representative of their communities as they would need to be. This concerns us. The noble Baroness, Lady Pitkeathley, referred to it briefly in relation to whether local healthwatch should elect to HealthWatch England. We are seeking to learn from this. We want to try to make sure that local healthwatch has as broad a spread as possible. It is worth bearing in mind that it has a place on the board of the health and well-being boards and so there will be information feeding back to local healthwatch from the others on the health and well-being boards and from local healthwatch into the health and well-being boards. We will come on to local healthwatch in relation to local authorities, but there is synergy there too.

While I feel that the Bill provides safeguards for the independence of HealthWatch England within CQC, I would like to repeat my commitment that we are prepared to listen to further views. It is very clear that we are all trying to head in the same direction. There is a variety of views about how best to do this. We would welcome noble Lords' continued input as we take this further forward. In the mean time, I thank noble Lords for flagging up these issues. I hope that the noble Lord will withdraw his amendment.

Lord Warner: My Lords, this has been an interesting and spirited debate. I will certainly reflect on the Minister's willingness to consider some of these issues

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further. My noble friend Lord Harris and I will certainly be considering this further and I would not rule out the possibility that we might come back to this on Report. I beg leave to withdraw the amendment.

Amendment 306 withdrawn.

Amendments 307 to 309 not moved.

Amendment 310

Moved by Baroness Massey of Darwen

310: Clause 178, page 176, line 10, after "people" insert ", including children,"

Baroness Massey of Darwen: My Lords, I shall speak also to Amendments 311 and 320. This group of amendments seeks to ensure that the voice of the child is heard in health matters. Too often in Bills that do not relate specifically to children and young people, they are marginalised, yet, as has been said before in debates, child health is a vital aspect of healthcare and children are patients, just like adults. They have opinions just like adults and, in my experience, consulting children about what works for them always results in improved services and policies.

These amendments seek to ensure that HealthWatch England's functions are clear and explicit in relation to children as well as to others and that its functions in providing advice to the Secretary of State, the NHS Commissioning Board and monitoring authorities on the views of patients and members of the public refer to the views of children, who are patients and members of the public.

Local healthwatch functions must also promote and support patient and public involvement in the commissioning, provision and scrutiny of local care services and must obtain the views of patients and the public about people's needs for and experience of local care services. I submit that those functions must be carried out to include children. HealthWatch England must provide support and assistance to local HealthWatch organisations in relation to this.

Furthermore, as noble Lords may know, Article 12 of the UN Convention on the Rights of the Child makes clear that children have a right to be heard on issues that affect them. Measures to promote patient and public involvement in decisions about their own care and in the development of health services and care services must include children from the start. I believe that this will make for better health services.

The Bill does not make this clear enough. Research commissioned by the NCB has found that local involvement networks or LINks, which the Bill will transform into local healthwatch, are not always clear that children and young people are part of their remit. Local healthwatch and HealthWatch England will need to be able to identify capacity and maintain the skills to reach out to and engage children, including the most vulnerable children and their families.

A recent review of law, policy and practice in relation to children's participation in the NHS and other public services and settings found that, in their efforts to support user involvement, the health authorities and

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NHS trusts had not specifically identified children as service users. The review also found that although 41 per cent of GP practices reported to have a patient participation group there was no evidence of children's active engagement in these forums. The Royal College of Paediatrics and Child Health has argued that reforms have been lacking in providing the structures and frameworks where children and young people are properly represented. And concerns about children's involvement in patient and public voice mechanisms were also reflected in the report of the NHS Future Forum. In 2009-10 Professor Sir Ian Kennedy carried out a review of how the NHS delivers to children and recommended a local partnership in each local authority that would co-ordinate public services in the best interests of children. His ambition was that,

My amendments here try to make clear that children are within the remit of local HealthWatch and HealthWatch England and that children's and young people's views should be heard. I beg to move.

Baroness Masham of Ilton: My Lords, I support these very important amendments. One only has to remember the tragedy of Baby P and all those vulnerable children who sometimes fall between the police, the social services and the health departments.

Baroness Finlay of Llandaff: I put my name to these amendments, which are incredibly important. I hope that the Government's response will be that they are listening and prepared to change this. It is worth noting that the Government's response to Professor Sir Ian Kennedy's report said:

"In the past, the NHS was not always set up to put the needs of patients and the public first. Too often patients were expected to fit around services rather than services around patients. Nowhere was this more the case than for children, young people and their families ... If we are to meet the needs of children, young people, families and carers, it is vital that we listen to them in designing services, gather information on their experiences and priorities, provide them with the accessible information that they need to make choices about their care, and involve them in decision making".

That is the Government's own response to the report.

I also draw attention to the report from the ombudsman in Wales. I know we are going to debate ombudsmen later but I will make this one point. The ombudsman upheld a complaint that Health Inspection Wales,

The Royal College of Paediatrics and Child Health is very concerned that "no decision about me without me" must extend to children and should involve both children and young people. Without that we will have poorer service planning and, as a result of that, poorer health outcomes. A voice for children and young people needs to be incorporated in the decision-making process of the NHS Commissioning Board, health and well-being boards and clinical commissioning groups, and a safe conduit for this involvement may be HealthWatch and local healthwatch.

I want to briefly draw the House's attention to the fact that we have many young carers so it is not only children as patients that we need to consider. In the

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2001 census it was found that there were 175,000 young carers and no one is disputing that those numbers have gone up significantly since then. A third of those are caring for somebody with mental health problems and the average age of young carers is 12 years old. Reading their comments, society clearly does not understand the pressures that they are under. There is evidence that when they get to school late, the school does not understand. When they try to accompany their parent to out-patient or even in-patient appointments, they are not listened to even though they have been providing all the care. The facilities where their relative is looked after are not appropriate for them to stay overnight. I remind the Committee that when a young parent is dying, the children will want to stay at the bedside. They may want to sleep in the same room. They do not want to be taken away. They may want to have a break; they may want to go out; they may want to watch a video. If we are really going to invest in quality of care and health outcomes for the next generation, and meet the Marmot review's requirement for health inequalities not to be widened but narrowed, we must address the needs of this group in our population who provide a lot of care, who are incredibly important and who will be the citizens of the future, but to whom the system does not currently give a voice. To expect adults to be a voice for them is completely unrealistic, because, when they are a young carer, there is no other adult there apart from the person whom they are caring for.

