§ 6 Before Clause 16, insert the following new clause—
§ "Establishment of Patients' Councils
§ (1) The Secretary of State shall, subject to subsection (2), 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 comprise 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.416
§ (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—
- (a) facilitate the co-ordination of the activities of member Patients' Forums including by the provision of staff and services to Patients, Forums,
- (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,
- (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 (functions of overview and scrutiny committees), 8 (joint overview and scrutiny committees etc) and 10 (application to the City of London) of the Health and Social Care Act 2001 (c. 15)) the views of members of the public in its area about matters affecting their health, and
- (d) advise the bodies mentioned in subsection (5) on involvement of the public in its area in consultations or processes leading (or potentially leading) to decisions by those 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 decisions in question at subsection (4)(d) are those made by—
- (a) health service bodies,
- (b) other public bodies, and
- (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 and in particular provide as to—
- (a) the Patients' Forums and other community interest groups from which members of the Council are to be appointed,
- (b) any qualification or disqualification from membership,
- (c) terms of appointment,
- (d) the proceedings of a Council,
- (e) the discharge of any functions of a Council by a committee of the Council or by a joint committee appointed with another Council,
- (f) the circumstances m which Councils will co-operate with each other in the exercise of their functions and exercise functions jointly with one or more other Councils,
- (g) funding of Councils and the provision of staff, premises and other facilities,
- (h) the preparation and publication by a Council of annual accounts,
- (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 I 9A of the National Health Service Act 1977),
- (j) the provision of information by a Council to another person,
- (k) the preparation and publication of reports by Councils,
- (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
- (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.
§ (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 1 of 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.".
§ 7 Clause 18, page 23, line 16, after "premises" insert "and"
§ 8 Page 23, line 17, leave out "and staff'
§ 9 Page 23, line 26, after "by" insert "a Patients 'Council"
§ 10 Page 23, line 38, after "by" insert "Patients' Councils,"
§ 11 Page 24, line II, after "Forum" insert ", a Patients' Council"
§ 12 Page 24, line 15, after "15" insert "and a Patients' Council established under section(Establishment of Patients' Councils)"
§ 13 Clause 19, page 24 line 34, after "Forums" insert "and Patients' Councils"
§ 14 Page 24, line 43, leave out paragraph (g) and insert—
§ "(g) co-ordinating and supporting the activities of Patients, Councils in respect of their activities as provided for in section (Establishment of Patients' Councils),"
§ 15 Page 25, line 6, at end insert "and to co-ordinate and support the activities of Patients' Councils in respect of activities provided for in subsection (4)(d) of subsection (Establishment of Patients' Councils)"
§ 16 Page 25, line 27, at end insert—
§ "( ) The Commission will provide to Patients' Councils services, including staff and other facilities, to support those bodies in the exercise of their functions,"
§ The Commons disagreed to the Lords amendments but propose the following amendments in lieu:
16A Page 20, line 38, at end insert—
( ) The members of each Patients' Forum are to be appointed by the Commission for Patient and Public Involvement in Health.
§ 16B Page 20, line 40, after "the" insert "range and"
§ 16C Page 20, line 42 leave out "services" and insert "matters"
§ 16D Page 20, line 45 after first "to" insert "the range and operation or'
§ 16E Page 21. line 10, after "view" insert "(a)"
16F Page 21. line 11, at end insertx2014;
(b) should be brought to the attention of the Commission for Patient and Public Involvement in Health it may refer that matter to the Commission.
16G Page 21, line II, at end insert—
( ) Subsection (4) does not prejudice the power of a Patients' Forum to make such other representations or referrals as it thinks fit, to such persons or bodies as it thinks fit. about matters arising in the course of its exercising its functions.
16H Page 21, leave out lines 12 and 13 and insert—
(5) Patients' Forums must in prescribed circumstances—
§ 161 Page 21, line 44, at end insert the following new clause—
§ "Additional functions of PCT Patients, Forums
§ (1) A Patients' Forum established for a Primary Care Trust (a "PCT Patients' Forum") has the following additional functions—
- (a) providing independent advocacy services to persons in the Trust's am or persons to whom services have been provided by, or under arrangements with, the Trust,
- (b) making available to patients and their carers advice and information about the making of complaints in relation to services provided by or under arrangements with the Trust, and
- (c) representing to persons and bodies which exercise functions in relation to the area of the Trust (including, in particular, any relevant overview and scrutiny committee) the views of members of the public in the Trust's area about matters affecting their health.
§ (2) In subsection (1), references to services have the meaning given by section 15(6).
