National Health Service Reform and Health Care Professions Bill

HL Deb 11 April 2002 vol 633 cc531-91

3.37 p.m.

The Parliamentary Under-Secretary of State, Department of Health (Lord Hunt of Kings Heath)

My Lords, I beg to move that the House do now again resolve itself into Committee on this Bill.

Moved, That the House do now again resolve itself into Committee.—(Lord Hunt of Kings Heath.)

On Question, Motion agreed to.

House in Committee accordingly.

[The CHAIRMAN OF COMMITTEES in the Chair.]

Baroness Noakesmoved Amendment No. 104A: After Clause 14, insert the following new clause— "COMMISSION FOR HEALTH IMPROVEMENT: INDEPENDENCE (1) In section 20 of the 1999 Act (function of the Commission for Health Improvement) subsections (3) and (4) arc omitted. (2) Schedule 2(1) to the 1999 Act is amended as follows—

1. (a) in paragraph 2 (general powers) the words "Subject to any direction given by the Secretary of State" are omitted.
2. (b) in paragraph 4(a) and (c) (membership) for "Secretary of State" there is substituted "NHS Appointments Commission".
3. (c) in paragraph 6(1) and (2) (remuneration and allowance) for the words "the Secretary of State" there is substituted "it",
4. (d) in paragraph 6, sub-paragraphs (3) and (4) are omitted,
5. (e) in paragraph 10(1) (payment and loans to Commission)—
1. (i) for "may" there is substituted "shall", and
2. (ii) for "he considers appropriate" there is substituted "are agreed with the Commission",
6. (f) in paragraph 10, sub-paragraphs (7), (8) and (9) are omitted."

The noble Baroness said: Amendment No. 104A is designed to improve the independence of the Commission for Health Improvement.

Clause 14 contains some useful measures relating to the independence of CHI. They take away the Secretary of State's power to consent to the appointment of CHI's chief executive and to give directions in relation to the terms and conditions of CHI staff. Amendment No. 104A goes further in several important respects by further amending the Health Act 1999.

Subsection (1) of the new clause would delete subsections (3) and (4) of Section 20 of the 1999 Act and, thereby, remove the Secretary of State's power to give directions to CHI and the corresponding obligation on CHI to comply with those directions. Paragraph (b) of subsection (2) replaces the Secretary of State's appointment powers over the chairman and members of CHI with the NHS Appointments Commission, thus depoliticising appointments. Paragraphs (c) and (d) remove the Secretary of State's power over what is to be paid to members of CHI and its committees, including powers over pensions and compensation for loss of office. Paragraph (e) takes away the Secretary of State's discretion as to how much he pays CHI for its work, turning it instead into an agreement between the Secretary of State and CHI. Paragraph (f) removes the Secretary of State's powers and those of the National Assembly for Wales to direct CHI as to how it should spend its money.

That may all sound rather complicated, but the bottom line is that, with such amendments, CHI would become more independent of government. Earlier in Committee, my noble friend Lady Cumberlege spoke powerfully about the need to take politics out of the NHS. One place that should be totally devoid of politics is the NHS' independent inspectorate. An inspectorate cannot be independent if its governing body is appointed by the Secretary of State. It cannot be independent if the Secretary of State can tell it what to do and it cannot be independent if its funding is determined by the whim of the Secretary of State. This amendment seeks to give CHI proper independence so that it can be totally free of political interference.

The mere existence of powers such as powers of direction reduces the independence of a body such as CHI. The power of direction does not have to be used as such, but the ability to use a power secures the effect of subservience; that is the history of powers of direction for public bodies. The powers are rarely used but are often relied upon.

I believe, or at least I hope, that the Government are edging towards a properly independent CHI. For that reason I hope that they will embrace these extra and essential components of that independence. I beg to move.

Lord Peyton of Yeovil

I should like, first, to make what is becoming my habitual protest about the way in which this Bill—along with others—has been drafted. It would be desirable to provide at least some kind of Keeling schedule to indicate to anyone taking part in discussing a Bill what the law will look like if the Government's proposals are carried. I cannot repeat too often or say too strongly how revolting I find it that successive governments show such total contempt for Parliament that they will not provide even the modest degree of furnishing for which I am asking. I hope that the noble Lord, Lord Hunt, who is good about these matters and who does listen, will pay attention to my remarks. He should realise that some of us will simply go on and on and on until Bills are produced which can be readily understood by people who do not have eyes in the back of their heads so that they can read two Bills at the same time. Such improvements will make it possible for sensible discussion to take place.

I should like to congratulate my noble friend on her amendment. Personally, I have long believed that the National Health Service suffers from an excess of investigation, monitoring and examination by persons who, although sometimes skilled in examination, have seldom any concept of the disruption, delay and waste of time that their interventions cause.

Recently I took the opportunity to conduct a superficial examination of the body known to its friends as CHI. For myself, because it has a slightly ironic title, I give the name in full: the Commission for Health Improvement. The noble Lord will correct me if I am wrong, but there was a time when I suspected that the duty of the Department of Health was, to put it quite simply, to improve health. Either the officials found themselves so incompetent that they could not do that, or they so wished to introduce reinforcement that they set up this body, which has huge powers.

However, while the body's functions are declared under Section 20(1) of the 1999 Act, in subsection (2) it is made quite clear that the Secretary of State may, by regulations, make provision. Thus, in effect, the Secretary of State may tell the commission what it can do, when it can do it and how it should be done. Other points are covered, but I shall not bore your Lordships by relating the detail of the entire contents of the clause. I refer also to the subsection to which my noble friend's amendment refers. The Secretary of State can regulate and direct the commission with regard to what it does and when it does it.

What is the commission for? It does not have even a pretence of independence. It is the lackey of the Secretary of State. I see that the noble Lord is shaking his head. I shall be most interested to hear how any body can possibly enjoy independence when it is subject to ministerial direction of the kind set out here and of the kind against which my noble friend is protesting.

A brief examination of the commission on my part has revealed that, as a paper mill, it is deserving of quite a high place. Within two years it has established itself as a major source of paper. I have just some of it with me, from which I propose briefly to weary noble Lords with one or two paragraphs. The chairman, whom I am told enjoys a good reputation outside the commission, has written a foreword which is an astonishing piece of optimism: You are warmly invited to this exciting prospectus when was a prospectus ever exciting?— that we hope captures the essence of the Commission for Health Improvement's … properly demanding responsibilities for 2001–2004. CHI's"— at this point the commission's "nickname" is used— first year … was rich in challenge and included the requirement"— here there is a split infinitive— to simultaneously design and establish the organisation, construct wide ranging methods, and employ them across the breadth of our responsibilities. As CHI sets its goals for the next three years, the scale of challenge increases as we commit ourselves to deliver substantial elements of our long term work programme. We have increased the volume and complexity of our activities to support the high levels of performance required". I do not doubt that those who suffer from the visits and investigations of this body are enduring increasingly sharp nightmares as a result of that phrase.

3.45 p.m.

Lord Hunt of Kings Heath

I am most grateful to the noble Lord for giving way. Would he not agree that the very appearance of a split infinitive in the foreword to the report demonstrates the wholly independent nature of CHI? If the department had been as interfering as has been suggested by noble Lords opposite, then the split infinitive would never have appeared.

Lord Peyton of Yeovil

I say only that in the Act of Parliament passed in 1999, Parliament was induced by the Government to give this body extremely large functions and then to tell it exactly how to perform them. If that is freedom, then I simply do not understand the language. The fact that so far the Government have not seen fit to follow what it has done in every detail is neither here nor there. The Secretary of State has powers which he ought not to have and which make a nonsense of the commission's alleged independence.

I should like to refer to what is called the Executive Summary which states fairly briefly what tie commission did during its first year. It, published pilot clinical governance review reports … five investigations … research and field work on NHS progress … recruitment of over 180 permanent staff, and assessment a id training of over 240 reviewers All those people are going to run around like scorpions, annoying those trying to do a decent job for and near to patients.

Its last claim is that it has established, effective internal management arrangements to ensure standards of performance including corporate governance". I dare not weary the Committee with the chairman's introduction to its next report.

The commission claims to have looked at itself in the mirror. It must have been a nice, friendly mirror. Amazingly, it saw reflected a very good view of itself and was quite fascinated.

But there is another view. I asked one or two people of eminence whether they endorse and share the view which the commission takes of itself. "Nothing of the kind", they say. Some regarded it as superficial and aggressive, devoting itself to investigating problems which were well known. The effect of its investigations, they say, is not to cure problems but to delay tackling them. What the commission does often enough, although I have not been able to follow its tracks myself, follows disruption and frustration. The efforts to put things right by those in a position to do so are therefore delayed.

I hope that the Minister will not attribute to me a desire to sound off and oppose efforts to put things right, which deserve respect, but people whose duty it is to investigate need to be careful that they do not greatly upset, disturb and frustrate those who are trying to do an important job of work. I support most warmly what my noble friend said.

Baroness Northover

I support—perhaps more straightforwardly—the amendment of the noble Baroness, Lady Noakes.

Professor Kennedy concluded in his report on the Bristol cases: The quality of healthcare should be regulated through bodies such as the National Institute for Clinical Excellence and the Commission for Health Improvement. These bodies should be independent of government". He states that it is essential that CHI, should be suitably structured so as to give it the necessary independence and authority", to carry out its work.

In my view, CHI is already doing a useful and commendable job. The Government should be supported. They set up these bodies in the first place and we welcome the extension of CHI's independence proposed in the Bill. However, we agree with the noble Baroness, Lady Noakes, that the Secretary of State's role should be removed in order that genuine independence is, and is seen to be, the order of the day and to ensure that there are no loopholes through which a Secretary of State might be tempted to squeeze. We are happy to support the amendment.

Baroness Finlay of Llandaff

I, too, support the amendment, which seeks to increase the independence of CHI and other such organisations.

The noble Baroness, Lady Northover, quoted from the Kennedy report. That report also states: The various bodies whose purpose it is to ensure the quality of care in the NHS (for example, CHI and NICE) and the competence of healthcare professionals (for example, the GMC and the Nursing and Midwifery Council) must themselves be independent of and at arm's-length from the DoH. All the various bodies and organisations concerned with regulation, besides being independent of government, must involve and reflect the interests of patients, the public and healthcare professionals, as well the NHS and government". I reinforce the view that the work undertaken by CHI has been very valuable. It has highlighted deficits in care and deficits in the management of services for patients. All the improvements in patient care are long overdue and welcomed by everyone. Everyone in this Chamber—just as everyone in the population as a whole—will, on one day or another, be a patient in a service which is absolutely crucial to the well being of the country.

Lord Chan

I, too, support the work of CHI. Previously in Committee I asked who will review CHI and received the answer that it will be the National Audit Office. There are therefore sufficient safeguards in regard to CHI's position. It is doing an excellent job. The amendment can certainly be supported.

Lord Hunt of Kings Heath

The noble Lord, Lord Peyton, again draws to our attention the problems involved in following different legislation. I sympathise with him. I am anxious to see a consolidated measure on NHS legislation generally. I shall see whether between the Committee stage and Report stage we can produce some guidance to enable us to follow this legislation more clearly.

The noble Lord has never been very keen on any of the committees for which I have sought parliamentary support. But, as the noble Baronesses, Lady Northover and Lady Finlay, said, the appointment and establishment of the Commission for Health Improvement has been a great advance in driving up standards in the National Health Service.

Despite having had a national service for 53 years, it is interesting to note that we have never had any kind of national inspectorate. One of the reasons why, historically, there has been such patchiness and inconsistency between different parts of the NHS is that we have not had a robust inspectorate.

The noble Lord quoted from the annual report of the Commission for Health Improvement. I commend to him some of the reviews it has undertaken of clinical governance in a considerable number of NHS trusts. As has been suggested by other noble Lords, CHI has identified unsafe practices. It has identified certain organisations whose boards have not been getting the information required to make proper judgments and decisions, and it has raised issues of poor leadership within individual organisations.

But the commission has not had a wholly negative impact. It has also identified many examples of good practice. It has a role in helping to spread good practices as much as in identifying problems in particular NHS organisations.

The commission is a crucial part of the Government's strategy to drive up standards in the National Health Service. In that context, there is no reason at all why the Government should seek to undermine the independence of the commission. My own experience, as the Minister responsible for the commission, is that the chair. Dame Deirdre Hine, who used to be the Chief Medical Officer in Wales, and the chief executive, Mr Peter Homa, are extremely vigorous people, well able to embark on rigorous discussions with the Department of Health. In the reviews that they undertake of NHS organisations they are wholly independent in what they seek to do.

The Government have always sought for CHI to be at arm's length from Ministers and the Department of Health. That is why we established the commission as an executive non-departmental public body. CHI is no different from other executive non-departmental public bodies across government. It is a key feature of its establishment that the Secretary of State remains fully accountable to Parliament for the performance and the governance of the body in question. There is no justification for the Secretary of State abdicating that responsibility in the case of the commission. It is a vital part of constitutional arrangements and of ensuring public accountability that the Secretary of State appoints the chairman and other members of the commission. CHI is in no respect different from any of the department's other executive non-departmental public bodies —the General Social Care Council, the Human Fertilisation and Embryology Authority, the National Radiological Protection Board, the Public Health Laboratory Service Board and the National Care Standards Commission.

I do not believe that it would be appropriate for appointments to be undertaken by the NHS Appointments Commission, which was set up essentially to make appointments to local NHS bodies.

4 p.m.

Lord Peyton of Yeovil

The Minister's speech takes little account of Section 20(2)(a) of the 1999 Act: The Secretary of State may by regulations make provision … as to the times at which, the cases in which, the manner in which, the persons in relation to which or the matters with respect to which any functions of the Commission are to be exercised". Those are sweeping powers. One might say that the Secretary of State was entitled to give guidance but those are detailed powers. If the Minister says that the Secretary of State would never do such things, why not accept my noble friend's amendment and abandon a position that, from what the Minister is saying, is quite unnecessary?

Lord Hunt of Kings Heath

It is quite appropriate for the Secretary of State, in his role of directing the National Health Service and in accounting to Parliament, to set the parameters within which CHI works. Of course we have regular discussions with the commission about its workload, budget and the number of reviews that it undertakes each year.

The substantive point is that there is no suggestion and there will be no suggestion of any ministerial interference in the conduct of reviews undertaken by CHI. The basis for the robustness of the changes that we are making depends on a vigorous, independent inspectorate.

As to the new direction-making powers that the new clause would remove, I stress that those are reserve powers. There has never been any suggestion that they should be used as a matter of routine. It has always been our intention that they should be used only rarely, if at all. There has to be a backstop of reserve power if a situation ever arose where there was a serious problem in relation to activities or governance that the commission, for whatever reason, failed to address.

As the Secretary of State is accountable to Parliament for how the commission acts, surely it is right that he should be able to take whatever action is necessary at the time. I stress that such a power would be used in extremis. Not only is CHI already independent but—as the noble Baroness, Lady Noakes, suggested—its independence is enhanced by the Bill.

Baroness Finlay of Llandaff

Will the Minister confirm that the appointment of chief executives to the commission will be done by CHI itself, not by the Secretary of State or the First Minister of the National Assembly for Wales?

Lord Hunt of Kings Heath

CHI's chief executive had to be appointed with the consent of the Secretary of State. The Bill will leave it to CHI to make the appointment without requiring that consent. The Bill also gives CHI control over the terms and conditions of its employees. The commission will be able to delegate its functions and will for the first time publish its own independent annual report on the quality of services to NHS patients—which will be presented to Parliament.

With those changes, CHI's degree of independence and powers of direction compare favourably with other executive non-departmental bodies. The Public Health Laboratory Service and the National Care Standards Commission must comply with any directions given by the Secretary of State for their staff terms and conditions. The Bill abolishes the power to give such directions to CHI.

It is in the Government's interest to have an independent inspectorate which will be tough and robust and will ensure that the NHS pays careful attention to its reviews and inspections. Nothing in any of the Government's plans for the future or the NHS would, in any circumstance, seek to undermine those independent reviews. We have the balance right between the necessary accountability of the Secretary of State to Parliament and the considerable independence of the commission. On that basis, I invite the noble Baroness to withdraw the amendment.

Baroness Noakes

I thank the Minister and noble Lords who have supported the amendment—particularly my noble friend Lord Peyton for his usual powerful contribution. He pointed that CHI has extensive functions but without freedom because potential use of the powers in the 1999 Act take away the commission's freedom and independence.