I hope that these amendments will not be dismissed with a whole lot of reasons as to why they cannot be put into practice. If we are really committed to changing healthcare services for the population, we should listen to the voice of children and young people.

Baroness Thornton: My noble friend Lady Massey is, as usual, correct about these matters. I am always happy to take my lead from her. All my experience of working with NCH and lots of children's organisations over the years, and, more recently, of talking to YoungMinds, leads me to think that this is a matter that the Government need to take into consideration.

Lord Warner: My Lords, my name, too, is on the amendments. I support what my noble friend Lady Massey and the noble Baroness, Lady Finlay, have said. I want to refer to adolescent health services. We know that primary care services are not often very user-friendly in relation to adolescent health needs. I have come across GPs who have had special sessions and even private doors so that adolescents can come into their surgeries without being spotted by nosy neighbours. There are some real issues of privacy with young people in the adolescent years. They do not always find these services easy to use, when they often have considerable health needs and sometimes quite serious mental health needs. In my time as chair of the Youth Justice Board some time ago, we were starting to find that for many young offenders the origin of their offending was when someone significant in their family had died. It was the absence of any bereavement services that caused them to go off the rails. It is more than just symbolism to put these extra words in the Bill; it is a very important signal to the NHS that

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Parliament recognises the need to pay attention to the needs of children, to listen to them and to meet a set of needs which are often not being met.

Baroness Northover: My Lords, I thank the noble Baroness, Lady Massey, for flagging up this issue and for the work that she has long done in this area, which I saw particularly clearly when she and I were both trustees of UNICEF. Our aim is that HealthWatch England and local healthwatch organisations should be there to understand the views and needs, locally and nationally, of patients and other service users and members of the wider public-everyone.

I reassure noble Lords that, at both national and local level, this clearly includes children and young people. I realise that the concern expressed by noble Lords arises from deficiencies in how things have operated in the past. The Future Forum flagged up the need to ensure that, for example, local healthwatch should be more representative of communities than had been the case previously, which why is my honourable friend Paul Burstow in the other place introduced an amendment to the effect that local healthwatch should represent the breadth of views and diverse characteristics within a community, whether it be carers, young people or otherwise.

4.45 pm

It is important that children should not be overlooked, either as patients or carers. The key is empathy and understanding whoever the person is, focusing on the patient and their family and looking at things from their point of view. As we change from LINks to local healthwatch this may be an important opportunity to try to work out how better to address, in a more strategic, holistic view, what the needs of patients, their families, children and young people might be, including those in the kind of incredibly difficult situation to which the noble Baroness, Lady Finlay, referred.

It is clear that not only within the National Health Service are children often overlooked-as are the elderly often-but that the patient groups are not as focused as they might be. In the annual reports of LINks and so on there are wide areas which currently are not getting the attention that they should be, which I am sure local healthwatch will wish to address.

Specifically, local healthwatch needs to represent the views of all people within the local population, including children and young people. However, we do not think that this should be in the Bill because, whatever the age of the patient or their family, and however marginal they may seem, we want to be inclusive and not exclusive, and if you list one group you are in danger, therefore, of excluding others.

However, we hear what noble Lords say and, as these organisations and the pathfinder local healthwatch organisations come into play, we will ensure that what noble Lords have said is flagged up to them. I hope that on this basis the noble Baroness will be willing to withdraw the amendments.

Baroness Finlay of Llandaff: If we come back later with an amendment which specifies people of all ages-I accept what she said about the elderly also not

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having an adequate voice at times to meet their needs-will the noble Baroness consider it? This is one occasion when the legislation can give a lead and set a moral code. I also seek an assurance that there will be specific mention of children in the official guidance that goes with the Bill so that they are incorporated at every stage and do not remain left out, as they have been until now.

Baroness Northover: I hear what the noble Baroness says. It is interesting that she said "people of all ages". The purpose of healthwatch and the NHS is to help and try to assist people of all ages, whether they are patients, their families and so on. We need to make it more person-centred-we all agree that that is what we are seeking to do-and I hear what she says in regard to the regulations.

Baroness Massey of Darwen: My Lords, I thank the Minister for her words. I have some concerns, to which I shall come in a minute. I am glad that so many noble Lords contributed. I am particularly glad that the noble Baroness, Lady Finlay, mentioned young carers and that the noble Lord, Lord Warner, talked about adolescent health, so long an area which has been very much neglected in relation to health services.

I would also like to thank the Minister for meeting a group of noble Lords to discuss the issue of children's interests in this Bill. I hope that the Government have got the message about the need to involve children in decisions about their care and treatment. Many have considerable health needs, although the young population is generally considered the healthiest. They have health and care needs, including mental health needs, disability and so on. I worry that when children get lumped in with expressions such as "the community" or "the family", their needs are ignored. Children have very little redress on this. If we do not make it explicit that we should consult children, they often do not have the ability or contacts to come back at that and make a protest. We have to do that for them, and children must be included in and consulted on all Bills that affect them.

I would like the words "children" and "young people" and consultation with them to be made very explicit in this Bill. I have amendments later, although I cannot remember their numbers, which will also reintroduce the notion of children into this Bill. In the meanwhile, I will withdraw the amendment, but I may well wish to return to the matter on Report with other noble Lords and look at it again.

Amendment 310 withdrawn.

Amendments 311 to 317A not moved.

Amendment 317AA

Moved by Lord Low of Dalston

317AA: Clause 178, page 177, line 4, leave out ", so far as practicable,"

Lord Low of Dalston: My Lords, I rise to move Amendment 317AA and shall also speak to Amendment 317AB, 336B and 336C and 318BA to 318BC, which are in the name of the noble Lord, Lord Whitty.



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The Bill contains a number of provisions which relate to the handling of information by various bodies. Amendments 317AA and 317AB relate to HealthWatch England and Amendments 336B and 336C relate to health and well-being boards. Amendments 317AA and 317AB come in Clause 178 and seek to strengthen the safeguards against HealthWatch England publishing information which relates to the private affairs of an individual.