§ (3) It is also the function of a PC7 Patients' Forum—
- (a) to promote the involvement of members of the public in the area of the Trust in consultations or processes leading (or potentially leading) to decisions by those mentioned in subsection (4), or the formulation of policies by them which would or might affect (whether directly or not) the health of those members of the public,
- (b) to make available advice and information to such members of the public about such involvement,
- (c) to advise those mentioned in subsection (4) about how to encourage such involvement (including, in the case of bodies mentioned in subsection (4) to which section 11 of the Health and Social Care Act 2001 (c. 15) applies, advising them how to comply with the requirements of that section in relation to the area of the Primary Care Trust), and
- (d) to monitor how successful those mentioned in subsection
§ (4) are at achieving such involvement.
§ (4) Those referred to in subsection (3) are—
- (a) Strategic Health Authorities whose areas include any part of the area of the Primary Care Trust,
- (b) the Primary Care Trust itself,
- (c) NHS trusts which provide services to patients in the area of the Primary" Care Trust.
- (d) other public bodies, and
- (e) others providing services to the public or a section of the public.
§ (5) In section 12 of the Health and Social Care Act 2001 (c. 15) (which inserts anew section 19A concerning independent advocacy services into the 1977 Act), in that new section 19A, after subsection (6) there is inserted—
§ "(7) The Secretary of State may direct a Patients' Forum established for a Primary Care Trust to exercise any of his functions under this section so far as they relate to independent advocacy services provided to persons in the area of the Primary Care Trust or persons to whom services have been provided by, or under arrangements with, the Trust; and if he does so—
- (a) the functions of that Patients' Forum are to be taken to include those functions, but
- (b) the Patients' Forum may not make any arrangements with itself under this section."
(6) In this section—
carer" and "patient" have the same meaning as in section 15,
independent advocacy services" means services provided under section 19A of the 1977 Act (independent advocacy services),
relevant overview and scrutiny committee" has the same meaning as in section 15.
16,1 Page 24, line 5, at end insert—
( ) The regulations must also secure that the members of a Patients' Forum established for a Primary Care Trust also include—
- (a) at least one member of the Patients' Forum established for each NHS trust all or most of whose hospitals, establishments and facilities are situated in the area of the Primary Care Trust and
- (b) if it appears to the Commission for Patient and Public Involvement in Health that there is a body which represents members of the public in the Primary Care Trust's area in matters relating to their health, at least one person who is a member or representative of that body (or, if there is more than one such body, of any of those bodies)."
§ 16K Page 24, line 20, at end insert "(in addition to its function of appointing members of Patients' Forums)"
§ 16L Page 24, line 34, after "providing" insert "staff to Patients, Forums established for Primary Care Trusts, and advice and"
§ 16M Page 24, line 42 leave out "and"
§ 16N Page 24, line 42, at end insert ", and making recommendations to them about how to improve their performance against those standards"
§ 160 Page 24, line 43, leave out paragraph (g)
16P Page 25, line 10, at end insert—
( ) It is also the function of the Commission
- (a) to review the annual reports of Patients, Forums made under section 17, and
- (b) to make, to the Secretary of State or to such other persons or bodies as the Commission thinks fit such reports or recommendations as the Commission thinks fit concerning any matters arising from those annual reports."
§ 16Q Page 25, line 11, leave out subsection (5)
§ 16R Page 25, line 37, leave out subsection (12)
§ Lord Hunt of Kings Heath
My Lords, I beg to move that the House do not insist on their Amendments Nos. 6 to 16 to which the Commons have disagreed and do agree with the Commons in their Amendments Nos. 16A to 16R in lieu thereof.
We are coming to the end of what has been a long and interesting journey to strengthen patient and public involvement in the health service. From the NHS Plan, published in July 2000, through to the Health and Social Care Act 2001 and now to the Bill, we have reached a position that I can truly describe as one that is as good as it gets.
My ministerial colleagues and I—and our officials—have been in discussion with many stakeholders during the past year and a half to ensure that we develop the best possible set of arrangements. At the end of the day, that has been an extremely constructive process. Although we have not agreed with all of the views expressed to us, all have played a part in fine-tuning the system that we now put before your Lordships.
420 Patients councils were, I think, the turning point. The patients council amendments voted into the Bill last month were not welcomed by the Government because of our concern that they would add another tier to the arrangements that we proposed. But the Government always said that much of the purpose of patients councils fits with our view of a strong and comprehensive public and patient involvement system. We have attempted to ensure that the system builds on the strengths of patients councils without weakening the overall structure.