The Minister likes to describe CHI and the powers held over it in terms of an ordinary, non-departmental public body but he is making the wrong comparison. He says that it is appropriate for the Secretary of Stale to set the parameters and proper for Ministers to have powers of direction. If one compares CHI with a body such as the National Audit Office or Audit Commission, those are genuinely independent inspectorates. There are no powers of direction over those bodies and the same degree of proposed ministerial control over the money that they receive to undertake their work.

The Department of Health's view of CHI can be characterised as having its own poodle, not a watchdog over the NHS.

Lord Hunt of Kings Heath

Surely the noble Baroness agrees that since CHI's resources come from money voted by Parliament and given the Secretary of State's responsibilities, there must be discussions between him and CHI about the budget—based on CHI's likely workload over a financial year. That seems a perfectly proper and appropriate relationship. I have stressed that in the actual conduct of reviews and the reports that it writes, CHI will be wholly independent.

Baroness Noakes

I thank the Minister. I can see that he has been trying to make a distinction between the powers over the body and the work that it does. But if powers of direction exist, they can infiltrate into the work in a way which may not be seen.

I agree that the Secretary of State should not be able to write CHI a blank cheque—the Secretary of State would be accountable for moneys voted to him. However, if we look at the way in which the Audit Commission is financed and the different way in which the National Audit Office is financed, we see that there are different sources of income, not dependent on the decision of the Secretary of State. My amendment seeks to replace the process of agreement. That could be made transparent; it could be brought into the open if there were disagreement. However, the Bill as drafted merely says that the Secretary of State determines the amount of money. I am attempting to move that into an environment where the debate which may well be taking place behind closed doors will properly take place in public, with CHI stating what it believes it needs to do the work that is implied in its functions. That should be wholly in the open in order to enhance the independence of CHI.

I can see that the Minister has not listened to the reasoned arguments of noble Lords who have supported the amendment. I should like to reflect on his remarks, as I am sure others would. I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

4.15 p.m.

Earl Howemoved Amendment No. 105: Before Clause 15, insert the following new clause

"COMMUNITY HEALTH COUNCILS: SCHEME FOR REFORM

(1) The Secretary of State shall lay before Parliament within twelve months of the date of coming into force of this section regulations setting out a scheme for the reform of the Community Health Councils in England. (2) Before laying regulations under subsection (1), the Secretary of State shall consult the Association of Community Health Councils for England and Wales and such other bodies representing the interests of patients as he considers appropriate. (3) The scheme set out by the Secretary of State in regulations under subsection (1) shall extend to all parts of the health service (including the provision of Part 2 services under the 1977 Act). (4) The Secretary of State may make regulations providing for access by members of a Community Health Council to premises from which services under Part 2 of the 1977 Act are provided. (5) The scheme set out by the Secretary of State in regulations under subsection (1) shall provide for the proper representation of the population in the area served by a Community Health Council on that council. (6) Regulations under subsection (1) may not be made unless a draft of the statutory instrument containing the regulations has been laid before, and approved by a resolution of, each House of Parliament.

The noble Earl said: We now come to the issue in the Bill which, more than any other, has provoked controversy and passionate disagreement across the party-political divide. I refer of course to the Government's proposal to abolish community health councils. The proposal is not new to us. It has been regurgitated by the Government from the legislative programme that they were forced to truncate at the end of the previous Parliament, when, following extensive debates on the Health and Social Care Bill in both Houses, community health councils were saved from extinction by a decisive vote in this place.

Following that, there was, very noticeably, no pledge in the Labour Party's election manifesto that they would do away with CHCs if re-elected. That is hardly surprising in view of the outright hostility with which the healthcare professions and patients had greeted the original proposals. Yet, instead of abandoning the idea gracefully, the Government have returned to it with renewed vigour.

It would be one thing if Ministers had begun this exercise with the express aim of wanting to enhance and improve patient and public involvement in healthcare. I have no objection to that idea. Indeed, I am thoroughly in favour of it. Community health councils, as we have said previously in this Chamber, are not perfect creatures. They require modernisation. Although many work very well indeed, many do not.

However, rather than taking as their starting-point the imperative to find a working formula that is best for patients, the Government began with a decision that, whatever happened, CHCs must be swept away. The consultation document sent out by the Government stated at the beginning: The immediate focus of this document is the Government's intention to legislate at the earliest opportunity to replace CHCs".

In other words, whether anyone liked it or not, that would be the conclusion of the consultation exercise.

My attachment, and the Opposition's attachment, to CHCs is not borne of sentiment, awkwardness or cussedness. Unlike the Government, we are open-minded about how best to ensure that patients have an independent voice and an independent watchdog within the NHS. We believe strongly that there should be reform. The reason we want to see CHCs retained and strengthened, and not abolished, is simply that no other model for patient representation that we have seen has the potential to do as effective a job. The arrangements that the Government wish to substitute for CHCs are slightly different from those that they presented to us before the general election. It therefore behoves us all not to dismiss them out of hand, but to examine them in a constructive spirit.

There are several key tests for any replacement arrangements for CHCs. Will they be truly independent of government and of the health service? Will they be effective in acting as a watchdog on behalf of patients and the general public? Will they be convenient to users? Will they command public confidence? It is my contention that the Government's proposals fail every single one of those tests.

What do the proposals amount to? They amount to inventing a number of new types of body and parcelling out the functions of CHCs among them. In acute hospital trusts there will be in-house patient advice and liaison services whose job it will be to provide information to patients. For each trust and PCT there will be a patients forum, whose members will inspect and monitor health services for patients and make representations on their behalf. To whom will representations be made? They will be made either directly to the trust on which each forum is based, or to the overview and scrutiny committee of the relevant local authority. The overview and scrutiny committees will perform the scrutiny function currently undertaken by CHCs.

If you want to make a complaint, to whom do you go? Do you go to a patients forum or to an overview and scrutiny committee? No. You go to the independent complaints advocacy service. That service will not be a unified service, but rather it will be provided by a range of separate NHS organisations. So who will draw everything together? Overseeing patient involvement nationally and reporting to the Secretary of State will be the new commission for patient and public involvement. It will be the job of the commission to support and co-ordinate patients forums.

Assuming that you have that structure clearly in your head, what is its most striking feature? Clearly, it is highly fragmented. It is far from being immediately understandable to the ordinary patient. The transparency of the current system has been lost. It is not, like a community health council, a one-stop shop for the patient, a place where he or she can be guided, informed, supported and represented on an independent and impartial basis. The separation of the scrutiny work, the monitoring work and the complaints work of CHCs will automatically reduce the extent to which these areas of activity mutually inform one another.

It is therefore less likely, not more likely, that the new system will sort out problems for patients in a speedy and effective way. That is because many patients have quite complex problems involving a number of different services. Where a patient's journey spans a number of different trusts, it will no longer be possible for one body to monitor or track the whole of a patient's experience. Individual patients forums will have a remit only for considering their own trusts' functions, with no formal way of coming together to provide an informed local overview.

The matter can be summed up very simply. Instead of being centred on the needs of the patient, the new structures are simply being bolted on to the existing machine. I suggest that that fact should make us suspicious. The obvious question is: what is being lost in the wash? The answer is: a great deal. The remit of patients' forums and of the commission for patient and public involvement will be considerably restricted compared with that of CHCs and ACHCEW at present. They will not, for example, be able to campaign against the closure of a hospital. They cannot query major capital projects or call for public consultation. They cannot take legal proceedings to enforce their rights or those of patients. They cannot undertake "casualty watch"-type exercises. They will have no overarching remit to represent the interests of the public or engage in work for the general public benefit in the field of healthcare. Unlike CHCs, the forums will have no power to refer contentious or disputed decisions to the Secretary of State. The Government have said that overview and scrutiny committees will have that function, but those committees will have no statutory duty to scrutinise the reports that they receive; they will have only a power to do so.

What is also being lost is independence. How can we call the Commission for Patient and Public Involvement in Health independent, when its chairman and first chief executive will be appointed by the Secretary of State? How can we call PA LS independent when they will be staffed by trust employees? How will patients forums present themselves as truly independent when they are trust-based organisations with an inbuilt trust-based perspective? How, indeed, can the public have 100 per cent confidence in a forum that is not separate from the National Health Service but based within it?

Every key test that I set out earlier for the Government's proposals has been failed. We need to ask the Government to think again, to take the tried and tested model of community health councils—for which there is widespread support—and work up proposals to strengthen and build on that model, consult on those plans and come back to Parliament again. I beg to move.

Lord Peyton of Yeovil

I warmly support what my noble friend has said, and the amendment that he has proposed. My complaint about the Government setting up these organisations is that they always behave like gardeners who, having planted a nice rose, or some vegetables or trees, cannot restrain themselves digging them up to see how the roots are doing. Nothing grows in those circumstances, yet all governments persist in doing this. The prose it Government are worse than most in relation to this thoroughly bad habit.

The Government suffer, au fond, from a certain confusion. They are very keen to be seen to be concerned with the welfare of the patient—the ill, the sick—and they are right to be so. They are also concerned, however, to do things in a way that is convenient to them, and that tends to edge forward and be given a priority that is denied to patients. I do not suppose for a moment that the Minister will get up and say that he entirely agrees with me, but I am bold enough to hope that, before he retires to bed tonight, he might just wonder whether there is not a grain of common sense and truth in what I am trying to say.

Lord Clement-Jones

I have a great deal of sympathy with what the noble Earl, Lord Howe, has said, and particularly with his powerful critique of the Government's proposals. Under those proposals, at least four organizations—possibly five—will take over from CHCs: patient advocacy and liaison services; patients forums; the independent complaints advocacy service; and the local authorities' overview and scrutiny committees. There will be a patients forum for each trust locally. The functions of CHCs will he fragmented; no single body will have an informed local overview of health services. The benefits of the one-stop shop provided by CHCs will be lost. Many points of uncertainty surround the scrutiny role of local authorities, particularly in relation to the lack of a duty to act.

Forums will not be independent of trusts, and their membership will potentially be too much under the control of Ministers. They will have limited powers, even in comparison to CHCs, and will not even have staff of their own. The role and independence of the Commission for Patient and Public Involvement in Health, and its provision of staff, is extremely uncertain, ambiguous and unsatisfactory, particularly in terms of its activities at local level. There are many other objections to the proposals, and they will no doubt be the subject of debate today. Even the cost of the system has been estimated to be 10 times that of the current system.

If we were to put the clock back 18 months, we might well go further and support this amendment. Some people might still prefer CHCs to be reformed, rather than being abolished and having something new put in their place. I am tempted to say that we, on these Benches, would not have started from here. However, we have to deal with circumstances as they are. We have been debating these issues for more than 18 months, and matters have moved on. Many of your Lordships will remember the battle we had over the abolition of CHCs during the passage of the Health and Social Care Bill. A compromise over the powers of new patients councils, which was inserted in the Commons, might have been reached if the general election had not intervened. We believe that patients, the public, and the staff of the CHCs would be better served by agreement on definite proposals in this Bill, rather than by waiting for a scheme to be devised over the next 12 months.

It was interesting to read the letter in the Guardian today from a member of a modernisation agency, who also happened to be the chairman of the Long Term Medical Conditions Alliance. She admonished a number of us for political points-scoring in what I thought was a very political points-scoring way, praying in aid a discussion that she had had with 23 members of the alliance, which comprises some 117 organisations. The one area of agreement that I share with her, however, is that there has been enough uncertainty over the past 18 months, and we need some certainty in the Bill.

One-fifth of the membership of the CHCs has fallen away. Staff morale is getting lower by the day. We need to make decisions soon about the new patient and public consultation and representation structure, otherwise valuable expertise will be lost to us. In Committee, we wish to explore whether the Government can agree with opposition parties on a scheme whereby we can establish patients councils as a one-stop shop for patients and the public, and as a powerful voice in the National Health Service for the local community, but one that works from within the health service, as recommended by the Kennedy report. Failing such a willingness by the Government to agree, an insistence on the status quo for CHCs may be the only option open to us. We do not believe that we have yet reached that point, but a great deal depends on the Minister's reply to this and other amendments.

Baroness Pitkeathley

I rise to oppose the amendment, and that is not because I have any lack of admiration for the work of many community health councils. Indeed, I was the chief officer of one myself for a short time in 1974, when they were set up. We have to recognise, however, that the world is very different now. Many of your Lordships will not be old enough to cast your minds back that far, but in 1974, the very idea that a body representing patients' views should be set up was revolutionary. Now, much more than that is demanded: patients must be at the centre of the running of the National Health Service. I have bored your Lordships before with my experience as a patient over long months last year, and with the fact that I feel that we have come a long way in enabling patients' views to be at the centre of the National Health Service, but there is still some way to go.

The Government's proposals in the Bill show their commitment to putting patients at the centre. We need organisations and structures that reflect that commitment, and it is a credit to consumer and patient organisations that we have reached the stage of being able to propose radical changes. On the simple issue of complaints, for example, the present system is cumbersome and takes a long time. Many patients' concerns are quite simple to deal with and could be resolved by the provision of information by the patient advocacy and liaison services, enabling them to be settled at an early stage. There will be many more PALS available than there have been CHCs. In addition, every primary care trust will have a forum that will monitor and review services, obtain the views of patients and carers—I am particularly pleased about that—provide advice and make information available. They will also provide annual reports to enable monitoring of how they are getting on.

The skills and experience of CHC staff and members will not be lost when the new system is set up. I would be very concerned about that, but I am convinced that they will be able to be integrated into the new system.

I am delighted with the Government's proposals to set up a national commission, which will have far greater powers at national level than ACHCEW ever had. The title of that national body—the Commission for Patient and Public Involvement in Health—shows that it will go even wider than involving patients.

We must be careful of overstating how well known and integrated CHCs have been. Many of your Lordships will be familiar with the MORI survey that showed that fewer than 3 per cent of those making a complaint had even heard of a community health council. The new structures will provide more accountability and will be much more focused, with a national voice. Make no mistake, these are radical proposals, but that is what we need. We want to make patients and the public an integral part of the running of the National Health Service. Everyone who is committed to that should welcome the proposals.

4.30 p.m.

Baroness Finlay of Llandaff

I find myself in a strange position when speaking to the amendment, because in Wales we shall be maintaining CHCs, but our experience of them and the way in which they are evolving may have been slightly different. Their collective memory has been extremely valuable. I have served as a non-executive member of a health authority in which the CHC members acted a little like sand in a shoe, but were also useful to inform what was going on. For patients and their carers they act as a single point to which they can go when they feel angry, confused, frightened or upset and are not sure which route to take. It is very important that patients and their carers have a single point of contact that can help them filter out the most appropriate route to take in the future.

I have also experienced the advocacy role of CHCs at the sharp end. A member from Cardiff CHC came along with a patient of mine to speak to me and help to resolve issues. The CHC member was extremely helpful in acting as the patient's advocate. We have some examples of good practice there which I hope will be picked up throughout whatever other systems evolve in the rest of the UK.

I would welcome any moves to simplify the complaints procedures. Any delays in complaints for patients and their relatives and carers increase stress and anger and make them feel that there is a conspiracy to withhold information from them. Any way in which that process can be simplified and speeded up must be welcomed.

Lord Skelmersdale

I am the first to admit that the current consumer representation in the health service has its faults, as we have heard over the past few minutes. However, that is no reason for the Government to throw everything up in the air and go nap on something entirely new. Reform is certainly needed, but wholesale destruction is not.

In an article in the Health Service Journal, much favoured by the Minister, CHCs are described as a channel for patients' concerns, with limited powers and very small budgets. Both those faults could and should be remedied in the Bill. However, the article does not point out that the Bill replaces a longstanding system of proven efficiency that is easily understood and—importantly—accessed by the public.

Above all, the article does not say that CHCs are independent of the NHS. That independence gives them authority in the eyes of the public. Nor does it say how, if at all, patients forums are to interact one with another. As my noble friend Lord Howe has said, the Government propose that individual patients forums will be able to consider only the work of trusts in which they are based. Even worse, they are to be situated in NHS buildings and staffed principally by NHS staff. What patient is going to complain in the same place and to the same organisation where the complaint originates?

The proposals are very complicated and, as I understand it, are still being worked out in the department, despite the amount of time that his been available for that. I can find nothing in them that could not be achieved through a reform of the existing system. Like the noble Lord, Lord Clement-Jones, I urge the noble Lord, Lord Hunt, who is well versed in the ways of the NHS, to stand back and for goodness sake think again.