The Bill already contains some safeguards, but I do not believe that they are adequate. Clause 178(4) states that,

and,

should be excluded from the reports that HealthWatch England is empowered to produce. But it states that information should be excluded only when it "seriously" prejudices an individual's interests, not if it prejudices their interests less than seriously-and who decides what is serious and what is prejudicial-and that it should be excluded only "so far as practicable". It is not clear to me why information that relates to the private affairs of an individual should be published at all. It seems to me that the prohibition should be absolute and that, in Clause 178, proposed new Section 45B(4) should simply read:

"Before publishing a report under subsection (1)(b) or (3), the committee must exclude any matter which relates to the private affairs of an individual".

That is what Amendments 317AA and 317AB would bring about. Paradoxically, this is a case where no safeguards would be better than the inadequate ones we have in the Bill.

Similarly, health and well-being boards are given wide powers under Clause 196 to request information-powers that are clearly wider than they need to be. As the Bill stands, a health and well-being board can ask a local healthwatch organisation for details of people who have complained or raised concerns about a service and, as the Bill stands, a healthwatch organisation would be obliged to disclose that information. Amendments 336B and 336C would stipulate that no information be requested which would require the disclosure of personal information within the meaning of the Data Protection Act.

The noble Lord, Lord Whitty, will speak in more detail to Amendments 318BA, 318BB and 318BC, which come in Clause 179, but I would like to indicate my support for these amendments. I am aware of concerns that have been raised about the independence of local healthwatch organisations arising from the fact that they will be both funded by and accountable to the local authority. It is explained in paragraph D35 of the integrated impact assessment that this is based on the importance of localism. Paragraph D106 of the integrated impact assessment states:

"There is a risk that tying local HealthWatch into local authorities could reduce their independence and effectiveness".

So it seems that the imperatives of localism trumped those of independence and effectiveness.



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The integrated impact assessment goes on to recognise that the duty on local authorities to fund local healthwatch arrangements may be perceived as giving rise to a conflict of interest for local authorities, given the role of local healthwatch organisations in relation to scrutiny. It is stated that work is under way to map out the concept of independence for local healthwatch organisations, and to use this to promote the arrangements as accountable to local government for performance and to local citizens for the issues raised with commissioners and providers, but we do not know the outcome of this work as yet. The Bill does not provide any detail on the membership of local healthwatch organisations. It is left to regulations to specify who makes appointments to these bodies, and how. It would be extremely helpful if the Minister could give some indication of how this separation of accountabilities, which is evidently envisaged, is to be realised and institutionalised.

In any case, however, the fact that the local authority holds the purse strings remains a risk to the independence of local healthwatch. There is therefore a strong case for local healthwatch organisations not to be funded by the local authority. The argument that the importance of localism requires accountability is not as strong as the need to have effective, independent local services. These amendments would make local healthwatch organisations responsible for their own activities and accountable only to HealthWatch England, rather than the local authority, but I fear the risk from local authority control of the purse strings would still remain.

Lord Rix: My Lords, I shall speak to Amendment 324, tabled in my name and those of my noble friends Lord Tenby and Lord Wigley, in this rather Christmas stocking grouping of amendments. This regards the provision of independent advocacy services for people who are in the process of making a complaint against the NHS. This amendment is particularly relevant to the needs of disabled people, including those with a learning disability, and I would like to take this opportunity to declare an interest as president of the Royal Mencap Society.

For those who are unfortunate enough to encounter it, the NHS complaints system is deeply flawed and ineffective. It is complex in its make-up and lengthy during the course of its deliberations. I welcome the Government's proposal for local authorities to make appropriate provision to support people in the complaints process, through the use of advocacy services. Effective and high-quality advocacy services are of course an essential prerequisite for many families to secure the answers they want and the justice which they really require.

Without this amendment, there is a risk that advocacy support could be started and then abruptly halted some time before any conclusion to the ongoing complaint which has been made. As I have already mentioned, the NHS complaints system is a lengthy and complex process and the level and scope of advocacy support made available by local authorities should reflect this.

I am also aware that in some cases advocacy support services have been denied to families, as the level of support deemed necessary has been regarded as too onerous and burdensome on the provider. This is an

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unacceptable state of affairs, where people are denied the help they need on the basis that they may need too much help. At a time when families could be dealing with the emotional upheaval and distress of coping with the loss of a loved one, any uncertainty about the level and period of advocacy available to them is, to put it somewhat generously, an unhelpful distraction. This is why I believe it necessary to ensure that advocacy support during the NHS complaints system is not restricted in length and type for those families who need it. This amendment would help to provide such a guarantee.

5 pm

Baroness Cumberlege: My Lords, perhaps the noble Lord, Lord Whitty, ought to speak next, because I suspect that his amendments relate to what the noble Lord, Lord Low, was saying, and it may be that the synergy would be better that way.

Lord Whitty: My Lords, I thank the noble Baroness very much. In this case, logic trumps chivalry.

I have four amendments in this group, all of which relate to the independence of the local healthwatch-some of them in some slightly indirect ways. We spent some time at an earlier stage, and again today, talking about the independence of Healthwatch England from the regulator. I did not intervene today, but it is evident that the Government are not persuaded that we need to unravel them. I am afraid we are going to have to return to that at a later stage, because I am certainly not convinced by the Government's arguments. However, I think that even the Government must recognise that a body representing patients, users and consumers of health and social care services has to be independent from the provider.

The problem with some of these clauses is that the local healthwatch organisation, as the noble Lord, Lord Low, has said, is not clearly independent from the local authority in all respects. We are not yet clear how independent of the local authority it will be in its membership and how that membership is appointed. Schedule 15, which comes in with Clause 179, is pretty general as to who the members would be. As the noble Lord, Lord Low, said, we have to await regulations before we see that. Meanwhile, there are other reasons why one is a bit suspicious that the local healthwatch organisations would come too much under the sway of the local authority, which is going to be the provider of many of the services to which they relate.

There may be other ways of doing this, but these amendments are attempting to make clear the independence of the local healthwatch body by establishing that it sets its own priorities and manner of operating, subject only to any guidance given by Healthwatch England; that is, it would not be subject to any guidance, restriction or direction from the local authority. There are then a number of clauses which are pretty complicated in themselves, but appear to treat the local healthwatch as if it were an excrescence of the local authority.