The effect of Amendments Nos. 16A to 16R is to give to primary care trust patients forums the functions that we had previously envisaged for the local offices of the Commission for Patient and Public Involvement in Health. Essentially, that means that the commission will appoint staff to every primary care trust forum in England. On a day to day basis, the staff of the forum will of course be accountable to the members of the primary care trust forum.
That will ensure that a robust process is in place for the work of the staff to be informed by local people and that there is real accountability to local people. It will then be the job of the primary care trust forum to promote the involvement of the local community— in particular, disadvantaged patients and typically excluded groups—in local decision-making processes, and to promote the views of people in their area to local decision-makers and in particular to their local overview and scrutiny committee.
In addition—and this where the key strengths of patients councils have been picked up—the staff of the PCT forums will be able both to provide and to commission advocacy support. As commissioners, primary care trust forums will also be able to commission additional support as local needs determine—for example, specialist services such as bilingual advocacy. The intention is to enable primary care trust forums to be the core providers of independent advocacy services but to retain the flexibility to ensure a comprehensive service that fits local needs.
It will also be the responsibility of the primary care trust forum to act as a kind of one-stop shop for local people, providing them with advice and information about how they can get involved locally and how to make a complaint. The amendment is drafted in a way that enables the primary care trust forum to provide advice and information about making complaints about the services provided and practices and policies adopted by the NHS. They will also be responsible locally for monitoring the arrangements that local NHS bodies have in place to fulfil their duty to involve and make arrangements to consult the public about changes to services. We intend that duty to come into effect later this year.
We have also amended the composition of primary care trust patients forums. They will now include members of local interest groups that represent the public on issues that affect their health. An example may be a residents group concerned about the erect ion of a local mobile phone mast. They will also include a 421 member of the NHS trust forums in their area so that there is an in-built mechanism for forums to share ideas and agree areas of mutual concern.
It is extremely significant that we are placing all of those responsibilities with the primary care trust patients forum. That means that we have shifted the power base of the new system for patient and public involvement to local communities. We will be removing the middle layer of our original proposals—the local office of the commission. However, we recognise that there needs to be a way for forums to come together across an agreed area. We have therefore strengthened the provisions in the Bill about the circumstances in which forums should work together. Those will be made explicit in secondary legislation.
I know that concern has been expressed about forums duplicating effort and resources. We intend to involve stakeholders fully in the development of the working arrangements for forums. We will encourage partnership arrangements to be developed whereby one primary care trust forum takes a lead on a specific issue; for example, the commissioning of specialist services that covers several primary care trusts, or the provision of independent advocacy services. Another example might be a primary care trust forum taking the lead in collecting and analysing the data relating to a specific cross-boundary scrutiny exercise being undertaken by a social service authority overview and scrutiny committee.
The important issue to stress is that those arrangements will need to be developed through effective communication and will result from the continuous development of partnership working right across the system. At national level, the commission will perform the critical role of developing best practice and providing resource material on how to ensure that effective practices and outcomes are achieved. It is important to remember that patients forums are independent bodies. I stress that to your Lordships. It will be up to forum members to decide the exact nature of their collaboration. The regulations to be prescribed will provide the structure for that collaboration and it will be vital that we test out real-life scenarios in the formulation of those regulations.
We are also amending the provisions that apply to both primary care trust and National Health Service trust patients forums. We are making it explicit in the Bill that patients forums will not only have a role in monitoring and reviewing services that a trust provides but will also be able to identify gaps in service provision and make reports and recommendations to trusts about them. Trusts will have to publish forum recommendations in their annual patients' prospectus, together with the action that they are to take as a result, further ensuring that forums have real influence.
We have also made explicit the width of the powers for forums to be able to refer matters not just to overview and scrutiny committees, as previous amendments provided, but also to the commission and indeed to any other person or body that the forums 422 themselves deem appropriate. So we have taken away some of the functions envisaged for the commission at national level that would have been carried out in its local offices. We have also strengthened the functions that it will carry out at a national level.
On top of its job of setting and monitoring quality standards for all patients forums and providers of independent complaints advocacy, the commission will now also be able to make recommendations to them about how to improve their performance—a point that my noble friend Lord Harris has consistently raised during the passage not only of the Bill but of the Health and Social Care Act 2001. The important thing is that that will ensure that, wherever they are; the public and the NHS can be assured of consistently high standards for patients forums and providers of independent advocacy.
We have listened to parliamentarians and to stakeholders—in particular to the Association of Community Health Councils for England and Wales and community health councils—in relation to the often-cited need for a "casualty watch" exercise. My view, and that of the Government, is that the key thing about the commission's responsibility is that it should be able to undertake national reviews of patient experience data on issues that appear to it to be of national concern. That may include waiting in accident and emergency departments.