Baroness Carnegy of Lour

I think that I picked up from the noble Lord, Lord Clement-Jones, that the Liberal Democrats are not going to support the amendment and that they fancy their own ideas which they will put forward later. I do not know what the rest of the Committee thinks about that, but it seems to m that my noble friend is giving the Government a chance to achieve what they want to achieve— obviously they have thought deeply about what they want to achieve—by reforming the existing community health councils, not by disruption. I am sorry that the Liberal Democrats do not support the amendment, which seems a sensible first shot. If the Government cannot be persuaded or forced to agree to it, we shall have to resort to some later measure, but this is the best possible objective.

I do not want to repeat all the arguments, but I should like the Minister to tell me one thing. When talking about patients forums, the Government always talk about patients, not the public. Do the Government consider that every member of the population of a given area is a patient presumably because we all go to see a GP—or do they mean only those who have been or are patients in a hospital?

Lord Hunt of Kings Heath

Perhaps I can respond to that point now. For a trust that covers an acute hospital, for example, we mean only those who are or have been patients, but for primary care trusts, all patients who are registered with a GP within that area will be covered. Primary care trusts will have a broad public role in that sense.

Baroness Carnegy of Lour

In that case, the Bill would be clearer if there were a reference to patients and the public. My noble friend Lord Howe asked the important question of who will campaign against a hospital being closed. Can a patients forum do that? That and many other issues would be of concern to the whole community, not just to people who see themselves as patients at a given moment. With the destruction of community health councils, that role will be left to local authorities. As we all know, local authorities will act in a party political way—that is their nature. We do not want that. We want the job to be done by the community as a community on grounds of health. Any member of a local authority knows that it is difficult to separate such issues from the political scene. In that respect alone, the Bill is inadequate. I hope that references to patients can always include the public when that is what is intended. I also hope that somewhere—presumably in the patients forum, if the current proposals are adopted—the ability to campaign will be included, because it is essential.

Lord Morris of Aberavon

I find it difficult to be enthusiastic about community health councils. The Government's proposals for England have positive attractions. In 1974, I was responsible, as Secretary of State, for the appointment of all members of community health councils. I had high hopes for them and thought that they would be the means of dealing with the matters set out by the noble Baroness, Lady Finlay. There is a great need to provide the patient, who is at the heart of our health service, with the machinery to ensure that his or her views are made known and to monitor our health system.

Regrettably, the record has been patchy. I started off with high hopes and was responsible for community health councils for five years. I have not heard reports that they have improved since that time. CHCs' records depended on the quality of their membership and perhaps even more so on their staff. Generally, however, they were a disappointment.

I should like to give the Government's proposals, certainly as they apply to England, a fair wind. The machinery is badly needed, and it needs to be improved. I have found the record of the CHCs to be extremely patchy, and I had hoped for very much better.

Baroness Thomas of Walliswood

I apologise that, earlier in the proceedings, I interrupted the noble Baroness, Lady Carnegy of Lour, but I had forgotten the point we had reached in the exchange between her and the Minister. I simply wanted to raise an issue which has not yet been discussed—the potential for conflict between patients forums, which in a way represent the two contractual parties to the local health service. I was wondering what the Minister can tell us to reassure us about that.

Based on my experience of the health service—I have been a member of a hospital trust board and of a CHC—I realise that the patients forum for a given primary care trust and the forum for a given acute hospital trust will not always agree on who is at fault, what has gone wrong, whether something has gone wrong, or any of the other issues that the patients forums may wish to examine. Unless I have misunderstood the proposals, that situation will be exacerbated by the fact that the officials of the two bodies will be employees of those bodies.

Lord Hunt of Kings Heath

I must make it clear that the staff who support patients forums will be employed by the national commission. They will be wholly independent of the individual NHS trusts.

Baroness Thomas of Walliswood

I thank the Minister for that intervention; it clarifies a point I had not fully taken on board. Nevertheless, there remains the potential for a conflict of interest which could go against what I assume to be the Government's objective—to improve things for patients and, as the noble Baroness, Lady Carnegy of Lour, said, for members of the public.

Baroness Masham of Ilton

No one could have explained the situation of the fragmentation of the Government's new National Health Service as far as patient support bodies are concerned more clearly than the noble Earl, Lord Howe. I shall speak to the group of amendments on patients councils— Amendments Nos. 111 to 136—because I feel so strongly that there must be an independent body to which patients know they can go. It is interesting, however, that Wales and Scotland are retaining their CHCs. I believe that that will just cause more confusion.

4.45 p.m.

Lord Hunt of Kings Heath

This has, once again, been an extremely interesting debate. This is one of the very important parts of the Bill, on public and patient involvement in the NHS. As some noble Lords will know, I have a particular interest in community health councils because, like my noble friend Lady Pitkeathley, in 1974, I was one of the first CHC secretaries to be appointed. As my noble friend Lord Morris has suggested, those were heady days. At the time, we all thought that CHCs would be tremendous organisations that would have a real impact on how patients were dealt with within the NHS. Experience, however, has not been as positive as one would have wished.

Of course some CHCs have done very valuable work, and I pay tribute to CHC members and staff who have served in the years in which CHCs have operated. The fact, however, is that CHCs' performance over the years has been patchy. Can any noble Lord, hand on heart, say that the NHS is in such good condition that it can identify that the patient comes first, or that, since CHCs began operating, the NHS has become completely sensitive to the needs of patients? I do not think that any noble Lord can honestly say that. The fact is that the NHS still has a considerable way to go before it treats patients as we all want them to be treated.

I fully accept that the key test will be whether the Government's combined proposals have led to much more powerful patient and public involvement in the NHS than was achieved by the CHCs. However, I am absolutely confident that our proposed arrangements will be very much more powerful and effective than the current arrangements under CHCs.

Life has indeed moved on since 1974. We have very clear views on the need for consent and public involvement and on ensuring that NHS staff can be very positive about talking to patients, involving patients and seeking patients' consent. I believe that our proposals will enable that to happen. As the noble Earl, Lord Howe, suggested, we have debated the proposals at length, and the Government have been able to develop our thinking in the light of the many debates we had during passage of the Health and Social Care Act 2001.

Our new system does place different functions in the hands of different bodies, but I make no apologies for that. The intention is that a specifically identified function can be performed in the optimum manner. Rather than expecting a simple single organisation with limited powers to perform a complex range of functions, we are putting in place specific and appropriate mechanisms to deal with various functions that we believe are encompassed within public and patient involvement.

On complaints, for example, rather than having one complaints officer per CHC—totalling about 200 nationally—we shall have many more people within the patient advocacy and liaison services who will be based within each NHS trust and be available whenever a patient or his relative has a complaint, and who will in many instances be able to deal with the problem on the spot. I recently visited the Luton and Dunstable NHS Trust, which has already appointed a patient advocacy and liaison service. That service has a booth in the outpatient A and E department and is already very successful in dealing with complaints and problems as they arise. I recommend that noble Lords make contact with local NHS trusts to see at first hand the effectiveness of a service that is instantly available to the public. It is obviously much better to deal with a problem immediately than to allow people to leave dissatisfied with the health service and to make a complaint subsequently. It is much more effective to try to nip problems in the bud as they arise.

One accepts, however, that PALS will not be able to deal with every problem and that the public will seek to pursue some problems. That is where independent advocacy services will come into play. We shall have very professional people available across the country, where patients or their relatives want the service, to help people to make their complaints. I also certainly accept the comments of the noble Baroness, Lady Finlay, on the complications of the current complaints system. She will know that we are reviewing that. Nevertheless, availability across the country of effective, professional, well-trained and independent advocates—not patchy availability, as with CHCs——is one of the guarantees of the type of independence described by the noble Earl, Lord Howe.

Patients forums will have extensive powers, including a statutory right to inspect health authority and local health board premises and local authority premises where healthcare is provided on behalf of a trust, as well as the power to make reports and recommendations for the improvement of services to the trust board. Reports will be made available to key decision makers in the community, including the local overview and scrutiny committees, and local strategic partnerships about the views and concerns of patients. If a patient forum wishes to provide and pull together the views of patients on the issues raised by the noble Earl, Lord Howe, of course it will be fully able to do so.

The noble Baroness, Lady Thomas, asked me about the position if perhaps a primary care trust and a neighbouring patient forum disagreed with each other. Surely it is more healthy for opinions that the public are putting forward to be expressed rather than that a group of 30 people, whom very few in the community know, should purport to represent the views of the entire community. It is not tenable to believe that that would be effective. If there are disagreements between patients, as there often are about how the NHS should proceed, it is much more effective for those views to be in the public domain.

I believe that patient forums will be effective, but we are making other changes as well, such as the establishment of overview and scrutiny committees of local government, for example. The noble Earl, Lord Howe, is disappointed that we are essentially giving them a power rather than a duty. On the first day of our debate, he chided me about over-centralisation and suggested that the Government were determines to dictate what local bodies should do. I should have thought that the noble Earl would support the general principle that it is for local government to be given the ability but for individual local authorities to make their own decisions. My experience is that local government generally takes a very close interest in health service issues. I should be very surprised if every principal local authority did not establish effective overview and scrutiny committees.

We are addressing one of the principal criticisms that has always been levied at the health service—the so-called democratic deficit. When we come to crucial discussions and debates about changes in services to which the noble Earl referred, surely it is a much more powerful measure to give local authorities the right to refer such issues to the independent reconfiguration panel at national level, which will then advise the Secretary of State. Surely that is a very powerful indication of democratic local government having a very great influence in the future development of the National Health Service. A democratically elected local authority will be in a much more effective position to give its views on major changes of services than we currently see with community health councils.

The only test for the Committee is to decide whether our proposals will be more powerful and effective than the position under the current community health councils. I have long been interested and passionately concerned about improving patient and public involvement in the NHS. I am absolutely convinces that we are introducing an extremely powerful package of measures, which includes patient forums, independent patient advocacy, patient advisory liaison services, local authority overview and scrutiny committees and, at national level, the Commission for Patient and Public Involvement in Health, which will also have an important role locally, enabling the work of patient forums to be co-ordinated in the way suggested by the noble Earl, Lord Howe. I look to the Committee to support those measures.

Earl Howe

I thank all noble Lords who have taken part in the debate, not least the Minister for his clear and full reply. He knows that this is not an issue on which we shall see eye to eye. He has defended the Bill as best he can. For example, he referred to the merits of patient advocacy and liaison services. I do not disagree with his analysis, but PALS are not part of the Bill, nor of the amendment to which I have been speaking.

The Minister referred to the patchy performance of community health councils. I agree with him on that count, which is why we believe that CHCs should be reformed and strengthened, rather than abolished. He defended the separation of CHC functions on grounds broadly of modernisation and the need to distinguish different roles relating to patient involvement. I cannot accept that analysis. It seems to me that the Government's proposals for patient and public involvement follow the classic formula of divide and rule. That is what the fragmentation and filleting of CHC functions amount to. As my noble friend Lord Peyton pointed out so well, they are designed to suit the Government and not the patient. They will give Ministers an easier life.

I am particularly sorry that the Liberal Democrats do not feel able to resume the support for CHCs that they mounted so effectively and robustly last year. It is curious that in professing to want to listen to patients and the public, the Government are deaf to the cries of the public about the abolition of CHCs. The noble Baroness, Lady Finlay, reminded us that that has not been so in Wales, or indeed, in Scotland. If CHCs are abolished under this Bill, it will leave England as the only part of the UK without a robust—

Lord Hunt of Kings Heath

I am grateful to the noble Earl for giving way, but I must say that I have not heard the cries of the general population on this issue. I have certainly heard the cries of community health councils, which is perfectly legitimate, but surely the substantive point is made in the article in the Health Service Journal by de Montfort University, which my noble friend Lady Pitkeathley quoted. CHCs have extraordinarily low visibility in the public mind. My noble friend quoted the MORI survey showing that less then 3 per cent of those making complaints had heard of the CHC. That is the problem.

Lord Clement-Jones

I wish to ask the Minister a question, although I do not know whether it is in order to do so at Committee stage. What will be the budget of the new system compared to the old one? It is sad that the Minister is complaining about the lack of visibility of CHCs when he probably argued for years in particular posts within CHCs that they were highly underfunded and did not have the resources to have higher visibility. Yet, a great many more resources will be put behind the bodies that he and his colleagues are now proposing.

Lord Hunt of Kings Heath

The budgets have not yet been fully worked through, but there will be more people. More resources will be spent on patient and public involvement as a result of the changes that we are making than was spent under community health councils.

Lord Clement-Jones

That begs the question whether the self-same resources that were devoted to CHCs could not have done a rather better job.

Lord Hunt of Kings Heath

I doubt that very much. I come back to the point that I raised earlier. Rather than putting all the different functions together into one body, it is better to separate them out so that there is the right expertise to deal with the separate functions more effectively.

Lord Clement-Jones

Better? Perhaps. I doubt it, but it will certainly be more expensive.

Earl Howe

The Minister challenged me to cite organisations that have voiced support for the concept of CHCs. I have a list of them, including the Patients Association, the National Pensioners Convention, Mencap, and others that I shall not bother to read out. Those organisations have expressed concern in writing about the abolition of CHCs and the inadequacies of the replacement structures.

Lord Hunt of Kings Heath

With respect to the noble Earl, he talked about the general public, not organisations.

Earl Howe

With respect to the Minister, he is splitting hairs. Many of those organisations represent the general public and specific interests of patients. However, I understand his concern that, to many members of the public, CHCs are invisible. I fully concede that. But that does not in any way detract from my general position; that is, that CHCs are worth conserving and worth improving.

I do not wish to prolong this debate. It is perhaps worth reminding ourselves of something Professor Kennedy said in his report on the Bristol Royal Infirmary. He said, Public consultation, whereby the public are presented with a fait accompli or their views are ignored leads to disengagement and cynicism. The net effect is frustration, loss of trust and an increasing lack of interest amongst the public in bodies and structures that are supposed to promote their interest". Nowhere could there be a better example of what Professor Kennedy meant than the Government's dirigiste approach to these issues. He precisely identified the risk we run with these proposals. My amendments respond to what I know for certain is a wide degree of support not only for the concept of retaining the model of the CHC but also for improving it and bringing it up to date. On an issue of such prime importance for patients I have no hesitation in seeking the opinion of the Committee.

5.1 p.m.

On Question, Whether the said amendment (No. 105) shall be agreed to?

Their Lordships divided: Contents, 90; Not-Contents, 117.

Division No. 1
CONTENTS
Ackner, L.	King of Bridgwater, L.
Anelay of St Johns, B.	Kingsland, L.
Astor of Hever, L.	Listowel, E.
Beaumont of Whitley, L.	Luke, L.
Blatch, B.	Lyell, L.
Bowness, L.	Marlesford, L.
Brightman, L.	Masham of Ilton, B.
Brougham and Vaux, L.	Mayhew of Twysden, L.
Buscombe, B.	Miller of Hendon, B.
Byford, B.	Monro of Langholm, L.
Campbell of Alloway, L.	Monson, L.
Carlisle of Bucklow, L.	Mowbray and Stourton, L.
Carnegy of Lour, B.	Moynihan, L.
Chadlington, L.	Murton of Lindisfarne, L.
Colville of Culross, V.	Naseby, L.
Colwyn, L.	Noakes, B.
Cope of Berkeley, L. [Teller]	Northbrook, L.
Cox, B.	Northesk, E.
Crickhowell, L.	Norton of Louth, L.
Darcy de Knayth, B.	O'Cathain, B.
Denham, L.	Onslow, E.
Dixon-Smith, L.	Park of Monmouth, B.
Dundee, E.	Patten, L.
Elton, L.	Peyton of Yeovil, L.
Fellowes, L.	Platt of Writtle, B.
Fraser of Carmyllie, L.	Rawlings, B.
Freeman, L.	Rees, L.
Gardner of Parkes, B.	Renton, L.
Goschen, V.	Roberts of Conwy, L.
Gray of Contin, L.	Roll of Ipsden, L.
Griffiths of Fforestfach, L.	Seccombe, B. [Teller]
Hambro, L.	Selborne, E.
Hanham, B.	Selsdon, L.
Hanningfield, L.	Shaw of Northstead, L.
Hayhoe, L.	Sheppard of Didgemere, L.
Hogg, B.	Skelmersdale, L.
Holderness, L.	Soulsby of Swaffham Prior, L
Hooper, B.	Strange, B.
Howe, E.	Swinfen, L.
Howe of Aberavon, L.	Tebbit, L.
Howe of Idlicote, B.	Thomas of Gwydir, L.
Hunt of Wirral, L.	Vivian, L.
Jenkin of Roding, L.	Weatherill, L.
Jopling, L.	Wilcox, B.
Kimball, L.	Williamson of Horton, L.
NOT-CONTENTS
Acton, L.	Clarke of Hampstead, L.
Alli, L.	Clinton-Davis, L.
Andrews, B.	Cohen of Pimlico, B.
Archer of Sandwell, L.	Corbett of Castle Vale, L.
Ashley of Stoke, L.	Crawley, B.
Ashton of Upholland, B.	David, B.
Bassam of Brighton, L.	Davies of Coity, L.
Berkeley, L.	Davies of Oldham, L.
Billingham, B.	Desai, L.
Blackstone, B.	Donoughue, L.
Blood, B.	Dormand of Easington, L.
Borrie, L.	Elder, L.
Bragg, L.	Evans of Temple Guiting, L.
Brett, L.	Evans of Watford, L.
Brooke of Alverthorpe, L.	Falconer of Thoroton, L.
Brookman, L.	Faulkner of Worcester, L.
Campbell-Savours, L.	Filkin, L. [Teller]
Carter, L.[TelIer]	Fyfe of Fairfield, L.
Chan, L.	Gale, B.
Christopher, L.	Gavron, L.