For example, I want to delete the bulk, or the purport, of Clause 181, which appears to treat local healthwatch organisations as if they came through the

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local authority rather than being independent bodies. Some of the requirements may well apply to healthwatch locally, but they should not be implemented and enforced via the local authority in any sense. The noble Lord, Lord Low, has already referred to some of the problems about freedom of information, but some of the other provisions could well raise difficulties if the local authority was the one ensuring that the local healthwatch met those provisions.

Independence of consumer organisations across the economy is important, and I will return to that on Report. Local bodies, in particular, need to be independent. They are the bodies to which individual patients and users will relate, and if they believe that the local healthwatch is in any way associated with, dominated by, or accountable to the actual providers of the bodies that provide the services, its credibility will be diminished. I would therefore hope that the Government took note of these concerns and made it more explicit in the final version of this Bill that local healthwatch organisations were independent of the local authority and made their own decisions, with their own priorities and manner of operation. I do not think that we can leave all that to regulation; it has to be more explicit in the Bill. This is one way of doing it, although the Government may well come up with better ways of doing it, but I think that we need to ensure that we reach that stage before we finish with this Bill.

Baroness Cumberlege: My Lords, I have a number of amendments in this grouping concerning local healthwatch. As has already been said this afternoon, local healthwatch is the source of intelligence from the people who are actually using the services. This intelligence is gathered through their enter and view monitoring visits to both health and social care services-we should not forget that it is social care as well-and through their local involvement work.

However, neither commissioners nor overview and scrutiny committees have the same binding arrangements to enter and view health and social care facilities. Local healthwatch has the opportunity to interview people at the time they are actually using the service. The local healthwatch has the independent messenger status with local people that neither commissioners nor overview and scrutiny committees have. Local healthwatch has the right to enter and view, to talk and listen, to the most vulnerable of all people, those with dementia or other mental illness, those lying on trolleys in A&E, or on mental health in-patient wards. "No decision about me without me" can be tried and tested when most fresh in the minds of patients and users. It is only here that the reality of the services that results from the theory of commissioning is to be found. To fail to take due account of this perspective in commissioning services is commissioning wearing a blindfold. The purpose of Amendment 318E is to ensure that commissioning is evidence based.

New Sections 14Z and 14Z11(2) require clinical commissioning groups to involve and consult on their commissioning plans. We know that this is a somewhat bureaucratic exercise, and it is often simply for the cognoscenti. Although these clauses are to be welcomed, they do not go far enough-hence the insertion of my

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new clause. Frail elderly patients lying in hospital wards who are not being fed will not be responding to consultations any more than will patients who have been sectioned under the Mental Health Act. The local healthwatch must talk to those patients and its findings must be an indispensable component of the evidence on which commissioning is based.

New subsection (3A), inserted by Clause 180(6), also requires commissioners and others to have regard to reports and recommendations from local healthwatch. This replicates the current arrangements for reports and recommendations from LINks, which has failed to bring the patient experience into the heart of commissioning. Compared to the status given to the views of health and well-being boards on commissioning plans-the strategic beginnings of commissioning-this is weak. What is needed is equal attention to the evidence on the outcomes of that commissioning, which local healthwatch is uniquely well placed to provide.

My new clause requires local healthwatch to hold the clinical commissioning group to account for incorporating the evidence that the local healthwatch has produced at the very start of the commissioning period. It should then heavily influence the commissioning plan for that period in taking the reality and applying it to commissioning theory. Binding the patient experience into commissioning is a much more specific requirement than merely "having regard to" local healthwatch reports and recommendations. The conjoint benefit of this new clause is that it increases the accountability of local healthwatch for producing robust evidence of the patients' experience. Providers must also satisfy the local healthwatch if they are to secure further contracts.

Lord Mawhinney: My Lords, I think that my noble friend said that providers must satisfy the local healthwatch before they can proceed with their commissioning. Is this another barrier to the commissioning process, or does she anticipate a collaborative conversation? I am not clear on whether this is another hurdle in the commissioning process or a lesser effect. It would be helpful, at least to me, if she would expand a little on that thought.

Baroness Cumberlege: My Lords, there is no intention that this should be a further hurdle, but if commissioners are going to commission services that are really relevant to local people then they need to take account of what the local healthwatch is saying. This is a huge resource that could improve services enormously and make contracts much more relevant than some of them have been in the past. I hope that that answers my noble friend.

I shall take three quick examples to illustrate my point. The first is a patient in an older persons ward who leant forward confidentially to the CHC visitor, saying, "They don't feed them in here, you know. They just put the food at the end of the bed, then they take it away again. Please don't tell them it was me who told you". The second one is the mental health in-patient in a unit with an outside garden, who explained that he could not go out even though the summer was

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really hot. There were not enough staff to accompany the patients outside so he "had to stay in all the time"-his words. What quality of life is that? The third is from another patient in an older persons ward who expressed concern about a patient whose hearing aid battery was flat: "They could just have gone to the audiology department to get another battery, but they wouldn't". The staff just spoke more loudly to the profoundly deaf patient, increasing his distress and isolation.

To some people these examples may seem quite trivial, but to the people concerned they are not-they are very important. I took those three examples because the first is over 10 years old, yet we know from the CQC's recent dignity and nutrition inspection programme, and from the evidence from Mid Staffordshire, that patients are still not always adequately fed in hospital. That makes the point of the amendment perhaps more powerfully than anything else. What we are doing now is not working; it is not effective, and does not bring about the radical changes that are necessary. We have to do things differently, and the suggested new clause gives us the opportunity to do just that. I feel strongly about this issue and I hope that the Minister will give it serious consideration. Otherwise, I may have to bring it back at Report.

5.15 pm

My remaining amendments, Amendments 320ZA, 321C and 322A, are designed to ensure that local healthwatch organisations have the status, powers and functions necessary to be efficient and effective. Without these proposals, they will be another initiative to involve citizens without the necessary infrastructure, and will betray all those volunteers who put so much time and effort into trying to get the voice of users heard. We cannot afford for another attempt at this to fail. Otherwise, our credibility will evaporate.