We propose an amendment to the commission's functions to provide for it to carry out a systematic review of the data contained in forums' annual reports and, on the basis of them, to identify what key issues warrant a national review. We wish the commission to facilitate the co-ordination of forum activity on a specific theme and then to make reports to the Secretary of State and any other person or body on the outcomes of such a review.
To summarise, in every NHS trust and primary care trust there will be a patient advice and liaison service ensuring that concerns are dealt with before they become a serious problem. There will also be a patients forum ensuring that locally the public have a vehicle to express their views about matters relating to health and that this will monitor and review local services. In every primary care trust forum there will be staff who will commission or provide independent support to help individuals to make a complaint, work to empower their local population to express their views about health issues that matter to them, and provide a one-stop service by providing advice and information to the public about public involvement and complaints processes.
Nationally, the Commission for Patient and Public Involvement in Health will set quality standards for the work of patients forums and independent advocacy, and performance manage them in relation to those standards. The commission will submit reports to the Secretary of State on how the whole patient and public involvement system is working. Alongside that we have the vital and important role of local authority overview and scrutiny committees.
423 I have always said that, ultimately, the test of these proposals is whether they will work more effectively; whether they will give individual patients more clout than they have at the moment. I have no hesitation whatever in saying that the proposals before your Lordships' House today will do that. They have been enhanced and improved by our debates and I commend them to the House.
Moved, that the House do not insist on their Amendments Nos. 6 to 16 to which the Commons have disagreed and do agree with the Commons in their Amendments Nos. 16A to 16R in lieu thereof.—(Lord Hunt of Kings Heath.)
§ 6.15 p.m.
§ Earl Howe
My Lords, this is the end of a long road. The destination we have reached is perhaps not the one that either the Minister or I expected we would arrive at when we started out on the Bill—or, indeed, the one that we anticipated before the last general election when we debated the earlier proposals set out in the Health and Social Care Bill.
We have before us an organisational structure for patient and public involvement that, happily, bears little relation to the one which the Government put before us only a few months ago. Those first proposals were, in my view, so very deficient, so very much weaker than the system that they purported to improve upon, that I had no hesitation in resisting them. We believed—and still do believe—that the Government were wrong to abandon so readily the model of community health councils. I make no apology at all for the position that we on these Benches took in arguing for their retention and reform.
Nevertheless, we are where we are, and I must now acknowledge that the Government have moved a considerable distance. The deficiencies and weaknesses that we identified in their original proposals were ones that we attempted to address in the amendments that were carried in your Lordships' House, creating patients councils.
It is worth reminding ourselves of what the original Bill gave us. It gave us a fragmented structure of patient representation, without a real voice, without proper independence and with a narrow remit and focus. It made no attempt to replicate the one-stop shop; it made no attempt to allow for a lay overview of the NHS in a geographic area; it created a national commission, but one with hardly any responsibility for real patient issues, only for issues relating to processes and structures. For my part, in the absence of CHCs, I should dearly have liked to have seen patients' councils become a reality because they have the potential for rectifying the vast majority of the failings that I have enumerated. I believe that the Government's objections to them are overdone and, in large measure, illusory.
Nevertheless, this House asked the other place to think again, and the other place has done so—not—simply by deleting our amendments but by inserting others in their place. The new amendments to which the Minister has spoken address a great many of the 424 key points of principle that were previously at issue between us. I am delighted by that. I do not believe that having secured those points of principle it would be constructive for the House to cling doggedly to the concept of patients' councils and insist on our previous amendments.
This is not a debate about achieving the best structures; it is a debate about how we can enable patients and the public to have their views listened to and represented within the NHS. Any alternative to patients' councils needs to be judged against four key benchmarks: the level of independence enjoyed by the new bodies; their degree of integration; the extent to which they are community led and accountable; and whether they have a real measure of power.
The Government's new model, which is light years away from their first one, can probably be made to work satisfactorily. It is less elegant than CHCs or patients' councils—it will certainly he more expensive—but, importantly, the key principles for which we have been consistently pressing are there.
Having said that, and having made the boast that I understand these new proposals, there are a number of questions that I should be grateful if the Minister could answer. Some are of considerable importance for the way in which the new structures will work.