Gibson of Market Rasen, B.	Mitchell, L.
Gladwin of Clee, L.	Morgan, L.
Golding, B.	Morris of Aberavon, L.
Gordon of Strathblane, L.	Murray of Epping Forest, L.
Goudie, B.	Nicol, B.
Gould of Potternewton, B.	Ouseley, L.
Graham of Edmonton, L.	Parekh, L.
Greengross, B.	Paul, L.
Grenfell, L.	Pitkeathley, B.
Grocott, L.	Plant of Highfield, L.
Hardy of Wath, L.	Ponsonby of Shulbrede, L.
Harris of Haringey, L.	Prys-Davies, L.
Harrison, L.	Puttnam, L.
Haskel, L.	Radice, L.
Haskins, L.	Ramsay of Cartvale, B.
Hayman, B.	Rea, L.
Hilton of Eggardon, B.	Rendell of Babergh, B.
Hollis of Heigham, B.	Richard, L.
Howells of St. Davids, B.	Rogan, L.
Howie of Troon, L.	Sainsbury of Turville, L.
Hunt of Kings Heath, L.	Sawyer, L.
Hylton, L.	Serota, B.
Irvine of Lairg, L. (Lord Chancellor)	Sewel, L.
	Sheldon, L.
Jay of Paddington, B.	Simon, V.
Jones, L.	Smith of Gilmorehill, B.
Jordan, L.	Stone of Blackheath, L.
Judd, L.	Symons of Vernham Dean, B.
King of West Bromwich, L.	Temple-Morris, L.
Kirkhill, L.	Thornton, B.
Laird, L.	Turner of Camden, B.
Lea of Crondall, L.	Uddin, B.
Lipsey, L.	Walker of Doncaster, L.
Macdonald of Tradeston, L.	Whitaker, B.
McFarlane of Llandaff, B.	Whitty, L.
McIntosh of Haringey, L.	Wilkins, B.
MacKenzie of Culkein, L.	Williams of Elvel, L.
Mackenzie of Framwellgate, L.	Williams of Mostyn, L. (Lord Privy Seal)
Milner of Leeds, L.	Woolmer of Leeds, L.

Resolved in the negative, and amendment disagreed to accordingly.

5.11 p.m.

[Amendment No. 106 not moved.]

Clause 15 [Establishment of Patient's Forums]:

Lord Clement-Jonesmoved Amendment No. 107: Page 20, line 38, at end insert", and (c) for each Care Trust

The noble Lord said: I rise to move Amendment No. 107 and to speak at the same time to Amendment No. 112. We had some debate after the Health and Social Care Act in respect of the status of care trusts. The purpose of Amendment No. 107 is to obtain what I suspect will be similar ministerial reassurances as regards the status of care trusts.

The purpose of Amendment No. 107 is to ensure that care trusts to be established under the Health and Social Care Act will also include patients forums. Legislative provision for the establishment of care trusts is contained in the Health and Social Care Act and it would be anomalous if patients forums were to be established for NHS acute trusts and primary care trusts, but not for care trusts themselves. The establishment of patients forums for care trusts, if regarded as separate bodies from PCTs or acute trusts, would require primary legislation, which is why they are included in the Bill.

I turn to Amendment No. 112. Clause 16(1) allows the Secretary of State to make regulations to permit inspection of other premises from which services are provided. The purpose of subsection (1) is to provide a commitment that regulations will include care trusts and other private providers, including nursing homes. Inspection of premises controlled by care trusts need to be brought within the ambit of the clause. At present it is not clear whether the clause includes private providers such as residential homes.

The Department of Health's document Involving Patients and the Public in Healthcare: Response to the Listening Exercise specifies new powers to inspect NHS care provided by the independent sector. Contracts between health service bodies and private providers cannot guarantee rights of inspection and give patients forums no power to enforce their rights. That is why the amendment is needed. I beg to move.

5.15 p.m.

Lord Filkin

On speaking to Amendment No. 107, I can give the noble Lord the assurance he seeks. A care trust does not have a distinct legal identity. It is either an NHS trust or a PCT and therefore in either case would have a patients forum established.

I understand what the noble Lord, Lord Clement-Jones, is seeking to achieve with Amendment No. 112, but I hope I can explain why it is unnecessary. In discussing Amendment No. 107, I explained that the legal status of care trusts as NHS trusts or primary care trusts is already provided for in Clause 16. The patients forum of an NHS trust or PCT which has become designated as a care trust will already be able to visit the relevant premises.

I turn to the question of whether, nursing homes and other privately owned facilities should be required to allow patients forums access to inspect. As Members of the Committee will be aware, we have established a National Care Standards Commission to inspect nursing homes and other such places. It has its own chief executive and so on. From April 2002 it took over the regulation of social care services and private and voluntary healthcare from local authorities and health authorities. The commission will register and inspect all care homes, children's homes, domiciliary care services, residential family centres, independent fostering agencies, voluntary adoption agencies and nurses agencies as well as private and voluntary healthcare establishments.

The commission will authorise inspectors to inspect establishments and agencies and it will interview service users and seek their views on the care they receive. It will have an important role in supporting consumers by investigating complaints about regulated services and giving the public information about services. Being a national body, it will also be able to inform government of the general availability and quality of care services.

The commission will cover the need for inspection of nursing homes and other care facilities. To extend inspection arrangements to patients forums would be an unnecessary duplication of that valuable work. Having said that, where, for example, a doctor provided general medical services at a nursing home, that would fall within Clause 16(2) and may be provided for in regulations, giving patients forums a right of entry.

I agree that patients forums should be able to inspect private sector premises where NHS patients are treated. In general, the relationship between the NHS and the independent sector is a contractual one, and so it is anticipated that usually forums will inspect by virtue of the contracting process. In other words, where the private sector provides NHS services in contracts with the NHS, patients forums will have a right of inspection. That will apply to all future contracts.

There will be significant human rights implications in a general right of access to private premises. While patients forums will represent a major element of the inspection regime, they need to liase with other agencies to ensure inspections are maintained at an appropriate level.

I share the concerns to ensure adequate representation and safeguard standards of care. But, as I hope I have demonstrated, the amendments are unnecessary and the Government resist them.

Lord Clement-Jones

I thank the Minister, particularly for his positive reply on the status of care trusts. I accept that; it is entirely consonant with replies that the noble Lord, Lord Hunt, has given in the past. However, the Minister's reply on Amendment No. 112 gives two legs to the three-legged stool and is not satisfactory. I welcome patients forums rights of inspection for healthcare in both the public and private sectors where there are contracts. But it seems anomalous that the care trusts' patients forums will have the right of inspection only in the healthcare sector and not the social care sector when they have responsibility for patient representation and consultation in both areas. The whole purpose of a care trust is the integration of health and social care; and yet, the patients forum that is applicable to that care trust will not have those powers of inspection.

I ask the Minister, his colleagues, and, indeed, the department to reconsider the matter. It seems that there is a gap in the process, and that there are just two legs of the stool. I believe that those serving on care trust patients forums will find it fairly anomalous not to have that power of inspection in such circumstances. I do not know whether the Minister wishes to add anything further to his response and, perhaps, give us an assurance that he will further consider the matter. I see from his facial expression at present that he does intend to budge one inch on the issue. I shall, therefore, withdraw the amendment at this stage, but I may well return to the matter on Report. I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Earl Howemoved Amendment No. 108: Page 20, line 39, at end insert "represent the interests in the health service of patients and in particular must

The noble Earl said: In moving this amendment, I shall speak also to Amendments Nos. 109 and 130. One of the principal features of community health councils has been their overarching remit to represent the interest of patients and of the public in the health service. It is that element of their remit that I believe has enabled them to adapt to changing circumstances over the years, such as the need to develop services for those who wish to make a complaint against some aspect of the health service. If patients forums lack such a remit, it seems to me that they could find themselves acting ultra tires if ever they were to engage in activities other than those prescribed in the Bill.

If patients forums are to be seen by the public as representing their interests, they should have a proper public profile; for example, they ought to be able—on occasions—to engage in public campaigns, whether locally or nationally, perhaps in opposing the closure of a hospital. They ought to be able to put resources behind such campaigns; they should have the ability to call for public consultations; they should be able to inspect premises, other than those specifically provided for in the Bill; and they ought to be able to initiate legal proceedings to enforce their rights, or to protect patient rights.

Unfortunately, there have been occasions in the past when CHCs have been warned by officials in the Department of Health that they are not permitted to engage in campaigns or to criticise government policy. CHCs have always been able to see off such attempts to stifle their public voice on behalf of patients. They have done so by virtue of their wide statutory remit, which Amendment No. 108 seeks to reproduce for patients forums. One of the most well-known "public profile" activities of CHCs is casualty watch, which has a tremendous value for both patients and the health service. However, as far as I can see, neither that nor any of the other activities that I have mentioned will be permissible for patients forums or for the Commission for Patient and Public Involvement in Health. Nor are they functions that overview and scrutiny committees of local authorities will be given to undertake. Under this Bill they simply fall away.

It is perfectly obvious to me that this is a deliberate omission. Concerted public criticism of the health service by patients will, effectively, be muffled. That is a matter of very great concern. If we look at the remit of the Commission for Patient and Public Involvement in Health, we can see that it will have very similar problems. It will not he able to engage in research, or in policy work on issues that are not in the domain of patients forums—in other words, almost any national issue. It will not be able to run or take part in campaigns; it will not be able to voice its view about national changes of policy affecting the health service; and it will not be able to take legal proceedings, as, indeed, ACHCEW did recently in a case that concerned a patient's right to confidentiality.

I turn to Amendment No. 109. I am very troubled by the provision in Clause 15(2)(e), which permits patients forums to perform, any prescribed function of the trust",

to which it relates. That seems to me to be a recipe for generating a conflict of interest. Patients forums must be independent of the trusts to which they relate and be seen to be so. In the new paragraphs that I propose for Clause 15(2), I am suggesting that the role of representing local concerns about matters affecting health should be carried out by patients forums and not by the commission. This would mean that information about local concerns, including matters that may form the subject of referrals, are provided as necessary by patients forums to the local authority overview and scrutiny committees. Responsibility for these activities would be removed from the commission, which will instead have responsibility for the provision of support to patients forums in fulfilling these functions. Amendment No. 130 would achieve that aim, but would leave the commission with a responsibility to make representations at national level, if that were ever necessary. I beg to move.

Lord Clement-Jones

The noble Earl, Lord Howe, put the case admirably for these amendments. We come now to one of the major problems for critics of the new arrangements in the Bill. When one looks at the way in which the powers of the new bodies are defined, or can be defined, in terms of regulation, one sees that they do not have the same breadth as the powers that the CHCs currently enjoy under the legislation governing such councils. It is extremely important that these new bodies should have the ability to mount campaigns, and that they should have the ability to commission surveys. I have in mind the accident and emergency survey and the casualty watch mentioned by the noble Earl, Lord Howe. They must have the ability to take a very broad view about the way in which patients and the public interest are represented; they must not be over prescribed by the Secretary of State as regards their remit. Such amendments are most important. Noble Lords on these Benches certainly support them.

Baroness Pitkeathley

I am a little puzzled by the purpose of these amendments. I hope that my noble friend the Minister will clarify the position in his reply. I thought that the Government's aim under the Bill is to move away from the idea of a body representing patients and the public and to enable patients and the public to be very much more involved in the fabric, as it were, of the NHS. Therefore, from that point of view, it seems to me that the proposed amendments are unnecessary.

Although it may be true that each part of the new system has less power than that currently enjoyed by the CHCs, on the whole it seems to me that they will have more power, much more accountability and, therefore, much more ability to allow the voice of the public and that of patients to come through.

Lord Clement-Jones

Perhaps I may briefly intervene. The noble Baroness has put forward a most interesting concept, if we wish to return to Athenian democracy whereby everyone gets together in the basilica. I am sure that that would be absolutely perfect in an ideal world, and that there would be no need for any representation. Indeed, patients would be directly involved in such processes. However, until that time, I regret to say that I believe that some form of representation will be necessary.

Lord Hunt of Kings Heath

It is very tempting for us to travel down the route of a debate on Athenian democracy. However, I shall resist that temptation. I believe that my noble friend is absolutely right. She has taken us back to what Kennedy said; namely, that the public should be on the inside rather than being represented by someone on the outside. That is why we believe that the essential building block to everything that we propose in relation to public and patient involvement must be the patients forums. The great advantage that they have, as opposed to the current arrangement, is that they are related to each individual trust and primary care trust. Therefore, they will be able to get very much closer to being able to put forward the varied experience and views of patients.

On reading Clause 15(2), which relates to the establishment of patients forums, it will be seen that we are talking about very wide-ranging powers. For example, a patients forum must, monitor and review the operation of services provided by, or under arrangements made by, the trust for which it is established … obtain the views of patients and their carers about those services and report on those views to the trust … provide advice, and make reports and recommendations, about matters relating to those services to the trust … make available to patients and their carers advice and information about those services", and so on. I do not believe that patient forums will have any difficulty in embracing and putting forward in the most effective way possible the views that they receive from patients and users of the service. My argument—

5.30 p.m.

Lord Clement-Jones

I apologise to the Minister for the fact that I keep popping up and down. I am interested in the example given in a recent booklet produced by University College London researchers about PFI and the hospitals in Birmingham. I am sure that the Minister has read the booklet, as it is close to home. Does he really envisage patients forums for the Birmingham acute hospitals performing the same excellent function as did the CHCs in Birmingham in campaigning to find out the real cost of those PFI hospitals in circumstances after the passage of the Bill?

Lord Hunt of Kings Heath

The noble Lord tempts me down an interesting route. He knows that I chaired an independent review into the future of the city's health services. He knows, I suspect, that the City of Birmingham suffered from malaise over 20 to 30 years because of a failure of parties in the NHS to agree on the future of a new university teaching hospital.

I do not agree, and never have done, with the views of the South Birmingham Community Health Council on those matters. Nor do I think that the great majority of Birmingham people so agree. If the city had followed the strictures of the South Birmingham Community Health Council we would not now have, as we do, the start of a process leading to a magnificent teaching hospital in the City of Birmingham.

Lord Clement-Jones

The Minister is saying, essentially, that that is not a legitimate role for the new patients forums, and that is why the Bill is drafted as it is. I can well understand the Minister's view. He is reacting against his own experience. That is why the powers of the patients forums are restricted. If the Minister admitted that, we would all be much clearer.

Lord Hunt of Kings Heath

The noble Lord misses the point I seek to make. I have no problem with the South Birmingham Community Health Council—a number of members of which I know rather well—putting forward its views. I said that I do not believe that those views represent the opinion of the great majority of people living in Birmingham.

Lord Clement-Jones

But the issue is whether the patients forums in Birmingham would be able to campaign in the same way as did the South Birmingham CHC?