Amendment 320ZA concerns the pay and rations functions of local authorities which need to be delivered to local healthwatch, and takes up the concerns expressed by the noble Lord, Lord Low of Dalston. It reduces the role of the local authority to the minimum needed for the local healthwatch to come into being and to work efficiently. It provides pay and rations for local healthwatch and gives the local healthwatch the option to have a budget, if that is what it prefers. The current contracting arrangements are unduly complex and inconsistent with the status of local healthwatch as an independent body rather than a mere creature of the local authority. Clarity and simplicity are essential. Local healthwatch needs to be an enabler of local people and local groups, including those groups which support vulnerable and marginalised people, who should have a voice that is heard directly at the decision-making table by those reaching decisions on health and social care. This is an important job that needs to be got on with as soon as possible.

Local healthwatch must of course have the rights, powers and functions necessary to work flexibly and to have some autonomy over its organisational destiny. It needs independence so that it can work with lay people on local programme boards, in partnership with local community groups through pooled budgets, or as commissioners of projects through support groups.

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Above all, it needs the confidence of vulnerable groups that will only speak openly through it. How local healthwatch then establishes its ways of working to meet its functions cost-effectively and efficiently is then for local determination.

For an effective local healthwatch to get on with the job of patient involvement and monitoring services-its core function-as soon as possible, five ingredients are essential: a simple, clear structure requiring minimal input locally before starting work; a set of functions on which local healthwatch can be held to account; consistent standards to measure that accountability; a suite of powers to enable it to achieve those functions in a range of ways for maximum efficiency and effectiveness; and a transparent enabling role for local authorities, rather than a directive one.

Many amendments in this group are designed to go some way towards this. Transition must be managed very carefully. Who steps into the body from the local involvement network should depend on how well the existing LINk has met a set of transition criteria, which could be set in consultation with LINks and others, and which should be transparently and consistently applied by local authorities. I hope my noble friend will consider these amendments very carefully.

I turn very quickly to my last two amendments. Amendment 321C enhances the structure of local healthwatch by giving it functions instead of activities controlled by the local authority. It is another attempt to make local healthwatch independent. Either local healthwatch is going to be independent or it is not. In the scheme that the Bill currently sets up, with the term "activities", the local healthwatch could be a creature of the local authority instead of an independent organisation hosted by it.

My final amendment, Amendment 322A, seeks transparency and consistency in local authority decisions on local healthwatch. At the moment, a local authority may cut funding from a local involvement network, and may do so in future for a local healthwatch, and then criticise the poor performance which has, in fact, been caused by inadequate funding. The Bill must safeguard local healthwatch from such undue interference and give confidence to local communities that we are creating something that will help prevent a repeat of Mid Staffordshire. Furthermore, in its role of scrutinising social care, local healthwatch scrutinises local authorities, who are also its funders, as commissioners of social care-a peculiar version of arm's-length accountability. This introduces the potential for bias in local authority decisions about funding and setting up local healthwatch. In Clause 182, new Section 223A(6) recognises that independent advocacy services must involve neither the person complained about nor someone who has investigated the complaint.

Therefore, I am seeking that a similar principle should apply to the role of local authorities, who are sometimes commissioners and even providers of social care themselves, as funders of local healthwatch. Greater transparency in decisions made about local healthwatch by a local authority is part of the solution, as it would make bias and undue influence much more difficult as a rationale. All the decisions would have to be explicit and aligned with the statutory functions of both

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organisations. This is not to reduce the autonomy of local authorities but merely to improve the transparency with which they exercise that autonomy. I hope the Minister will consider these amendments carefully.

Lord Harris of Haringey: My Lords, I will speak to the seven amendments in my name in this group, Amendments 319, 321, 322, 323, 325, 326 and 327. The noble Lord, Lord Rix, described this group as something of a Christmas stocking; I have to say that even my seven amendments do not have a common theme. They are on a variety of topics, ranging from some that simply correct what I assume are drafting errors in the Bill to others that raise rather more fundamental issues along the lines of the amendment of the noble Baroness, Lady Cumberlege.

Amendment 327 deals with what is, I think, a drafting error. Unless I have misinterpreted the interlaying Acts that are being subsequently amended, the Bill leaves a reference to primary care trusts in the base Act. Presumably the assumption is that the commissioning groups will take on those functions and should be expected to respond to the local issues raised by local healthwatch organisations. I am sure that is simply a drafting arrangement.

Amendment 323 would slightly tighten the wording on how independent advocacy is organised and says that the provision should be appropriate to the needs of those for whom that provision is being made available. I am sure that the Government will have no problem with that. It makes sure that advocacy arrangements recognise the very different nature of the problems and the client groups who will raise them.

Amendment 321 puts into the Bill a requirement that arrangements be made to enable members of local healthwatch organisations to have indemnity cover against the risk that a claim may arise from their duties. I am doing the Government a favour by highlighting this at this stage. I certainly recall, from the time of my involvement in community health councils, and in another sector prior to that-the work of electricity consultative groups for a completely different government department-that the same issue arose. I refer to the indemnity or protection that is there for people who are carrying out public duties if they are involved in an accident and a claim is made against them for it. What we will have-I am sure it will be in the Minister's brief-is some vague statement about Treasury indemnity.

The problem for individuals in this position is that it is not clear what such indemnity will cover and how they will be able to access it if, for example, they are involved in an accident or an incident during their work as a member of a local healthwatch organisation. I would advise-I am trying, as ever, to be helpful to the Government-that this should be sorted out now rather than waiting to get into a tangle about it. I remember spending many happy years, when I was Director of the Association of Community Health Councils, trying to get a definition that would satisfy local CHC members that they were protected. Otherwise, the answer goes back that you should claim on your own insurance policies; yet those insurance policies often exclude people who are carrying out work-even voluntary work-or similar duties. Acting on behalf

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of a local healthwatch organisation will almost certainly be excluded by the individual members' insurance policies. My experience on CHCs and in other organisations is that this is a constant pressure and a constant concern. There should be something explicit in the Bill to provide a degree of reassurance to people who are undertaking these activities on behalf of their communities.

Amendment 319 relates to the membership of local healthwatch organisations and is put forward today as a probing amendment. I hope the noble Baroness will give us details of how it is envisaged that local healthwatch members will emerge in that role. The question of how legitimate local healthwatch organisations will be-how representative they will be-depends critically on the precise arrangements by which people end up as members of the organisations. The previous Government's proposals in respect of LINks, which I never fully understood, left it in a state of limbo and people were, essentially, self-appointed as members of LINks. There must be a degree of transparency and clarity in the process by which people end up as members of local healthwatch organisations. The proposal here is that there should be some system of election. Often, although this was not exclusively the case, the most effective members of local community health councils were those who were elected by local voluntary organisations in the areas concerned. They were often the people with the most detailed, personal knowledge of the services they were monitoring. They often had a constituency they could draw back into for information and support for the work they were doing. Above all, they had the added legitimacy of having been chosen for that role by other local voluntary organisations.