The first relates to the Commission for Patient and Public Involvement and its power to appoint members of patients forums. How long does the Minister estimate it will take to appoint the 7,500 or so members of patients forums? It will be a lengthy process. How much will the process of appointment cost? The Secretary of State retains a power of direction over the commission. Can the Minister give an indication of the kind of directions that are likely to be issued by the Secretary of State? I hope that he will not mind ii I say that the ability of the Department of Health to influence the way in which the commission performance manages patient and public involvement at ground level should be controlled—and controlled in a way such as to avoid direct interference or, indeed, gagging.
As to the statutory powers of the commission to initiate legal action where that is appropriate, will the commission definitely have the locus to take legal action, if it needs to, on local issues referred to it by patients forums?
I am delighted that patients forums will now have a power of referral to the commission. Can the Minister comment on the status of the patients forum non-executive director on a trust board where, let us suppose, a legal action is initiated against that trust by the commission? The director would find himself or herself with an immediate conflict of interests. How is that to be dealt with?
Another conflict would arise with confidential business. A patients forum non-executive director would not be able to report back to the patients forum on business that was confidential. CHC members who attend trust boards have the right to disclose confidential information obtained as speaking observers where the public interest favours disclosure. 425 Am I correct in thinking that under these new arrangements this safety valve in terms of accountability will cease? The whole notion of patients forum non-executive directors raises, to my mind, quite serious difficulties relating to corporate responsibility and governance.
The government amendments extend the remit of patients forums to cover the whole range of health services, not only those being delivered by the trust. I welcome that. Can the Minister confirm that patients forums will now be a one-stop shop on all points of concern to the public and not only complaints? Does subsection (1)(b) of the proposed new clause in Amendment No. 161 provide a one-stop shop for any general concerns that the public might have—for example, on policy issues or contested reconfigurations, and not simply for complaints about local services?
I welcome the new power of patients forums to make representations and referrals as they think fit to whomsoever they think fit about matters arising in the course of their functions. Will the Minister confirm that patients forums will be able to make referrals on health inequalities as well as on straightforward service issues?
I note in passing that there is no obligation on any body, including the Secretary of State or an overview and scrutiny committee, to respond to a referral made to it. Can the Minister give any reassurance on that lacuna? I am sure that he recognises that accountability is a two-way street and that he wishes to see the process deliver such accountability.
Finally, perhaps I may ask the Minister about foundation trusts within the NHS. We are given to understand that foundation trusts may not be NHS trusts within the terms of the Bill. In view of that, what arrangements will they have for patient and public involvement, and how will this be performance managed to ensure consistency and equity?
The Secretary of State has been quoted as saying that he is looking at the potential for the direct election of patient representatives, implying that the system now under discussion will not necessarily apply to foundation trusts. How will their accountability to patients be guaranteed if they are outside the complex system of patient and public involvement that the Government are now setting up?
None of the changes made to the Bill will mean anything unless it is adequately resourced. Without an indication of the level of staffing and other resources, it is impossible to judge how robust the proposals really are. If the Minister cannot give an indication of that kind today, I hope that he can at least give an assurance that this point will be borne closely in mind during the current funding review.
It is probably right that we do not let this occasion pass without a mention of our old friend Mrs Archibald. In the absence of my noble friend Lady Cumberlege, who was the creator of this useful and ubiquitous lady, I believe we can say that Mrs Archibald will be better served by the revised 426 arrangements for patient involvement than she would have been under the original Bill. They are clearer, and certainly less confusing, but most importantly they have the potential, if set up correctly, to be joined up. If that is a victory for this House—as I believe it is—it is also right for me to express my thanks to the Minister for his part in bringing these changes about. He has listened to our concerns, and the Bill is much the better for it.
§ Lord Clement-Jones
My Lords, I always like to think of this stage of the Bill as the "penalty shoot-out stage"— that is the analogy which seems appropriate in the current circumstances. I believe, like the noble Earl, Lord Howe, that a considerable victory has been achieved by local health campaigners, by ACHCEW and by CHCs in securing from the Government the considerable concessions that the Minister has put forward today.
It is worth reminding ourselves of the status of the proposals at the beginning of this process, some two years ago. The proposals had all the defects outlined by the noble Earl, Lord Howe. There was no national commission or national body at all. There were no proposals for an independent complaints advocacy service. Patients forums were not to be independent, but were to be supported by staff employed by the very trusts that they monitored.
During the passage of the NHS reform Bill, even as it stands, the following improvements have been secured. The independence of patients forums has been protected by channelling their funding through the commission as opposed to the trusts they monitor. Patients forums have been given the power to refer issues of concern to overview and scrutiny committees. They will be able to refer issues of concern to the commission. They will be able to make reports and representations to people and bodies as they see fit rather than being restricted. The range of issues which patients forums will monitor and report upon have been widened. They will also monitor how well NHS bodies involve patients and the public and will make recommendations.