Lord Hunt of Kings Heath

There are two points there. We come on to the substantive nature of the amendment. The noble Earl, Lord Howe, seeks to give a much broader power to patients forums to represent the interests of patients in the health service. My view, which perhaps experience in Birmingham shows, is that there is and has been a big problem with some CHCs where a small group of members purports to represent the interests of an entire population. I do not believe that that is possible. As a result, many CHCs which tried to do that lost credibility and influence. How can CHCs purport to represent the entire population of a large community when less than 3 per cent of those making complaints had even heard of community health councils?

I envisage patients forums working effectively by enabling the many voices of the public—the patients— to be heard and considered, but they should not purport to represent the entire population and give a collective view on behalf of it. Alongside that we have to take account of the new role of local authorities through their overview and scrutiny committees. The noble Lord, Lord Clement-Jones, is a fierce democrat, as I am. I welcome the fact that Birmingham City Council will now have a measurably more important role in decisions on the health service in the future. Frankly, I prefer that to be done through the local ballot box than by a group of people who, with the best will in the world, cannot say, "We represent the people of the City of Birmingham".

I turn to Amendment No. 109. I am somewhat concerned with one aspect of it. First, the noble Earl, Lord Howe, expressed concern about the clause, which removes the forums' function of taking over a patient advocacy and liaison service in prescribed circumstances set out in Clause 15(2)(e). While I would anticipate that being a rare occurrence, we regard PALS as being an important service, critical to patients and their families. We believe that where a forum considers that the trust is failing to provide an adequate service, it should be able to do something about it. That is an example of how effective we believe patients forums will be in future.

Perhaps I may explain to the noble Earl, Lord Howe, how we think that would work. If, for instance, a forum were concerned about the quality of the PALS service, it would report that to the board of the trust or the primary care trust. Incidentally, PALS will be provided within primary care trusts as well as within other NHS trusts. If there is no improvement, it will report again, copying its report to the strategic health authority. If again there is no improvement, the forum will report the matter to the Secretary of State. The Secretary of State would then need to make a decision about what action he takes. He may choose to direct the trust to take action. He may also decide that the forum should take over responsibility for the PALS. If the latter, the forum will make arrangements for the provision of the PALS, perhaps arranging for another trust PALS to take over the service, but with the host forum retaining responsibility for it, or a voluntary sector organisation taking over PALS but reporting to the forum.

It is not intended that forums will provide the PALS services, as clearly they would not be equipped or resourced to do so. However, it is making abundantly clear to individual NHS trusts and primary care trusts that if they are not providing a satisfactory PALS service, their local patients forums, far from being a poodle, are in a very good position to see that something is done about it.

As regards Amendment No. 130, we do not accept that what is contained in Clause 19(2) should he replaced in the way the noble Earl suggests. I agree that the issue of patients forums collaborating and working together is important. However, we feel that the commission, working at local level, will be best placed to take an overview of the health service across the whole health economy area because individual forums, as the noble Earl suggests, are trust and primary care trust specific. The advantage of going down the route we suggest is that the commission working at local level will have the ability, staff resources and clear duty to ensure that indeed the various patients forums work together on specific issues, as the noble Earl suggested needs to happen.

Amendment No. 130 is consequent to Amendment No. 109. As I said, we remain convinced that the engagement of the wider public and representation of their views should be to the local commission. As regards the arguments raised by the noble Earl about the role of the national commission, the arguments I have deployed concerning the wider public interest are as relevant to the national commission as they are to local forums. At the end of the day, the more focused we are—as we are in the various arrangements we are setting out—the less opportunity there is for confusion or for a situation in which neither the commission nor the patients forums will be effective or credible because they seek to do something which they will not be able to do effectively.

Baroness Hanham

Perhaps I may intervene with a question that has been in the back of my mind during this whole discussion about patients forums. As chairman of a National Health Service acute trust I would put the other side of the point.

As the discussion continues I am conscious that there is a raft of organisations which will be able to encourage and enable patients to make complaints. I do not think that there is any problem with that. I am a little bothered about the other side of the equation, which is the ability and the resources to deal with the complaints. I say that because I am conscious of the pressure and the difficulties for staff dealing with many of the complaints which come to an NHS trust. Some of them are very difficult; some are very sad situations; and some involve an enormous amount of effort and work for those employed by the trust. This is not a job to which people rush. It is not one for which they may have received extensive training. Before we put in the raft of organisations which will beaver and burrow to ensure that everyone has the ability to make a complaint—however minor, but, perhaps more importantly, a major one requiring some investigation—can the Minister say what he proposes for the trusts which are already dealing with substantial numbers of complaints and which would find it helpful to have additional resources in order to deal with them?

Lord Hunt of Kings Heath

First, I welcome the intervention of the noble Baroness who brings a wealth of experience from running a busy NHS trust. It is always helpful to have that practical perspective.

I certainly agree with the noble Baroness that the current complaints system causes a great deal of work to be undertaken within individual trusts. I think that there is a variable quality about the way that trust; deal with them. I would also accept that there are views that the current complaints system is rather bureaucratic and cumbersome. She will know that we are undertaking a review of it.

I also accept that we need to do more to help trusts, not just in relation to the way they handle complaints, but more generally in responding to the inevitable increase in public and patient involvement in the health service and the inevitable increase in the scrutiny they will come under. That is life in the 21st century. It is life for all public organisations. The NHS will not be absolved from that.

I have been in discussion with the Modernisation Agency and the Leadership Centre on this matter to see what further support we can give to trusts in order to rise to the challenge of enhanced public and patient involvement. I should be happy to share some of my thoughts on the matter by writing to the noble Baroness.

However, I would also say that I am strongly of the view that the arrangements that we are putting in place will enable the NHS to deal with complaints in a more effective way. The development of the PAL service will ensure that many matters which, at the moment, end up in the complaints system will have been dealt with. I referred earlier to my experience of the PAL service in Luton. There is no doubt about the reduction in the number of formal complaints because it has been able to deal with issues as they arise. As we know, if one can deal with something there and then, many patients may feel that there is no need to go further. However, if the patient remains dissatisfied, we have established a very professional complaints service through independent advocacy. That will benefit the NHS trust because it will enable patients to articulate their complaints in the clearest way possible. It will enable the trust to deal with and focus on the issues being raised. The benefit of a patients forum is that it will be able to have face-to-face meetings with the trust board. If it has concerns about the operation of complaints within an individual trust, it will be able to bring to the trust board chapter and verse about the problems that are arising. I think that the trust board will find that extremely helpful.

I do not underestimate the challenges that trust boards will face. But I think that at the end of the day with the help and support that we can give them and with the undoubted helpful influence of patients forums and the PAL service, we will end up with a win-win situation where complaints are dealt with more promptly and more effectively and where the trust board will have the help of a patient forum in developing ideas about how one deals with these issues in the future.

5.45 p.m.

Baroness Hanham

I accept entirely what the Minister says about dealing with complaints at the outset and getting rid of them. I totally support that. I think that any reasonable trust does that now in the best way that it can. I am not really bothered about the trust board either. I am much more concerned about the people at the front line who deal with what are often extremely difficult issues. If they have a much more professional service coming at them from one side, they will be required to produce a much more professional service from the trust side. It is really a question of whether resources will be available to provide training and access to legal advice in order to be able to deal with the system or whether the trusts will be left on their own to deal with the financial aspects of what could potentially—at least in the initial stages—be resource intensive?

Lord Hunt of Kings Heath

As the noble Baroness will know, I am constantly being urged to let trusts get on with matters. We do expect trusts to be able to rise to challenges. But, as I have said, I am looking at the role of the Leadership Centre and the Modernisation Agency to see what support and advice we can give. I suspect that the work of the Commission for Patient and Public Involvement in Health—although expressly it will be giving support to patients forums—will be an extremely important help to trusts themselves. They will be able to learn from the kind of casework and experience that the commission will identify through the work of patients forums and their commission staff at local levels. I shall be happy to meet with the noble Baroness to discuss this matter and to see what further practical support we might give to NHS trusts. That of course does not mean money. In terms of finances, it is right that that should come from their general allocations.

Baroness Hanham

Resources are not always money, as the Minister knows.

Earl Howe

This has been a useful debate. I thank all Members of the Committee who have taken part. I particularly thank the Minister for the illumination that he has shed on a number of aspects relating to the functions of patients forums. I think that he has exposed a fundamental difference of approach in the way that the Government look at these matters. The internalisation of patient involvement, as the noble Baroness, Lady Pitkeathley, made clear, is central to these proposals.

A danger in the Government's approach is that the public needs to have confidence in a patients forum. If a patients forum is based within a trust, that is one thing, but the patients forums must not be "of" the NHS. That may be a distinction which the public will lose sight of if we are not very careful.

To revert to the substance of Amendment No. 108, the questioning by the noble Lord, Lord Clement-Jones, exposed successfully my own conclusion that a great deal is missing in the Bill when compared to the powers enjoyed by community health councils. We shall feel the want of that when these measures are passed into law, as I believe they will be.

Lord Hunt of Kings Heath

I am grateful to the noble Earl for giving way. Does he accept that we cannot simply compare powers between CHCs, on the one hand, and patients forums, on the other; we must compare CHCs against the whole panoply of our proposed measures in order to draw a broad comparison?

Earl Howe

Yes, of course I accept that, but I still believe that if we take that comparison, a number of gaps remain. We may address those when we discuss a later group of amendments headed by Amendment No. 101, so I do not want to anticipate them now.

I agree with the Minister that patients forums will not purport to represent the entire local population. The overview and scrutiny committees are there to perform that function. The only problem is that there will be no guarantee under the Bill, as there is at present, that the committees will scrutinise what they are given to scrutinise. As far as I can make out, that power is entirely discretionary.

Some issues may not be of prime interest to local voters but be vital to users of services. I am thinking especially of mental health service users, for example, who may not even vote. They will have little scope to make their voice heard other than through their patients forums, and they may not get far with them.

I should like to comment briefly on the Minister's reply to Amendment No. 109. I am not sure why the Government are seeking to retain the power for patients forums to take over PALS. Patients forums will have a largely volunteer structure and I should have thought that the Commission for Patient and Public Involvement in Health would be a more natural home for PALS than the patients forums.

I am also unclear to what other functions the power may apply. Would the forum concerned have any say were such a decision in the offing? What guarantee is there that the clause will not be used to pass the buck, if I may put it that way, on the Section 11 duty—the NHS consultation duty—to patients forums, making them effectively the market research departments of the trust? I shall have to consider carefully what the Minister has said between now and Report.

Turning briefly to Amendment No. 130, I was prompted to table it by a comment made by a colleague of the Minister's, Hazel Blears. I am advised that her office classified casualty watch as a discretionary activity. If that is the Government's view, that is a great shame. As I pointed out earlier, casualty watch is a service that is valued not only within the NHS but much more widely.

We shall have to return to the matter later, but in the knowledge that we have much more to debate this evening, I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

[Amendment No. 109 not moved.]

Lord Harris of Haringeymoved Amendment No. 109A, Page 21, line 11, at end insert— ( ) A Patients' Forum established under subsection (1)(b) must—

1. (a) in monitoring and reviewing the operation of services under arrangements made by the trust for which it is established, and provided by a trust for which another Patients' Forum is established, have regard to the views expressed by that Patients' Forum,
2. (b) obtain the views of the public living in the area for which services are provided or arranged by the trust for which it is established about the provision of health care services and the state of the public health in that area, and
3. (c) make a report on the views obtained under paragraph (b) above at least once a year to the trust for which it is established and to the relevant overview and scrutiny committee."

The noble Lord said: During consideration of the Bill, I have already expressed my view that the Government have moved an enormous way to answer some of the criticisms of their earlier proposals for representing and involving the public and patients in the NHS. However, a number of gaps remain and the amendment is intended to fill some of them.

The first element of the amendment is to recognise that the patients forums that relate to primary care trusts will be different to those that relate to other trusts. The reason for that is that they will relate to a trust responsible not only for the delivery of certain primary care services but for arranging for other services to be provided—essentially, they will be local purchasers. Those trusts will also be the only ones that relate to a specific catchment area and population. So the nature of the work of their patients forums will be definably different from that of those that relate to other trusts.

That is a positive factor that should be recognised in the Bill. One of the remaining gaps in the Government's proposals is that there is no mechanism to enable the co-ordination at local level of patients' views, nothing to permit the different strands to be put together. Those strands should be brought together in the patients forum that relates to the primary care trust, which in turn relates to a specific population and area. The amendment would require a patients forum relating to a primary care trust, in considering any services arranged by that trust but for which another patients forum existed, to take into account the views of that other patients forum, so that such co-ordination could occur.

The other element of the amendment is that there should be a clearly laid out mechanism for such patients forums to obtain the views of the public living in the area. That is because they will relate to a trust with a defined catchment area and population. After obtaining those views, the patients forums will be obliged to report on them at least once a year— although I would expect that it would report far more frequently than that—to both the trust for which it is established and which arranges many of the services for the population of that area and the relevant overview and scrutiny committee.

I accept that my noble friend will no doubt tell us that there are all sorts of flaws in the drafting of the amendment, but we have plenty of opportunity to deal with that later. The amendment is intended to ensure that it is clear at local level which patients forum is co-ordinating which issues and that there is a patients forum clearly responsible for obtaining the views of the local population, articulating them and putting them forward. I listened with great interest to the exchange between the noble Lord, Lord Clement-Jones, and my noble friend about the adequacy of otherwise of the views expressed by the South Birmingham Community Health Council, of which I have fond memories. The amendment would require patients forums to put forward in a balanced and properly reflective way the views of the local population and community concerned. I commend the amendment to the Committee and I beg to move.

6 p.m.

Lord Hunt of Kings Heath

I am grateful to my noble friend, especially for his acknowledgement that the Government have moved to meet some of the concerns that he expressed about patient and public involvement when we debated those matters during the last Session. I also understand clearly what he seeks to accomplish, and have a great deal of sympathy with the broad thrust of it. I do not criticise him on the grounds of the technical merits of the amendment. Rather, we have already made provision in the Bill for the substantive issues that he raises.

My noble friend's intention is to make explicit in the Bill the circumstances in which PCT patients forums should work together with other forums, specifically where services are arranged by a PCT that is covered by one forum and provided for by another trust, which is covered by another forum. Secondly, my noble friend's amendment would require patients forums to obtain the views of the public not only on local healthcare services but on public healthcare services. That is an important issue. It would also require forums to make annual reports to local overview and scrutiny committees. All those matters are covered, one way or another, in the Bill.

I agree with my noble friend that it is vital that the forums work together, not least so that they do not duplicate activity. Perhaps more significantly, they should be able to organise themselves—if necessary with the help of the commission—to ensure that their activities reflect the way in which the NHS works and what a typical patient journey looks like.

We will provide in regulations the circumstances in which patients forums should work together. That is provided for in Clause 15(5). The local branches of the commission will assist forums to work together and will be ideally placed to identify areas where there may be a need for joint activity. The reservation that I have about my noble friend's approach is that it would create a hierarchy of patients forum status. The primary care trust patients forum might be seen to have primacy over other patients forums.

I accept, of course, that PCT forums will have an additional degree of insight and awareness of the patient's role, due to their dual role of provider and commissioner. As such, they will have a good deal to offer the collective discussions that the local branch of the commission will encourage. However, it goes without saying that PCT forums will have a different role from NHS trust forums simply because of the different roles of trusts and primary care trusts. We should be wary of creating what might become a hierarchy of different types of patient forum.

The issue of whether primary care trusts should have a specific role in relation to public health is already covered in Clause 15(2), which provides that patients forums, will monitor and review the operation of services provided by, or under arrangements made by, the trust for which it is established". Given that primary care trusts will be the principal public health authorities in the NHS, the patient forum of a primary care trust is well able to discharge the responsibility relating to public health that my noble friend suggested.

The final point—an important one—relates to the issue of whether forums can make reports to trusts and overview and scrutiny committees. That is covered in several places in the Bill already. Clause 15(2)(c) says that forums shall make annual reports to the trust for which they are established. Clause 17(2) places a duty on forums to submit annual reports to, among others, trusts and overview and scrutiny committees. Clause 18 provides the Secretary of State with regulation-making powers to set out more details about the responsibilities of patients forums, with regard to making reports to overview and scrutiny committees.

I shall be interested to hear my noble friend's further thoughts, but I hope that he will recognise that, in the current terms of the Bill, we seek to meet many of the points that he has raised in this important group of amendments.

Lord Harris of Haringey

I am grateful to my noble friend for his response. I accept that it is possible to interpret other parts of the Bill in the way in which he said and that it would be possible for regulations to deal with the issues. However, it would be helpful to have something in the Bill, simply because of the protection that it would afford to such important functions.