I am not suggesting that as a model that should necessarily be adopted. What I am saying is that the clarity it gave those individuals was very helpful. Other members were appointed directly by the local councils for the area. Again, that gave clarity about who they were representing and what their legitimacy was. Some were appointed by regional health authorities, though this changed every time the health service was reorganised, which was every two or three years. That is something that does not change, even now, and I am sure we will be back here in two or three years unpicking whatever finally emerges from the sausage machine of legislation that we are processing now.

It is going to be critical to have a clear process by which local healthwatch organisation members are appointed. It is also important that they have legitimacy. Otherwise the organisations to which they relate will say, "You are not representative. You are self-selecting" or "You do not represent the communities you purport to represent". Clarity about the appointments process is important. Some system of election would be valuable, but it would be helpful if the noble Baroness could tell us today exactly what is envisaged. We certainly need to know that before we proceed further with the Bill.

The orange in the Christmas stocking is the relationship between the local authorities and local healthwatch organisations. I have tabled Amendment 322, which refers to local healthwatch organisations not being subservient to the body that is responsible for their establishment. That goes to the core of the issues

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raised by the noble Baroness, Lady Cumberlege, about the extent to which local healthwatch organisations can be effectively under the control of local authorities.

I know that we will be assured that local healthwatch organisations will be independent and have all this additional legitimacy because they will know that local authorities have provided them with support, and that that is why the proposed structure is being adopted. However, that model will not necessarily work. I speak as someone who was leader of a local authority for 12 years and I know how decisions are made. In particular, I know how decisions are made at times of financial stringency. Unless the resources for these local organisations are guaranteed in some way, they will be vulnerable-not necessarily because they are saying unhelpful things but simply because the local healthwatch organisation will not be seen as a core activity of the local authority at a time of stringent finances and resources. That is why this issue needs to be addressed head on.

There is a problem of potential conflict of interest. Local authorities are responsible for providing certain types of social care. They are responsible for commissioning and providing that care. They will have a responsibility with others through the local health and well-being boards. There is a danger that local healthwatch organisations will be seen as being conflicted because they are subordinate to the local authorities in their area.

There are two simple ways for the Government to solve this problem, both of which I know they are not currently minded to consider. One model is a separate structure that provides the funding and resourcing for local healthwatch organisations; and that would flow back to HealthWatch England. The other model is to ring-fence the resources that are passed through to local authorities for this purpose. I know that Her Majesty's Treasury is always against ring-fencing and, indeed, the Local Government Association, of which I have the honour to be a vice-president, always argues against the ring-fencing of resources because it is always better for local authorities to make their own determinations. However, this is not about determining local needs. This is about providing something for the local community on behalf of another government department.

The Department of Health has, no doubt, fought a valiant battle with the Treasury to secure the resources for HealthWatch and the Treasury is passing that money through the Department for Communities and Local Government down to local authorities. There is no ring-fencing. The reality is that local authorities will not be able to say to the Treasury at the next comprehensive spending round how those resources have been used. They will not even be able to demonstrate that those resources have been used for the purposes for which they were given, and they will lose the battle for the continuation of that funding. If there is a ring-fenced structure, you will ensure that the resources are there for local healthwatch organisations. There may then be a question about how effectively those local organisations operate, but at least the resources will be clear and the local authority will be accountable

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for how it has used that money explicitly, rather than for whether or not it has used the money for that or for other purposes.

Unless that issue is addressed, there will be not only perceptions of conflicts of interest but the problem that local healthwatch organisations may, in time, be starved of resources. This is not an idle concern. We have all received the correspondence from LINks, talking about the budget cuts that they have faced in the current financial year. We can expect that to continue. If the Government are serious about having vibrant and effective local healthwatch organisations, they have also to solve the resourcing question and the perceived conflict of interest between the local authority and local healthwatch organisations.

We heard much in our earlier debates about the synergies and wonderful effects that talking in corridors would have within the CQC. I thought at one point that the noble Baroness was going to talk about talking in the toilets about decisions and how you infuse ideas from one organisation to another if they are co-located. That will not be the case with local authorities and local healthwatch. You will not get that same connection. The mere fact of being in the same organisation will not matter because they will not be physically located with the people who are making the decisions about social care; they will probably be in an outward-facing office, meeting the public. It will be an outpost of the local authority. There will not be that informal interchange which we were told would be so valuable if Healthwatch England was placed within CQC. The issue is how you make these organisations effective. That will require independent resources and it will require that the question of conflict of interest is dealt with.

Viscount Tenby: My Lords, very briefly, I support the amendment in the name of my noble friend Lord Rix. He has clearly outlined the rationale behind the amendment; accordingly, I do not intend to keep the House long-sighs of relief all round, I should think-although, like my noble friend, I should declare an interest. Until last Wednesday, I was chairman of a residential home for those with learning disabilities.

I think we are aware that the complaints process against the NHS can be extremely complex and challenging for those involved. That nearly always coincides with a period of some personal distress. Indeed, the very inclusion of Clause 182 indicates that the Government, to their great credit, are aware of that factor. However, there is a danger that the provision is not sufficiently explicit. My noble friend has highlighted the potential for advocacy support to stop before a conclusion has been reached. I share his concern, and add that the amendment safeguards against the freedom given to a local authority to define what it deems to be "appropriate arrangements" for the provision of independent advocacy services.

The critical point is that, at a time when local authority budgets are particularly stretched, to expect them to provide additional resources for advocacy support could result in the needs of people being sacrificed in favour of councils balancing their books. We all understand that that goes on. In other words, the level of advocacy support offered might be dictated

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by available funds and, accordingly, "appropriate arrangements" might be taken as being what is appropriate for the council to offer.