A special role for PCT forums is now being proposed which has the potential to provide the integration for patients forums and the new overview and scrutiny which was previously lacking. Staff will be provided, and will be accountable to PCT forums at the local level rather than there being detached, staff-only groups with no local lines of accountability. I could continue. There have been a significant number of concessions. We have moved some distance since the early days of the first proposals almost two years ago.
There have been almost two years of wrangling, and the fundamentals of what it takes to have an effective patient voice—independent, community-based, with real accountability, integration and real powers—have finally emerged. By taking the approach that the Government tried to take, of imposing a model of patient involvement without involving patient representatives, the Government have, by their own failure to involve, demonstrated how essential proper 427 dialogue is. The Secretary of State delivered his initial off-the-cuff diktat in the NHS Plan in July 2000, announcing the abolition of CHCs and their replacement with a string of fragmented talking-shops, each with its own incomprehensible set of initials—PALS, ILAFs, OSCs, etc. We have come some considerable distance.
Yet,ironically, we now know, despite the length of time that it has taken us to get there, as a result of the Wanless report, that the success and probably the survival of the NHS is dependent on,a dramatic improvement in public engagement … leading to a more effective partnership between the public and the healthcare system".The report states that accountability is key to this:in devolving greater responsibility to the local level there must be strong arrangements for delivering high accountability",making the NHS more responsive and ensuring the right balance between centrally set targets and sensitivity to local services. We now have a real chance of achieving that.
I fully support the noble Earl, Lord Howe, in the assurances that he sought. Before giving a final blessing to these proposals, there are further key issues on which the Government need to give assurances. First, as regards independence, given the crucial importance of strong local accountability in terms of the NHS, it is important to evaluate these latest plans for independence, without which there can be no real accountability. If questions are asked by an organisation of the NHS on behalf of patients, the answers will be credible and enhance accountability only if that organisation is, and is seen to be, independent.
There remains a real risk that patients forums will appear to be under the thumb of trust chief executives, who themselves will be under the thumb of the Secretary of State. There is a serious likelihood that patients forums will not be perceived as independent by the public, especially if they have an NHS-type name, an NHS location and a seat on the board of the organisation that they are supposed to be monitoring.
There is a danger in patients forums being based, for instance, in trust premises. Will the Government confirm that they will make use of the existing 184 CHC premises, many of which are in high street locations and have been refurbished in recent years? In London alone, some £2 million has been spent on refurbishing these offices. What will, for instance, the patients forum non-executive director do if his patients forum asks the commission to take legal action against his trust as a last resort when its actions are unlawful? There needs to be some separation.
As regards the name, of course, that is a valuable sign of independence. I know that the Minister is a keen reader of the Health Service Journal. I wonder whether he has seen the suggestion by Dr Richard Taylor in this week's edition. He suggests what I think is a very sensible name for the new forums. After all, let us face it, "PCTPF", if spelt out, would be a very long name. Dr Richard Taylor proposed the term 428 "citizens health councils", which seems an admirable suggestion. It should certainly be considered by the Minister.
I turn to continuity. In bringing into existence the new structures, CHC staff and members can provide continuity. I very much hope that the Minister will give an assurance that there will be a fair and open appointments process for both staff and members and that every effort will be made to make use of existing skills and commitment in the new structures.
As for transitional provisions, what will happen to consultations which are ongoing at the date of abolition and to complaints for which assistance is being provided by a CHC at that date?
On configuration, there is the issue of and concern about the lack of coterminosity between overview and scrutiny and the new PCT patients forums. As well as agreeing to "take a lead" on certain issues on behalf of other PCT forums in an area—the model that the Minister outlined—another option would he for patients forums to exercise their overarching functions jointly in relation to, for example, a base for staff to support all the forums and do outreach work; the provision and commissioning of ICAS; and overseeing commissioning and public health issues. This would allow individual PCT forums to get on with the monitoring of individual PCTs' services in the same way that patients forums do for other trusts, a role which might otherwise be diluted by the other functions of PCT forums. It might also help to avoid some of the conflicts of interest that these arrangements will create.
Mr David Lammy, the new Minister, was kind enough to write to my honourable friend Dr Evan Harris setting out some of the assurances which my honourable friend sought on the new amendments. In his letter, the Minister said that there is a duty on NHS bodies to consult OSCs on substantial variations and developments. As I understand it, however, that is dependent on regulations being made to define what those services are. I certainly have not had any draft regulations. I should therefore be grateful if, in his reply, the Minister will clarify the status and ambit of those regulations.