I shall not be too upset if the consequence of the amendment is to demonstrate that there are two classes of patients forum, I suspect that, had those who drafted the Bill not wanted to create two classes of patients forums, they would have drafted it in another way. The forums are set up in different ways under paragraphs (a) and (b) of Clause 15(1). In those circumstances, it should be recognised that a particular set of functions fall on the patients forum that relates to the primary care trust.

I shall read what my noble friend said with interest, and I hope that, before Report, it might be possible for us to have some indication of the content of the various sets of regulations to which he referred. That would give us a way of judging whether the points have been adequately addressed. It remains my preference for such matters to be addressed in the Bill. At this stage, however, I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Clause 15 agreed to.

Baroness Noakesmoved Amendment No. 110: After Clause 15, insert the following new clause— "PATIENTS' FORUM MEMBERS (1) No member of a Patients' Forum may be appointed as a director of an NHS trust or a member of a Primary Care Trust to which the Patients' Forum relates unless that person has been recommended for appointment by the NHS Appointments Commission. (2) Where a member of a Patients' Forum is also a director of an NHS trust or a member of a Primary Care Trust to which the Patients' Forum relates, his responsibilities as a director of the NHS trust or member of the Primary Care Trust shall be the same as those of any other director or member of such trust.

The noble Baroness said: The amendment would add a new clause, the first part of which would create a requirement for any patients forum appointment to a primary care trust to be made on the recommendation of the NHS Appointments Commission.

Although there is nothing in the Bill that requires the appointment of patients forum representatives to PCTs or NHS trusts, I understand that the Government have stated their intention to do that. There are grave concerns about that among NHS trusts, and they were expressed forcefully by my noble friend Lady Hanham at Second Reading. There is a worry that patients forum people will not be subject to the selection procedures operated by the NHS Appointments Commission and that—not to put too fine a point on it—they will not be of the quality established by the conventional selection procedures. I imagine that PCTs will have similar concerns.

The second part of the amendment makes it clear that a person appointed from a patients forum has exactly the same responsibilities as other NHS trust directors or PCT members. That is a response to the concerns—also expressed by my noble friend Lady Hanham at Second Reading—that the patients forum members will not regard themselves as full corporate members of the NHS trusts or PCTs. There is a danger that they will see themselves as patients forum representatives and not as part of a whole corporate team, carrying collective responsibility for the affairs of the NHS trust or PCT. There is grave concern in the NHS about that.

The NHS Confederation fully supports the amendment. Nothing short of a statutory declaration that patients forum representatives must behave in exactly the same way as other directors or members will deal with the point. I beg to move.

Lord Clement-Jones

I support the amendment. It is interesting that the NHS Confederation, as the noble Baroness, Lady Noakes, said, supports the amendment. There are concerns relating to the role and selection of the patients forum non-executive director on the board of each NHS trust and PCT.

It is important that the patients forum-elected non-executive director becomes an ordinary board member with full corporate responsibility and that he or she fully understands the implications of the need for corporate responsibility. Failure to ensure that could inhibit the good operation of the board. That is an important factor. It is also important that the patients forum-elected non-executive meets Nolan criteria and that individuals go through a selection process similar to that for the other non-executives.

It is right that all non-executive board members should bring the requisite competencies to the board. For that reason, we support the amendment.

Baroness Hanham

I am extremely grateful to my noble friend Lady Noakes for having taken on the burden of working out these amendments and putting them forward Noble Lords will recall that I have been banging a rather lone drum on the question of a patients forum non-executive director on the board of a trust through our debate on Second Reading and in previous discussions. The amendments very much encompass my concerns. I am also grateful for the support at last of the noble Lord, Lord Clement-Jones— as I have said, I have been on my own with regard to this point until now—as well as that of the NHS Confederation.

It is extremely important that we get this right. If someone is to be imposed on a board, there must be a process by which the board can accept the appointment. On Second Reading, the Minister was kind enough to suggest that I should talk to him not only about my general concerns, but also about the detail here. What has been lacking all along has been a general acceptance that a great many details have to be worked out. I should like to acknowledge the fact that the Minister was kind enough to spend some time with me over this. I hope that that time was fruitful for him and that now I shall find that it will have been fruitful for me.

Briefly, my concerns remain the same and I hope that the Minister will be able to respond to them. At present, non-executive directors are appointed to a board by the new NHS Appointments Commission. Formerly they came via a different route, but they have always been appointed either by the Secretary of State, or now by the NHS Appointments Commission. It s absolutely inconceivable to me that the non-executive directors of patients forums should in some way bypass that process or, indeed, that the chairman of the board should have no role in seeing or otherwise, and accepting or otherwise, who is to be appointed. The NHS Appointments Commission could play an important role here by ensuring that there was some effective choice before the chairman of the board. I hope very much that now that will be part and parcel of any new proposals.

I am also concerned about several other elements. I understand that the patients forum representative will not be supernumerary to other non-executives. At present, there are five non-executive directors on a board, or six if, as I have, there is a university representative as well. When we have discussed this on previous occasions, I have always been led to understand that one patients forum representative would replace one of the non-executives. The question lies in how and when that is done.

Non-executive directors are usually appointed for a minimum of two, four or eight years. The two-year appointments almost always carry on for six years, while the four-year appointments, by definition, often carry on for eight years. That extended experience is absolutely invaluable to the stability of a board and helps it to continue and develop. What would be unacceptable and very difficult to understand would be a situation where someone is parachuted in and replaces, in the short term, a person already in place, who has already been through the "Nolanisation" process referred to earlier, who has been approved by the NHS Appointments Commission and who has been appointed for a set term with the possible expectation of being reappointed. If that were allowed to happen, it would set a poor example and establish a bad precedent. I hope that the Minister will be able to reassure me on that point.

As our discussions on patients forums have developed today, I have become increasingly concerned about exactly to whom this representative believes that he or she will be accountable. This matter forms the second part of the amendment moved by my noble friend Lady Noakes. If there is to be a non-executive director, it would be quite wrong for the accountability of that non-executive director not to rest with the board: that is, that they might have a completely different line of accountability out to someone else. It would make the corporate role of non-executive directors very difficult to manage. The last thing one would want from such a representative or, indeed, for such a representative, would be for them ever to be treated with suspicion by the rest of the board. We must ensure that the incorporation is carried out in a way which leaves no rancour or worry for other members of the board. They must be assured that the person forms a full part of the corporate body.

That point becomes even more important when one considers the inspectoral role of the patients forum. Again, it is quite possible that a patients forum with such a non-executive director could find itself at odds with a trust board because either the forum or the non-executive director would be the bearer of an adverse report. I would not expect that to happen in my case, but I see that it could happen in some trusts, either fairly or unfairly.

I hope that we shall see a little more roundedness introduced into this appointment. I look forward to what the Minister has to say. However, although I do not know whether I have a right, I shall reserve my right to respond once more before he sits down if I am not totally content with his remarks.

6.15 p.m.

Baroness Masham of Ilton

Having listened to the noble Baroness, Lady Hanham, perhaps I may ask the Minister a question. Will the patients forum representative be paid if he or she replaces a non-executive director, and will the appointee have time to do both jobs?

Lord Hunt of Kings Heath

I am grateful to the noble Baroness, Lady Noakes, for giving us a further opportunity to debate this matter. I recognise that, in particular for the chairs of NHS trusts, the appointment of a patients forum non-executive director to the board of a trust represents a challenge. However, my contention would be that the NHS is not unused to appointments such as these. For example, one of my first introductions to the NHS was in the mid 1970s as an appointee of Oxford City Council to the hoard of the Oxfordshire Area Health Authority. We know that, in general, NHS authorities are composed of people who come from different backgrounds and have different interests, but once they arrive at the boardroom they should be expected to take part in collective responsibility. Ultimately, I do not see any difference between the patients forum person and other members of the board of a trust— that is, those coming from a variety of backgrounds and interests.

I turn to the point raised by the noble Baroness, Lady Masham. The person appointed to the patients forum will receive the honorarium that non-executives generally receive for serving on NHS trust boards. With regard to timing, I fully recognise the major time commitment to be made by non-executive directors. We are very grateful for their contribution and obviously time is a factor that must he considered by the members of the patients forum when they come to discuss who should go forward for nomination. It is one of the criteria for successful appointment. A candidate must be able to devote the time required to meet the responsibilities of the job.

Having said that by way of introduction, I hope that I can reassure noble Lords that we have in place the mechanisms to make this work effectively. First, let me make it clear that the NHS Appointments Commission is the appointing body for all non-executive appointments to NHS trusts and PCT boards. We have made our intention clear, through the listening exercise and so far during the passage of the Bill, that patients forums will each elect one of their members to go forward to the NHS Appointments Commission for appointment through the standard process. That will mirror the way in which university representatives are currently appointed.

The forum nominee will be assessed by the NHS Appointments Commission against the same criteria of probity and expertise used in the selection of other board members. We can expect patients forums to take this into account when electing their nominees. I am confident that we will see very high quality candidates put forward.

In the exceptional circumstance that, for some reason, the nominee elected by the patients forum is found wanting in some important respect, the appointments commission will be expected to reject that nomination. The patients forum then will be required to carry out another election. I do not expect that to happen very often, but it is an important safeguard.

Once appointed, the new board member will be expected to accept corporate responsibility for board decisions in the same way as any other non-executive member. That is very important and I am happy to reaffirm that principle. They will undergo the same induction process that is given to other board members to explain exactly what corporate responsibility means and to help them to be effective across the range of board member responsibilities.

I do not depart from the point made by the noble Baroness, Lady Hanham. For the chairs of trusts there will be challenges ahead to ensure that corporate responsibility is discharged and that the patients forum non-executive is able to play a full part in the discussions of the board. Surely the value of having a patients forum representative on the board is that it will be a powerful route through which patients' views and issues of direct relevance and interest to patients are brought to the decision-making table. Surely that is another example of the inclusive approach recommended by Professor Kennedy in the Bristol inquiry report.

The noble Baroness, Lady Hanham, asked about the position of current non-executives on trust boards who may be affected by the appointment of a new patients forum non-executive. I can go some way, but not the whole way, that she would like me to go. Clearly someone who is already on a board will complete his or her current terms of office. In the future, we will have a fluid situation. While it may be expected that most trust boards will continue to have five non-executive directors in the fullness of time—including the patients forum non-executive director—I should remind the noble Baroness that the trust regulations 1990, as amended, allow NHS trust boards to have up to seven non-executive directors. I accept that, like her own trust board, the majority of NHS trust boards have five members, but there is some flexibility in this issue. No doubt we shall need to reflect on the matter in the future.

I hope that I have gone at least some way towards convincing the Committee that we accept that there are challenges. We believe that the role of the appointments commission ought to reassure the noble Baronesses on the substantive points that have been raised, but, ultimately, the advantage of having a patients for am non-executive on the board will, in the round, bring distinct advantages to the NHS and to the individual trust boards.

Baroness Hanham

I believe and hope that the Minister will acknowledge that I have never at any stage said that I did not think there should be a patients forum representative. I have been seeking all the way through to ensure that there is not only a proper process but a complete understanding of the accountability of this person.

I believe that we are beginning to dig ourselves out of a hole. Certainly what the Minister is saying is getting better as we progress. When we first started there was no question of the appointments commission having any role in this, so I am glad that that has now been accepted.

I was equally interested to hear about the seven voting members on a board because that has the potential—even with a trust that has a university representative—of easing-in a patients forum representative non-executive director without causing too many subsequent ripples. Indeed, at some stage it may be decided that there can be an additional member if seven are allowed. The Minister may wish to continue this discussion in the light of experience as we see how matters progress.

I am glad that the appointments commission will be able to reject a candidate. However, I am conscious that the appointments commission will also be responsible for the appointment of the patients forum candidates. Can the Minister reassure me that once the decision is made as to who the patients forum wants to be elected, there will then be a separate consideration by the National Health Service Appointments Commission of that person? There may or may not be quite a difference between being a member of a patients forum and a member of a board, but we need two processes in this regard.

Lord Hunt of Kings Heath

There will be different processes. The appointment of patients forum members will be the responsibility of the national commission and the bulk of the work will he carried out by its local staff. But it will be done under the auspices of the appointments commission, which will set the standards under which such appointments take place.

I accept that the noble Baroness was not seeking to criticise the appointment of patients forum non-executives. I fully accept that from her experience as a trust board chair she wants to make sure that the process works as effectively as possible. I will be happy to continue the dialogue over the next few weeks as we debate the Bill to ensure that we make as clear as we can how we expect the system to work.

Perhaps it would help if I gave some examples of where a patients forum representative might be rejected by the appointments commission. This might happen where a candidate lives outside a PCT area; where the candidate has been convicted of a criminal offence; where the candidate is not legally entitled to work in the UK; where the candidate would not he able to be available for approximately five days every month. That is a very important backstop.

Baroness Hanham

I am grateful to the Minister for that explanation. I shall read what he said—and I may take up his offer to come back on this issue yet again— but certainly, for me, his reply was helpful.

This is a completely different appointment to a board than any there has ever been. Like the Minister, I was an elected member on an area health authority, but I did not have inspectorial rights. This patients forum director will come from an organisation which has the right of inspection and criticism, and now a right to report to the overview and scrutiny committee. Such an appointment is potentially more contentious—it need not be—both for the board and the individual. That is my last word on the subject. It is a role that we may need to finesse a little—and, sadly, we may have to do so in the light of experience — but I hope not to have to come back to this issue. If I do, I hope that the Minister will allow me the latitude to do so at a later stage.

Baroness Noakes

I thank noble Lords who have taken part in the debate—particularly the noble Lord, Lord Clement-Jones, and my noble friend Lady Hanham—and the noble Baroness, Lady Masham, for her interesting question. I thank the Minister for his response, in particular for his affirmation of the involvement of the NHS Appointments Commission.

I was almost convinced until the Minister gave examples of the grounds on which a candidate would be rejected. Having told us firmly that candidates could be rejected— which sounded excellent—the grounds for rejection seem technical—for example, not living in the area rather than not meeting the criteria for being a good contributor to an NHS trust. I should like to press the Minister to say whether or not a patients forum representative could be rejected if that person did not bring anything to the corporate team in terms of directing an NHS trust. However, that point apart, the Minister's response in that area was very helpful.

It was also helpful that he reaffirmed that each director of a trust or member of a PCT would have full corporate responsibility. However, there must remain concerns about this because these people will be representatives of organisations with inspectorial rights. Going back to the position of the council-nominated members of health authorities, one of the reasons that they disappeared from the scene was because it was not felt that they contributed in a corporate way. On a universal basis there are honourable exceptions—including noble Lords here present.

I wish to consider the Minister's reply and possibly return to the point. Meanwhile, I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

6.30 p.m.

Lord Clement-Jonesmoved Amendment No. 111: Before Clause 16, insert the following new clause—

"ESTABLISHMENT OF PATIENTS' COUNCILS

(1) The Secretary of State shall, subject to subsection (3), establish a body to be known as a Patients' Council ("Council") in England in each area for which an overview and scrutiny committee has been established under section 7 of the Health and Social Care Act 2001 (c. 15) (functions of overview and scrutiny committees). (2) Each Council shall be appointed from among members of the relevant Primary Care Trust Patients' Forums and NHS Trust Patients' Forums operating in that area and representatives from the relevant community interest groups. (3) Where it appears to the Secretary of State that there is a need to establish a Council for an area other than that represented by a local authority with overview and scrutiny functions, he shall, after local consultation, establish a Council for such other area as appears to him will meet the needs of the local community. (4) The functions of a Council are to represent the interests in the health service of the public in its district and in particular to—

1. (a) facilitate the co-ordination of the activities of member Patients' Forums including by the provision of staff and services to Patients' Forums,
2. (b) provide or make arrangements for the provision of services under section 19A of the National Health Service Act 1977 (c. 49) (independent advocacy services) at the direction of the Commission for Patient and Public Involvement in Health,
3. (c) represent to persons and bodies which exercise functions in its area (including in particular the overview and scrutiny committees and the joint overview and scrutiny committees referred to in sections 7, 8 and 10 of the Health and Social Care Act 2001) the views of members of the public in its area about matters affecting their health, and
4. (d) advise the bodies listed in subsection (5) on involvement of the public in its area in consultations or processes leading (or potentially leading) to decisions by those 576 bodies or the formulation of policies by them, which would or might affect (whether directly or not) the health of those members of the public, monitor the effectiveness of this involvement and co-operate with the Commission for Patient and Public Involvement in Health in carrying out this function.