That detracts from what I assume is the object of making advocacy support available: to benefit the individual. The ability for people-often in mourning and in some distress-to seek justice should surely seek precedence over what is convenient to the local authority. By explicitly removing any upper limit on the length and type of advocacy, the amendment sends a strong message to councils that the individual must be the priority in this situation. It removes the excuse that a council might have not to provide the adequate level of advocacy support required by those who need it; and instead gives the individual the power to challenge any decision they feel is unjust on the basis that their advocacy needs are greater than the support proposed.

Baroness Masham of Ilton: My Lords, I shall add just a few words. If we do not get this matter right, we, the Members of the House of Lords, will be blamed. I hope that Ministers will act on what has been said this evening.

Baroness Wheeler: My Lords, noble Lords have spoken to their amendments effectively and comprehensively, so I will not deal with all the amendments. I start by giving our support to the spirit behind Amendment 318BA, tabled by my noble friend Lord Whitty and the noble Lord, Lord Low, and Amendment 322, tabled by my noble friends Lord Rooker and Lord Harris. They underline the crucial need to uphold the independence of local healthwatch organisations by enabling them to carry out their activities as they see fit, subject to any directions from Healthwatch England, and emphasise that they must not be regarded as either servants or agents of the local authority.

Local independence is vital for people to have trust and confidence in their local healthwatch organisations to articulate their priorities and the needs of the local community. To be effective, they must be able to scrutinise how consortia and health and well-being boards have undertaken public engagement and transparency, and how they are ensuring that the patient voice is embedded in the care pathway design. They also need to be able to scrutinise how lay representatives on consortia and health and well-being boards themselves undertake public engagement and transparency.

Amendment 318E in the name of the noble Baroness, Lady Cumberlege, would require local healthwatch organisations to provide the NHS Commissioning Board with their opinion on whether local plans take proper account of their views, as evidence in reports and recommendations. We support this, and of course underline that CCGs must also be required to consult local healthwatch organisations while commissioning plans are drawn up and developed.

On the question of how local healthwatch organisations are funded, we need to recognise the widespread concern raised by noble Lords and current LINks organisations that the arrangements for local healthwatch organisations and their dependence on funding from local authorities

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compromise their independence, particularly in terms of public perception and confidence in their role and work. With local authorities having greater involvement in healthcare-particularly public health-how will healthwatch organisations be able to exercise the independence that the public would expect?

A number of amendments seek to address that issue, either through guaranteeing resources or prescribing how the local authority should take decisions in relation to its commissioning of healthwatch, the allocation of resources and the governance arrangements. Perversely, some of them could have the unintentional consequence of tying in local healthwatch groups to the local authority more tightly. In view of the current economic climate and the massive cuts that local authorities are having to make, the concerns and unease over the future resourcing of local healthwatch organisations need to be addressed. I hope that the Minister will recognise this as a major issue, consult all stakeholders and come back to us on Report with reassurances and solutions.

This is the first time we have touched on the new independent advocacy services that local authorities will be required to establish to provide assistance to individuals making complaints about health or community care services or providers, including using the local healthwatch organisation to deliver this service. We are very sympathetic to Amendment 324 from the noble Lords, Lord Rix and Lord Wigley, and the noble Viscount, Lord Tenby. It seeks to prevent any case being dismissed from the outset or midway through as too complex or lengthy. Complaints against the health service are often complex and require long periods of support to be provided to the complainant. It is a service that should be provided to all users, and provision will need to be made to support people with mental health problems and learning difficulties, as well as people with disabilities.

We support Amendment 325 in the names of my noble friends Lord Rooker and Lord Harris. This would provide for advocacy to cover complaints about both health and social care. I look forward to the Minister's response on these issues.

Baroness Northover: My Lords, again, we have had a very impressive and wide-ranging debate. It links in with the earlier debate on this area, as well as with our discussion the other day.

The noble Lord, Lord Low, made a very strong point when he talked about the need for confidentiality. I hope I can reassure him that HealthWatch England will be subject to the provisions of the Data Protection Act and other applicable law. However, these are complex matters, involving a number of interlocking pieces of legislation and other issues. As a result, I hope that the noble Lord will allow me to write to him with full details of how we see these provisions working. However, I hope that he will be reassured about the overarching effect of the Data Protection Act. He made some very telling and important points.

Our aim is for local healthwatch organisations to become an integral part of the commissioning of local health and social care services. They will build on the

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strengths of the existing Local Involvement Networks and, we hope, address their weaknesses. I have listened to the concerns that various noble Lords have expressed about independence, given local healthwatch organisations' contractual relationships with local authorities. I hope I can reassure noble Lords that local healthwatch organisations will be very firmly in the lead in determining their own work programmes and local priorities. Local authorities, for example, cannot arbitrarily veto a local healthwatch organisation's work plan or stop a local healthwatch organisation providing feedback or recommendations to HealthWatch England, nor can they suppress local healthwatch organisations' reports with which they disagree. I am sorry that the noble Lord, Lord Warner, is not in his place, as no doubt he would be hopping up and down challenging me on these matters. It is extremely important that local healthwatch organisations are effective in this way: we have made the provision that we have. Nor can local authorities starve local healthwatch organisations of funds, as the noble Lord, Lord Harris, implies. Local healthwatch organisations must have sufficient resources to fulfil their statutory functions. Those are laid down and they have to deliver on that.

Lord Harris of Haringey: I-

Baroness Northover: Oh! Here we are.

5.45 pm

Lord Harris of Haringey: I thank the noble Baroness for giving way. The problem with not ring-fencing funds and simply relying on the statutory requirement is that there are many ways of interpreting a statutory obligation. For example, there is an obligation on local healthwatch organisations to provide information to the public. You can provide information at various levels. At one extreme, this could be leaflets to every household, or it could be telephone helplines. It could be all sorts of things-or it could simply be to say that the information manual has been placed in the local library. If the local healthwatch organisation does that, it has fulfilled its statutory obligation in providing information to the community. I am assuming that Ministers do not want that to be the scale of the provision, but simply saying that you have met your statutory obligation is not a sufficient safeguard to provide £60 million-worth of services, if that is the sum of money being made available to local healthwatch organisations.

Baroness Northover: The noble Lord, Lord Harris, made exactly this point at the meeting that we had the other day with my noble friend Lord Howe, who I thought countered his points extremely effectively. However, I realise that is now almost 6 pm and I know that noble friends have other appointments; maybe we would otherwise carry on until Christmas. We take on board what the noble Lord, Lord Harris, has said. I am sure that he takes on board the counterpoints from my noble friend Lord Howe, but we will continue to discuss how best to ensure that local healthwatch organisations are effective in the way that we need them to be.