Ministers have been uncharacteristically coy in discussing what resources will be available for the new patient and public involvement structure. We are continuously told that we must await the outcome of the spending review. However, we have been waiting two years for these sets of proposals. Ministers must have an idea of the resources that will be required. How do we know that the resources allocated will be sufficient to fulfil the many and complex functions of the patients forums and the OSCs and so on? Having agreed these proposals in the other place and in this House, it would be extremely galling to find that the resources were not available to implement the model with which we were prepared to live.
There is a similarly vague approach to the funding of PALS. Some trusts are not establishing them at all this year for lack of funds. We certainly do not wish that to be mirrored in the funding for PCT patients forums.
429 My final point is on the abolition of the Association of Community Health Councils for England and Wales. The Minister has given assurances that CHCs themselves will not be abolished until the new system is up and running, but it would be helpful if he could give an assurance on the future of ACHCEW itself. Will he confirm that ACHCEW will not be abolished ahead of CHC abolition? He might wish to argue that, once the new Commission for Patient and Public Involvement in Health has been appointed, there is no need for another national body. Clearly, however, ACHCEW needs to exist to represent and provide services to CHCs as long as they are in existence.
In many ways, we would have preferred to retain CHCs and the clarity of the structure of patients councils proposed in the original amendments. However, we believe that we have come as close as we possibly can to the model which we on these Benches proposed originally. Like the noble Earl, Lord Howe, we believe that, with the right assurance, this is a satisfactory and workable model. We will not stand in the way of the amendments proposed by the Government. I very much look forward to hearing the Minister's reply, and I thank him in advance for the flexibility displayed in this part of the Bill.
§ 6.30 p.m.
§ Lord Harris of Haringey
My Lords, the noble Lord, Lord Clement-Jones, described this as the "penalty shoot-out stage" of legislation, but given that we will probably have no Divisions at all, I suspect that it is more like the golden goal. I think it was Harold Wilson who said that a week in politics is a long time, but it is now 98 weeks, I think, since the Government first said they wished to do away with CHCs. However, the proposals had been made before. The noble Lord, Lord Jenkin of Roding—who spoke earlier but has left the Chamber—made similar proposals 20 years earlier. They were strongly opposed, however, and ultimately dropped.
What is interesting about the process of the past 98 weeks is the extent to which the Government have shifted their position and listened to concerns about the original, cack-handed set of proposals. I am pleased that the Government have listened to the arguments which I advanced in the House on patients forums attached to PCTs. It is essential that the one-stop shop—which is what I think we are creating—should be seen as locality based rather than institution based. I am also pleased that we have had various assurances on the independence of both the membership and the staffing arrangements of patients forums. The Minister's comments today have reinforced that point.
An added bonus in the later arrangements is the way in which the advocacy arrangements have been much more clearly integrated into the new structure. I believe that the current proposals offer clarity at local level. Previously, there was no clarity over how individual members of the public would relate to the structure. The structure is now undeniably coherent. 430 Given that neither clarity nor coherence was at all visible in earlier representations, that is clearly substantial progress.
It would be helpful, however, if my noble friend the Minister could give more indication of the resource levels that the Government think appropriate to make the new structure effective. It is possible, for example, that one isolated staff member from the Commission for Patient and Public Involvement in Health could wind up in a room dealing with individual patients forums for PCT areas. Such a structure would clearly not work and would represent less investment in the structure than is made now. What resource levels are envisaged? What resources do the Government think necessary to make the structure work? I appreciate that we are still awaiting the outcome of the spending review, but some guidance on the point would be very helpful.
Another matter that should have been dealt with in our many discussions—perhaps it was but I missed it—is a reassurance that patients forums will elect their own officers, such as their chairs and vice-chairs. It would be useful if my noble friend the Minister could confirm that those officials will be elected and not appointed by the commission. It would also be helpful if he could clarify at what stage the commission will be put in place, patients forums properly established and the appointments process started. We should like some idea of the timetable and how it relates to the winding down of CHCs and the association, which are currently withering on the vine, given that both staff and members are looking to the future and moving elsewhere. I hope that my noble friend can give some indication on those points.
I hope that all Members of your Lordships' House will agree that we now have a system which will act robustly in the interests of the public and patients. The Government have demonstrated a clear desire to listen to the arguments put forward on all sides of the House and outside Parliament.