(5) The bodies referred to in subsection (4)(d) are—

1. (a) health service bodies,
2. (b) other public bodies, and
3. (c) others providing services to the public or a section of the public.

(6) The Secretary of State shall, following consultation with the Association of Community Health Councils for England and Wales, Community Health Councils, patients' and carers' organisations and the wider community, by regulation make provision in relation to Councils as to—

1. (a) the Patients' Forums and other community interest groups from which members of the Council are to be appointed,
2. (b) any qualification or disqualification from membership,
3. (c) terms of appointment,
4. (d) the proceedings of a Council,
5. (e) the discharge of any functions of a Council by a committee of the Council or by a joint committee appointed with another Council,
6. (f) the circumstances in which Councils will co-operate with each other in the exercise of their functions and exercise functions jointly with one or more other Councils,
7. (g) funding of Councils and the provision of staff, premises and other facilities,
8. (h) the preparation and publication by a Council of annual accounts,
9. (i) the provision of information (including descriptions of information which are or are not to be provided) to a Council by an NHS trust, a Primary Care Trust, a Strategic Health Authority, the Commission for Patient and Public Involvement in Health, the relevant local authorities or a person providing independent advocacy services (within the meaning given by section 19A of the National Health Service Act 1977),
10. (j) the provision of information by a Council to another person,
11. (k) the preparation and publication of reports by Councils,
12. (l) the furnishing and publication by NHS trusts, Primary Care Trusts, Strategic Health Authorities and overview and scrutiny committees of comments on reports or recommendations of Councils, and
13. (m) the referral of matters of a prescribed description to any overview and scrutiny committee, the relevant Strategic Health Authority, the Commission for Patient and Public Involvement in Health or the Secretary of State for Health.

(7) The regulations shall also include provision applying or corresponding to any provision of Part 5A of the Local Government Act 1970 (c. 70) (access to meetings and documents). (8) In section 21(10) of the Local Government Act 2000 (c. 22) (overview and scrutiny committees) after "members of the authority" there shall be inserted "and shall include a person appointed by the relevant Patients' Council". (9) In paragraph I Schedule 5 to the National Health Service Act 1977 (c. 49), as amended by the Health Authorities Act 1995 (c. 17) after sub-paragraph (c) there is inserted— (d) persons appointed by the relevant Patients' Councils.".

The noble Lord said: The noble Lord, Lord Harris, was polite enough to talk about gaps in respect of the provisions relating to patient and public involvement. The situation is rather more serious. The word "chasm" would perhaps be more appropriate.

The amendment would establish patients' councils to integrate the work of the patients forums operating in their areas—which in the view of my noble friends and many of your Lordships is a major matter to be put right in the Bill. Amendment No. 111 is similar to that tabled by David Hinchliffe, chairman of the Select Committee on Health in another place, during the passage of the Health and Social Care Bill prior to the last general election—which enjoyed cross-party support in both Houses.

The Department of Health response to the listening exercise stated that patients' councils provided a sensible option for facilitating the co-ordination of patients and public involvement mechanisms—but the proposals do not build on that concept, which is surprising in view of those words.

The amendment provides for the creation of patients' councils as a statutory means of integrating the work of patients forums in a local area. I listened with some incredulity to the Minister talking about how the various forums would, by regulation, track the patient's journey and make sure that it was covered. The Minister seemed to be making a good case for patients' councils but I shall scrutinise Hansard to see whether I can pray his words in aid even further at the next stages.

The local areas covered by patients' councils could be coterminous with a local authority overview and scrutiny committee and provide support to its scrutiny function, although, following discussion, some other area may be preferred. For example, there may be more than one patients' council in a large county. Regulations would provide for membership of relevant forums in other community groups, which may include local strategic partnerships. As membership bodies, patients' councils would be accountable to patients forums. With lay membership and statutory duties, they would also be more accountable to local patients and communities than the Government's proposed commission local networks. As independent statutory bodies, they would help to reinforce the independence of patients forums at local level.

The Government's model is extremely top down, particularly in the workings of the commission. In theory, there is no reason for national or local emanations of the commission to take any notice of the views of the local community on any issue. It is not the commission's job to represent local communities. It is unlikely that local communities would be able to develop the same positive relationship with their local commission as they have in many cases with community health councils. Communities will not own the commission or direct its work—and certainly will not be represented on it.

Patients' councils would operate as a local base for staff provided by the commission for patient and public involvement. Support would be provided for patients forums as needed. Patients' councils would also be able to provide commission advocacy for people wishing to make a complaint about the NHS, in line with the provisions for the independent complaints advocacy service enshrined in the Health and Social Care Act 2001. Placing the advocacy function with patients' councils would inform the rest of their work. Wider problems in the local health service could be recognised more quickly.

As well as providing an identifiable locus where the public could raise concerns about the local health service, patients' councils could act as one-stop shops where the public could get independent information and advice. Community health councils currently provide easily accessible one-stop shops. If they ate abolished, the public will face a confusing array of' fragmented bodies from which to seek help.

The role of representing local concerns about matters affecting health would he taken by patients' councils rather than the commission. Information about local concerns, including matters that may form the subject of referrals, would be provided as necessary to the local authority overview and scrutiny committee. A local independent statutory body would take responsibility for ensuring that the local community's concerns are raised. Oversight and scrutiny committees and health service bodies could be required to comment on reports.

The national Commission for Patient and Public Involvement in Health would no longer have responsibility, as proposed in the Bill, for making such representations. It would support patients' councils that function and make representations nationally.

Patients' councils would share with the commission the task of ensuring that consultations were undertaken by health service bodies and assist where appropriate. That would ensure that a local independent body took on the vital role of ensuring that patients and the public were consulted locally. That would be more likely to result in local action than relying on outposts of a national, staff-only body.

The national commission would of course he included in the list of bodies to which patients' councils should send their reports. Local authorities have also been included as bodies that must provide patients' councils with information because their work will impact on the health of the local population.

Amendment No. 111 also permits the making of regulations to allow patients' councils to refer matters to oversight and scrutiny committees and, in specified circumstances, for patients' councils to make referrals to the relevant strategic health authority—the Commission for Patient and Public Involvement in Health or the Secretary of State. That is not intended to usurp the referral power of oversight and scrutiny committees but to allow patients' councils to make referrals where OSCs do not carry out their scrutiny functions or where referrals would be more appropriately directed at strategic health authorities.

Currently, OSCs have the power to scrutinise but they do not have the duty, unlike CHCs—which have both the duty and the power. Patients' councils would appoint members to sit on overview and scrutiny committees and strategic health authorities. That would ensure coherent representation of patient forum members' interests at a strategic level. Patients' council members would also be able to bring their overview of the work of patients forums to a wider forum.

The role envisaged for the commission of pioneering new ways of working with local communities and hard-to-reach groups is welcome and would not be compromised by the amendment.

There remains a strong case for a local, lay-led organisation that could pull together all the various fragmented functions of the system; provide and arrange complaint support; represent the local community; and provide a visible, accessible and approachable point of contact to the local community.

In summary, patients' councils would offer integration and simplification; a one-stop shop, less bureaucracy; local credibility and accountability; a powerful independent voice for local people; an overview of health issues and services; flexibility; support and back-up for local authorities; and a genuine local watchdog. All that would be compatible with the Government's overall plans—as they accepted in the 2001 Act. It would be a new way of working, not the recreation of community health councils. Patients' councils would embrace the Government's stated vision of a new approach to patient and public involvement while building on the most valued aspects of CHCs.

I shall not catalogue all the bodies that support patients' councils but they are legion. They include the Patients Association, Age Concern, Action for Victims of Medical Accidents, Help the Aged, Mencap, doctor-patient partnerships, the Royal College of Nursing, the Local Government Association and the Democratic Health Network.

I want to deal with one set of criticisms that appeared in the Guardian today because I know that the Minister, in his entirely dispassionate way, will wish to refer to it. It was interesting that the letter in the Guardian was received directly by noble Lords today. The chairman of the Long-term Medical Conditions Alliance states in her letter: It is time for the arguing to stop so that action can begin".

If anyone is guilty of having made sure that the arguing continues and that action cannot begin, it is the Government. The Government are the ones who unscrambled the proposals that were just about there before the last general election. They have wholly failed to come up with a scheme which the majority of people at local level can get behind.

Of course, there are a number of national charities which are frustrated by this situation. I am a trustee of two of them. But that does not mean that opting for some second-rate, inadequate system of public and patient involvement is the way forward. What we need is a proper scheme that will fill the chasm that I mentioned earlier and make sure that we have the proper involvement and that the new bodies do fulfil a proper duty and are able to carry on the job as worthy successors to the community health councils. I beg to move.

Lord Rea

The noble Lord, Lord Clement-Jones, has described very clearly the functions of the patients' councils proposed in the amendment. I put my name to it because I feel that the matter merits particular consideration by my noble friend. It is not that I feel that he does not give full consideration to every amendment; but, as he knows well, the amendment had considerable support in another place from government Members as well as opposition Members. My purpose is to give it support from this side of the Chamber.

Throughout our deliberations today, I have had a strong sense of déjà vu. However, matters have moved on since this time last year. The Bill as it stands is certainly an improvement on last year's version in terms of representing patients' interests. Nevertheless, the underlying disquiet about the abolition of the CHCs remains. That is not because CHCs are averse to reform or to change—quite the contrary. But by proposing simply to scrap them and start afresh, the Government have lost a wide tranche of support right across the political spectrum. I am afraid that that includes some of their most loyal supporters.

The uncertainty about the future of CHCs has already led to a haemorrhage of some of their most able staff and members. However, many of those who remain want to see an effective system of representation and independent scrutiny of the NHS up and running, whatever the name of the organisation, as soon as possible. They accept that many of the Government's proposals are attractive, but the system proposed in the Bill is complex. Patients and the public in general will need the equivalent of an A-Z guide to find their way through it.

The CHCs provide an entry point which people have learnt to use. Even if 97 per cent of people apparently did not know about their CHCs—and I find that difficult to believe—their social worker, if they had one, their local citizens advice bureau, and certainly their legal advisers or general practitioners, did know how to get in touch with the local CHC. The CHCs have provided a single entry point which people have learnt to use—the term "one-stop shop" should now perhaps be put on one side; it has become a cliché. It is useful for people to be able to go to one place—not only patients but, importantly, other people who are concerned about the working of the National Health Service in their area. These points were raised by my noble friend Lord Harris. The concerns of the population, as well as those of patients, must be looked into properly.

The proposal for patients' councils brings back such a single-entry facility. But more than that, as the noble Lord, Lord Clement-Jones, pointed out, the councils would act as independent, locally based co-ordinating bodies which would oil the wheels of the system of patients' forums, independent advocacy services and scrutiny which will come into being with the passage of the Bill.

The amendment received a great deal of support when David Hinchliffe's Bill was debated in another place. Its principles have wide support from national organisations. I have counted at least 24 which have voiced concern about the abolition of the CHCs and the inadequacies and complexity of the replacement structures. The noble Lord has mentioned a few. I mention the BMA, the GMC, the Royal College of Midwives, the Royal College of Obstetricians and Gynaecologists, the National Association of Citizens Advice Bureaux and the Consumers' Association.

I have also been reliably informed that, only yesterday, a meeting of the Transition Advisory Board (TAB), set up by the Department of Health to smooth the changeover from CHCs to the new system, reached the conclusion that a co-ordinating body very similar to the patients' councils proposed in the amendment should come into being in each local area. CHC representation in TAB is only one-third of its membership; and I am told that it did not advocate patients' councils as such. The other two-thirds include government representatives, local government representatives and the voluntary sector.

For all the reasons put forward by the noble Lord and those that I have mentioned, I hope that my noble friend will give serious consideration to the amendment and, if necessary, come back on Report with another one which embodies its principles but which may differ in detail to suit the Government's legislative rules.

6.45 p.m.

Lord Weatherill

My interest in the amendment, to which I have added my name, stems from my experience as Member of Parliament for Croydon North East for many years and the high esteem in which the Croydon CHC was held, not only by volunteer groups in my borough but also by individuals and by Croydon council. Indeed, when the abolition of the CHCs was first mooted, the council passed a resolution which was supported by all the political parties—which rarely happens in Croydon.

Perhaps I may place on record what the resolution said: This Council is proud of the way that Croydon CHC provides a strong and independent voice for the people of Croydon on NHS matters and of the way it carries out its functions as the local watchdog … This Council judges that the involvement of an independent watchdog role is essential in helping the Council undertake its proposed new responsibility for scrutiny of the NHS and in adding cohesion to, and commanding public confidence in, other initiatives in the NHS Plan". Against that background, I am sure that many in Croydon and many others elsewhere—judging from my post-bag—will share my disappointment that the CHCs are to be abolished. That is why I have added my name to the amendment. It is a compromise. As a Whip for many years in the other place, as Chairman of Ways and Means, and as Speaker, I have had considerable experience of the art of compromise. Patients' councils would provide a means of progressing the most important role of the CHCs and would work perfectly well within the context of the Government's own framework for patient and public involvement.

Unless we seize this opportunity to achieve consensus on this issue, it is hard to see how or why the public should have confidence in the Government's proposals. I therefore hope that the Government will accept this compromise solution to a matter that is causing concern to so many in the health service in my former constituency and elsewhere, and among many other organisations across the nation. I repeat that this proposal has strong support in the other place, and I hope that this amendment will find favour with Her Majesty's Government and with the Minister at the Dispatch Box this evening.

Baroness Pitkeathley

Many of us who have worked for a long time with patients and user organisations are aware of the frustration expressed in the letter from the Long Term Medical Conditions Alliance quoted by the noble Lord, Lord Clement-Jones, and of the anxieties that the alliance expressed about the promotion of bureaucracy at the expense of the voice of individual users of the National Health Service. We are also aware of the excitement and anticipation felt by many groups about the possibilities offered by the new structures, and of their wish to get on with making them work for the benefit of patients, carers and tie general public. It is certainly true that we do not yet know how these structures will work, but I believe that there are adequate safeguards as to accountability and review built into the process.

Prolonging the debate and making new proposals is not helpful at this stage. The Government have shown great commitment to public and patient involvement, and the Minister has also shown his personal commitment to that, time and again. It is now time to get on with it, and to take advantage of the great good will that exists in the field towards the proposals. I oppose the amendment.

Baroness Carnegy of Lour

It seems to me that we are at last having a realistic discussion on the subject of patient involvement, because patients are being treated as what they are, which is customers of the National Health Service. When the noble Baroness, Lady Pitkeathley, contributed before—and my noble friend on the Front Bench commented on this—she let the cat out of the bag by saying that the Government see members of the public as, in a sense, members of the National Health Service. She implied that the National Health Service was a big tent that included the patients. It is not like that. The National Health Service is a service provided for the public. The public are the customers, and they must be able—at some point in this huge, byzantine structure that is being set up—to have an independent view.

When my noble friend Lady Hanham was describing, from the point of view of the board, the problem of having the chairman of a forum as a member of the board, I wondered what would happen if a patient happened to disagree in a way that could not be reconciled with the view of the board. What would happen to the wretched chairman? By creating this big tent, the Government have created big problems for themselves. The noble Lord, Lord Clement-Jones, has suggested a mechanism by which there could be straightforward representation of public and patient interests from outside the National Health Service, which is, after all, their service, provided for them and paid for by them. That proposal does, indeed, clarify the issue.

As I listen to this discussion, I see the Government getting themselves into the most amazing muddle, and, in the long run, their proposals will not work. They cannot work because there is a conflict of interest in the system. The public must be able to say, "We think you are wrong, and we want something different". They must be able to do that through a body that is independent of the service. To that extent, the noble Lord, Lord Clement-Jones, is making a very important suggestion.

Baroness Masham of Ilton

In the last few months there has been a mushrooming of health organisations, both voluntary and statutory. The Minister has launched many of them, and nobody could do it better than he could. I recently attended a reception for the National Patient Safety Agency, a much-needed National Health Service body. Last night, the Minister also spoke at the Parkinson's Disease Awareness Week reception. Nobody could be more aware of the importance of these valuable bodies, which do excellent work.