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Some of the amendments of my noble friend Lady Cumberlege would increase the role of the Secretary of State in relation to local healthwatch organisations. Though we understand the intent behind the amendments, we do not feel that that is quite the way to go. Nevertheless, we acknowledge the need to keep the issue of local healthwatch organisations' independence under review and we are working closely with stakeholders to look at how best we can support that independence at local level.

My noble friend made a range of proposals which were extremely interesting and we will take those back, along with other noble Lords' suggestions. We are keen that local healthwatch organisations have the flexibility to work with and for their local communities. I am aware of the concern expressed by a number of stakeholders that the Bill does not contain sufficient flexibility. I can confirm that we also want to make sure that the process of getting local healthwatch organisations started is as efficient as possible. We want to assist in that and again we discussed this with stakeholders yesterday. We would not want to see local healthwatch's ability to get on with its valuable role slowed down.

My noble friend suggested that local healthwatch organisations should have a stronger role in relation to CCGs' commissioning plans. I sympathise with the sentiment behind this amendment and with other proposals to try to make sure that the voice of the patient is heard. However, this would place a further statutory function on local healthwatch organisations, and it might be unnecessarily prescriptive. There are, of course, arrangements in place in the Bill for local healthwatch organisations to feed their concerns to HealthWatch England, and HealthWatch England can also provide the NHS Commissioning Board with information and advice on the views of local healthwatch organisations on the standard of healthcare. Were a local healthwatch organisation to have concerns that a clinical commissioning group had not taken proper account of its views in commissioning plans, they could be raised by this route. However, this is an important issue, and I will take it away to consider it further.

Lord Harris of Haringey:Will the Minister clarify whether she is seriously suggesting that rather than having a route going direct from a local healthwatch organisation to a clinical commissioning group, it is better to have a route that goes from the local healthwatch organisations to HealthWatch England-I do not know whether we would include CQC in that process-then through the national Commissioning Board and then back down to-

Baroness Northover: I did not put that clearly enough. Local healthwatch organisations will be feeding into clinical commissioning groups. That is already apparent. They have all sorts of ways, not least through the health and well-being boards, to make sure that the needs of the community are clearly expressed so that commissioning is as appropriate as possible. Where that is not being properly listened to, and therefore serious issues need to be addressed, there are other ways of ensuring that actions can be taken.



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However, all these groups need to be talking to each other. I hope very much that they will. One of the reasons for local healthwatch organisations to have the association with local authorities is that local authorities have responsibility for so many areas that also affect the health of the population. They will have new responsibilities in public health as well. All this needs to link up to make sure that the quality of health is improved. This is part of that arrangement. We are looking at it locally and nationally. However, I will take back the suggestions that my noble friend Lady Cumberlege made. We want to make sure that this system works effectively without being overly prescriptive.

I agree that indemnity is a fundamental issue. It is one to which the Government have given significant consideration. We have concluded that it is most appropriate for it to feature in local contractual arrangements rather than in primary legislation that may lack flexibility.

The noble Lord, Lord Harris, is right that the system by which people serve on local healthwatch organisations needs to be transparent-all this needs to be transparent. I heard what he said in that regard, and I will feed it into the discussions that are going on at the moment.

On some matters it is probably best, if I need to follow up, that I do so in writing, as I am acutely aware that my noble friend Lord Howe and the noble Baroness, Lady Thornton, have another engagement this evening, and we must release them.

I turn to NHS complaints advocacy. Clause 182 has the effect of transferring a duty to commission independent advocacy services for NHS complaints from the Secretary of State to local authorities. The principle behind advocacy will remain unchanged: it is the provision of appropriate support to people who wish to make a complaint about the NHS to enable them to make their own decisions. We propose that commissioning of advocacy shifts from the Secretary of State to local authorities to best meet local needs.

I note the wonderful Amendment 324, tabled by the noble Lords, Lord Rix and Lord Wigley, which seeks to ensure that advocacy will be provided without limits on the length or type of support. I commend them for their ambition but it would not be appropriate to put that limit in the Bill. I am sure they understand that but we take what they say about the importance of advocacy and commend them for their strong advocacy of advocacy.

I realise that all these areas are of great concern to noble Lords. This may be just one part of the Bill but in many ways it is the heart of the Bill, which is about patients and how best you ensure that patients' experience translates into an improvement in quality in practice. Other noble Lords have grappled with this before. The previous Government did and Governments before that. We are trying to take this further forward, both in terms of the national and local arrangements. We hear what people say in response to the proposals but I hope that in the mean time the noble Lord will not press his amendment.



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Lord Low of Dalston: I am grateful to the Minister for the way in which she appeared to take the force of the points that I was making with my amendments about the use of information. When she referred to the overarching effect of the Data Protection Act it appeared that she was listening more to my amendments about health and well-being boards than those relating to HealthWatch England, but I will wait to receive the letter that she kindly has promised to write to see how fully she has taken the force of my points in relation to both those bodies. I was encouraged by what she said so for now I will withdraw my amendment.

Amendment 317AA withdrawn.

Amendments 317AB to 318B not moved.

Clause 178 agreed.

Clause 179 : Establishment and constitution

Amendments 318BA to 318BC not moved.

Clause 179 agreed.

Amendments 318C to 318E not moved.

Schedule 15 : Local Healthwatch Organisations

Amendment 319 not moved.

Schedule 15 agreed.



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Clause 180 : Activities relating to local care services

Amendments 320 and 321 not moved.

Clause 180 agreed.

Clause 181 : Local authority arrangements

Amendments 321A to 322A not moved.

Clause 181 agreed.

Clause 182 : Independent advocacy services

Amendments 323 to 326 not moved.

Clause 182 agreed.

Clause 183 : Requests, rights of entry and referrals

Amendment 327 not moved.

Clause 183 agreed.

Clause 184 : Dissolution and transfer schemes

Amendment 327ZA not moved.

Clause 184 agreed.

Clauses 185 and 186 agreed.

Amendment 327ZB not moved.

House resumed.

House adjourned at 6.01 pm.


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