Many voluntary organisations give much-needed information to people who are devastated when they have been diagnosed with a long-term medical condition. Those people need information and support. With the complexity of the National Health Service and the need to pass on information about patient groups, there needs to be a powerful, independent voice for local people. I have spoken to many people who have stressed that independence is the most important aspect of a people-led, not staff-led, body. There must be a central point, with easy, friendly access, to co-ordinate and direct the public to the many different bodies. That is why I support the need for patients' councils. If these councils are not independent, many members of the public will not come forward for help and advice, as they will feel that they might be victimised or branded as troublemakers.

During the Easter Recess, I attended a dinner in Harrogate. I talked socially there to a doctor who sang the praises of the Harrogate Community Health Council, and said what a pity it would be if it were disbanded. He also told me that a rumour was circulating the North of England that the Secretary of State for Health had fallen out with a local CHC, and that that was the reason they were being disbanded. I would like to ask the Minister if that is fact or fiction. The Secretary of State should surely be wise enough not to go against the wishes of the public on a matter such as this.

This is an opportunity to make patients' councils more effective and to allow them to do more than CHCs. People have become frightened of having an operation in case they develop an infection such as MRSA in hospital. If the councils are not independent, and if people do not feel free to speak out, there will continue to be endless cover-ups by some trusts.

I would like to see the patients' councils help to bring health and social services into a better and closer relationship. Patients are left in hospitals, blocking beds, because of the slowness of social services in providing aids and adaptations to make their houses suitable. Patients' councils could help to stimulate the co-ordination of public health matters. I must declare an interest here, because my husband has to have his INR checked periodically—that is a blood coagulation test—and I use a mattress to prevent pressure sores. I have in my bag a letter from the Northallerton Health Services NHS Trust, which tells me that the district nurses service will continue to be provided by the community nurses based at Bedale, but from 1st April 2002, the mattress—which is currently rented by the Northallerton trust—will be rented by Harrogate, because Masham, where I live, will fall under the Harrogate primary care trust.

I give the Committee this example to illustrate how the new system is already causing fragmentation. The public will need patients' councils to be flexible, to cross trusts, to be able to network across strategic health authorities on issues of wider geographical concern, and to sort out many of the small issues of confusion before they become expensive big problems of discontent.

I hope the Minister will be helpful today. So many people support their local healthcare facilities in so many different ways. Patients' councils could encourage them to do more. The National Health Service needs all the help it can get from everybody.

7 p.m.

Earl Howe

I am pleased to support the amendments, which the noble Lord, Lord Clement-Jones, has so ably introduced. I do so mindful of the fact that politics is the art of the possible. I echo the remarks of the noble Lord, Lord Weatherill, that the best model for patient and public representation, for everybody's sake, would be a reform and strengthening of community health councils, as I proposed in my earlier amendment. To my regret, that is not going to happen. Putting our disappointments behind us, it is right that we should examine the proposals that are on the table and suggest ways of improving them.

I shall not repeat all my earlier criticisms of this part of the Bill, but it might be appropriate to focus on a few of its key features. There is a huge gulf between what the Government say they want and what we are being offered in the Bill. The Government say that they want a patient-centred service. How can that be achieved by setting up institution-based representation? As we have said on a number of occasions, a patients forum will monitor only the services of the trust on which it is based. Who will monitor the NHS more generally from the patients' perspective or look at the wider dimensions of health-related issues? The best of the CHCs have achieved that informed overview very well. We shall lose that if patients' councils are not established.

We are told that there will be mechanisms to ensure that patients forums work together on key issues. Such informal arrangements are no substitute for having an overarching, lay-led organisation that the public can clearly identify and hear speaking up for them across the NHS. A patients' council would be founded on the combined authority of patients forums, each of which would contribute inside knowledge of its local NHS.

The next main issue is independence and impartiality. I shall have more to say on that theme on a later amendment, but for now I shall underline one point. If patients' forums are to do their job effectively, the public have to have confidence in them. How will that be possible when the only information fed to the forum will come from the trust? How will the forum be able to check up on what the trust is telling it? How will it know whether it is being given the whole picture on clinical priorities in waiting lists, on real trolley time waits in A&E or on the financial state of the trust? Such reassurance and verification would be achieved through patients' councils, which would also be guarantors of independence, giving the public confidence that their interests were being put forward impartially by its constituent patients forums.

The noble Lord, Lord Clement-Jones, has listed many more advantages that could come with patients' councils. The one-stop shop could be restored. As the noble Lord, Lord Rea, said, that may be a cliché, but it is still very much to the point. Many services that the patient could relate to could be centred in one place—complaints handling, information, advice, access to local consultation and so on. We could bring together the array of groups and bodies that the Government are currently proposing for lay reference panels, for local providers of ICAS services, for local networks of the Commission for Patient and Public Involvement in Health. A patients' council would embrace the whole lot and in so doing would vastly improve local lines of accountability, which are singularly deficient in the arrangements as now planned. Patients' councils would also act as community-led health watchdogs, which is perhaps the single most significant net loss arising from the abolition of CHCs.

Those are the main reasons why I support the amendments. The letter from the chairwoman of the Long-Term Medical Conditions Alliance opposing the amendments has been referred to. I have no doubt that she is an admirable and public spirited person, but, if I may say so, she puts herself at risk of being classified as a stooge of the Government. The envelope in which her letter reached me today was identical—with an identical label—to an envelope containing a helpful letter from the Minister. I should be delighted to be told that I am wrong in concluding that both letters were dispatched centrally by the Department of Health.

I hope that the Minister will not give us a dusty answer to the amendment. If he attempts to do so, he ought to bear in mind that the concept of patients' councils, as embodied here, is supported not just by Members of this House but by numerous patient and voluntary organisations, as the noble Lord, Lord Clement-Jones, mentioned. I hope that we can collectively convince the Government that these are sensible ideas which, if implemented properly, could be a major plank in the delivery of a patient-centred health service.

Baroness Chalker of Wallasey

I hesitate to intervene in the debate, as I am more associated with medical services overseas than those in the UK. I do so a result of my experience long ago, as Member of Parliament for Wallasey, when we formed the patients participation association to buttress one element of the then CHCs that did not work terribly well. That concerned the links between general practitioners and the local hospital and social services.

That organisation did some excellent work in the late 1980s and through the 1990s. It has now dwindled, but it did so only when the CHCs took up the challenge set by the association. The issue is very important, particularly for older people, who have less confidence in what is going on than some of us who are lucky enough to be told by the Minister and to hear of all the changes in a different way.

The proposal by the noble Lord, Lord Clement-Jones, and others is fundamental for encouraging confidence in the health service. Being sick—even a little sick, as I was some time ago—is not something that one views with any confidence, however good the doctor may be. Being part of the great wheel of the health service terrifies the over 60s and probably people much younger as well.

Establishing a council for the care and consideration of the needs of the patient would be a very valuable service. I hope that the Minister will give serious consideration to accepting the amendment—or a parallel one if there is something not quite right in some aspect of it or if it is not quite correctly drafted, as I well know that Ministers so often say. I believe that the amendment is very well drafted, but should the Minister believe that it is not perfectly drafted I beg him to come back with something that will give greater confidence in the National Health Service, which sometimes has a few problems at the moment.

Baroness Finlay of Llandaff

I support the amendments. I have listened to the comments that have been made so far and feel that, as a healthcare professional, it is important that I voice my support. The independence of the view of patients is crucial. I cannot over-emphasise how vulnerable patients feel when they are ill. If they feel that they are complaining into an organisation on which they are dependent for their care, they are terrified that there may be some backlash against them.

Only this week I sat with a patient who asked whether he had grounds for complaint. He was frightened of raising the issue with me. I went through the issues and felt that he might possibly have grounds for complaint, but not for litigation, and explained the situation to him. As he looked at me with tears in his eyes, he said that I had put his mind at rest, for which he was grateful. However, he also said that he had been frightened even to raise the issue.

I believe that such independence is crucial, and that the House ignores the issue at its own peril and at the peril of the public. Healthcare professionals ignore the need for an independent patient voice at their peril, because that is the safeguard in ensuring that we improve the standards of practice.

7.15 p.m.

Lord Hunt of Kings Heath

Like the noble Lord, Lord Clement-Jones, I regret that it was not possible in the dying stages of the previous Parliament to reach a final settlement on the successor arrangements to community health councils. If we had been able to do so, much of the current uncertainty would not exist. That was unfortunately not to be, but life moves on.

I have absolutely no quarrel with the motivation behind the amendment or with the noble Lords who have spoken in favour of it. The need for co-ordination at local level between patients forums is inescapable and very important indeed. However, I disagree with the noble Lords on the way in which that coordination should operate. The noble Lord, Lord Clement-Jones, described our proposals as "top down", but I very much disagree with that description. We are simply saying that patients forums—which are at the local level where the patient receives services—will be the truly important agency for involving the public.

My worry about patients' councils as proposed by the noble Lord, Lord Clement-Jones, is that rather than helping a decentralised model to work more effectively, they will create a further statutory tier of patient involvement which will get in the way of a fluid approach to co-operation between patients forums at a local level. I stress that all of the functions described in the amendments are already provided for in the Bill. Moreover, we have reached the current position after being informed by a great many views from a wide range of stakeholders and informed observers. That makes me very confident about the integrity of our proposals. Our system has been recognised by many people as stronger, more independent and better placed to deliver the necessary empowering structure.

The concept of patients' councils is not new; indeed, it has been a critical developmental stage for our proposed arrangements. In many respects, our debate on patients' councils in the previous Session was the catalyst for moving us on to think through the key issue of how to ensure both an informed and continuing process of review at the organisational level, through patients forums, and how to meet the need to build up a picture of patients' experience across a wider health economy. We are proposing that the latter need be met through the auspices of the commission at the local level.

When we discussed patients' councils in the previous Parliament, the proposal was that they should be matched to about 100 health authorities. As noble Lords know, however, it is now envisaged that there will be 28 strategic health authorities in England. That is another very big change from the circumstances which applied when we last debated patients' councils.

As I understand it, the noble Lord, Lord Clement-Jones, is also proposing that patients' councils should match the local authorities which are responsible for establishing overview and scrutiny committees. Surely he will accept, however, that the flow of patients does not necessarily match local authority boundaries. Therefore, even if we established patients councils at the local authority level, we would still have to make other arrangements to ensure that we can capture the patient experience of people outside those local authority boundaries. I believe that our proposals much better meet the need for flexibility and recognise that patient flows go very much wider than current local authority boundaries.

I think that we can all agree that the overview of the patient experience must result from the combined activity of the elements of the new system which we are proposing. We believe that patient forums and the independent complaints advocacy service providers have to be empowered to perform their functions effectively and in a manner which develops their capacity to grow. We all believe, I think, that forums must work together to share outcomes, to plan joint work and to identify key themes and trends from across their respective boundaries. We believe that the system must he informed by the real life experience of patients and not just of a few patients by proxy. I think that we also agree that the public must know how to access support if they want to complain, how to get their views heard, how they can make a difference, and who is responsible for decisions to put things right. I think that we all agree that we must have consistent standards across the country.

All of those issues are addressed in the Bill. The fundamental change to our proposals since we debated the previous legislation is our proposal to establish a Commission for Patient and Public Involvement in Health. The commission will have not only core functions at a national level, which we shall debate shortly, but—and this is so important—a range of local functions. Therefore, as we have discussed, the key issue is the relationship between patients forums and the commission at the local level. It is clear that the forums will require effective and skilled staff support, and it is the commission that will provide it. Forums will also require briefing support and assistance with administration and secretariat roles and the management of finances.

The noble Earl, Lord Howe, dealt with forums' need to have information so that they can make judgments on the effectiveness of the trusts which they will review. The commission will have a very important role to play in that. Moreover, the CHI reports will be a very valuable addition to the resources available to each patients forum. We are also proposing in the Bill the creation of a new Office for Information on Health Care Performance which will also provide much needed valuable information to individual patients forums. Commission staff working at local level will clearly have a very important role to play in supporting the work of patients forums and enabling those forums to make the most of the responsibility being given to them.

We intend to make regulations requiring patients forums to come together on a regular basis to share their findings. As is argued for the patients' councils amendments, this sharing of information is critical to ensuring that the "patient's journey" is truly understood and captured. We shall also use the regulation-making powers in the patients forums clause—Clause 15(5)—to require forums to work together. Clause 19(2)(d) allows for the commission to provide assistance to patients forums and to facilitate the co-ordination of activities. Clause 19(5) states: The Commission is, so far as practicable, to exercise its functions by reference to the areas of Primary Care Trusts". I would argue that the crucial importance of the work of the national commission at local level, with a staff resource that will be available at local level, will give a much more flexible approach to achieving the kind of co-ordination between patients forums that noble Lords desire and it captures the entire patient journey, as so eloquently suggested by the noble Earl, Lord Howe, without setting up another statutory patient organisation at the patients' council level.

I would he very cautious about detracting from the primacy of the role of the patients forum at that level. Statutory patient councils would do that. Our approach in using the auspices of the national commission at local level will achieve all that noble Lords desire.

Lord Clement-Jones: I thank the Minister for his very interesting reply. He tried to pull out all the stops in his arguments, but it is clear from the speeches of other noble Lords that the arguments are against him. He can be in no doubt about the feeling of the Committee, with the exception of the noble Baroness, Lady Pitkeathley. I wish that I could be excited about the proposals and the new structures. It is far more preferable to reduce our enthusiasm slightly and wait a little longer until we have a set of proposals that we can support.

I very much appreciate and agree with the arguments of the noble Lord, Lord Rea, as to the importance of the single point of access. I have not used the phrase "one-stop shop"; we must clearly desist from overworking that phrase. That is one of the key arguments, and the noble Lord, Lord Weatherill, made some important points about the trust and confidence that people have in their local CHCs. We must ensure that any scheme of reform has the same degree of public trust.

The noble Baroness, Lady Carnegy, is not known for supporting my propositions, but she really put her finger on the point. Ministers talk obsessively about the system being one of patient and public involvement, which comes from inside rather than outside the NHS, and so on. The argument advanced by the noble Baroness about there being a conflict of interest tucked in there somewhere is extremely important.

The vital issue of independence was raised not only by the noble Baroness, Lady Carnegy, but by the noble Earl, Lord Howe and the noble Baronesses, Lady Finlay and Lady Masham. The Minister did not give the lie to that argument. I thought when considering the wider element of confidence in the NHS that the remarks of the noble Baroness, Lady Chalker, were extremely important. It is a matter of fundamental confidence and one that will have great significance for the public, whether they are patients, family, carers, or whatever incarnation they may have. It is important to have that broad view of both primary and acute care. The patients' councils would do that.

It is gratifying that the Minister accepts the need for co-ordination, but the way in which that takes place is crucial. He talked about a fluid approach, but others might describe it as an incoherent approach. He talked about not being top down. The commission is the creature of the Secretary of State for Health. How more top down than that can one get? I cannot agree with the Minister on that either.

The Minister is extremely confident about the integrity of his proposals. I am afraid that outside this House, vast numbers of people do not have great confidence in those proposals. It is interesting that the Minister talks about these proposals—patients' councils—being part of the genesis of the new exciting era, as outlined in the Bill as it stands. It is certainly not a building block; it is rather like a stage of a rocket that is dropped off half-way through its ascent to the stars. That is all that it is and it bears no relationship to the Government's current proposals. It is all very well for the Minister to say that patients' councils no longer fit as we now have strategic health authorities, but that is just because the goal posts have been moved. I do not agree with that scheme of devolution, but that is clearly a separate matter.

The proposal for patients' councils does not assume coterminosity with local authorities. It is a matter of discretion. They could be coterminous where appropriate, but they may not be, and they may need to be wider than the boundaries of local authorities.

We have had a good debate. I hope that the Minister is considerably more flexible and sympathetic than appears because we shall be a ferocious dog with this bone throughout the passage of the Bill. I assure him that it is the single most important matter to which we shall return on Report and Third Reading, if necessary. I trust that the Minister will ponder further between now and the next stage. In the meantime, I thank Members of the Committee for their support and contributions. I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Clause 16 [Entry and inspection of premises]:

[Amendments Nos. 112 to 114 not moved.]

Clause 16 agreed to.

Clause 17 [Annual reports]:

[Amendment No. 114A not moved.]

Clause 17 agreed to.

Lord Hunt of Kings Heath

I think that this is a convenient time to break. I suggest that we return to this business not before 8.30. I therefore beg to move that the House do now resume

Moved accordingly, and, on Question, Motion agreed to.

House resumed.