§ Lord Rea
My Lords, I hope that my noble friend will clarify a point which might have been obvious if I had read every word spoken during the 90 weeks. I am a little uncertain about how the Commission for Patient and Public Involvement in Health will be chosen. Clause 19(1) states:There shall be a body corporate to be known as the Commission for Patient and Public Involvement in Health".Nothing in the clause states how the commission is to be appointed. Perhaps I should know what a body corporate is and who chooses it but I am ignorant about it. The point applies not only to the main commission but also the subsidiary branches of the commission in local areas. I am concerned that if appointment lies in the hands of the Minister, the independence of the commission will be compromised. For instance, there is a rumour that one of the persons being considered as chairman of the commission is a senior officer in—
§ Lord Hunt of Kings Heath
My Lords, the intention is that the NHS Appointments Commission will undertake the appointments.
I am grateful for the contribution of all noble Lords. I listened with great interest to the interpretation that the noble Earl, Lord Howe, and the noble Lord, Lord Clement-Jones, put upon what has occurred between the introduction of the last Act and now. I do not share their view. I maintain that the principles before noble Lords today are wholly consistent with the principles enunciated in the Health and Social Care Act. Some of the practical effects of those principles have been tested and. I believe, improved upon by debates in this House and another place. I am grateful to all noble Lords for their constructive participation in those debates.
It was the suggestion of the noble Lord, Lord Harris of Haringey, in debate on Report on the role of primary care trust patient forums which unlocked the door to where we are today. I am grateful to him for that.
A number of questions were asked. I shall attempt to answer them as quickly as possible. The noble Earl, Lord Howe, asked how wide the remit was on making available advice and information on complaints about policies as well as services. In drafting the amendment we took on board comments from ACHCEW to ensure that those wider issues were encompassed. The critical element of the amendment is the making of complaints relating to services. It is drafted on the basis that that means advice and information on complaints in the wide sense that noble Lords indicated.
On the power of the commission to initiate legal proceedings, the commission will be a corporate body. It will have power to initiate legal proceedings in its own name.
On consultation, regulations will be made later in the year and consulted upon.
There is no question about the independence of the Commission for Patient and Public Involvement in Health. I made clear in my opening remarks that it will be able to undertake national reviews.
As I have said on a number of occasions, the direction-making powers are only in respect of functions that the commission carries out ancillary to its core functions. It is not a general direction-making power. It is a power to make the carrying out of ancillary actions subject to directions and is, therefore, of a limiting nature only. Concerns have been expressed about the independence of primary care trust patient forums. I have maintained that they will be wholly independent. They will not be under the thumb of the trust chief executives. Anyone who has discussed these matters with trust chief executives 432 knows that they understand that we are putting a robust independent mechanism in the heart of the organisation for which they are responsible.
I did not understand the description of the noble Lord, Lord Clement-Jones, of chief executives being under the thumb of Ministers. The noble Lord will know that that is wholly in conflict with shifting the balance of power on the basis of which this Bill was brought before your Lordships' House. In my right honourable friend's subsequent speech, he spoke of the need for the department to withdraw from micro-management of the health service.
My only caveat is this. We have debated this week a number of issues on health and social care. I can think of four or five instances when, far from asking me to withdraw the thumb of control, the noble Lord, Lord Clement-Jones, has asked me to intervene much more. I am disappointed—
§ Lord Clement-Jones
My Lords, I take the Minister's jests as a total assurance about the independence of trust chief executives.
§ 6.45 p.m.
§ Lord Hunt of Kings Heath
My Lords, trust chief executives are employed by their employing authorities, not the Secretary of State.
The noble Lord made a good remark with regard to accommodation for primary care trust forums. Of course we want them to be accessible. Primary care trusts might be placed in community hospitals or health centres. Using vacated CHC premises is also an excellent idea. I make the point that there are 184 CHCs. There will be many more primary care trust patient forums. That is one of the advantages of the changes we make.
The noble Earl, Lord Howe, asked about health inequalities. That is a focal point about the work of primary care trusts in their role of assessing health needs. The patient forums of those primary care trusts will be able to comment and to draw attention to issues of concern about that matter.
The noble Lord, Lord Clement-Jones, said that I was uncharacteristically coy about resources. I am always coy on the issue of resources. Although we have the headline figures for the health department on funding—they are for the next five years for the NHS and three years for social services—we are still deciding how that should be "divvied" up. I cannot go further tonight on how we shall fund patient and public involvement. However, I can repeat our stated intention and commitment that we shall ensure that the new arrangements are resourced so that they work successfully in practice.
I was asked about the timetable. The headquarters of the Commission for Patient and Public Involvement in Health will be established in January 2003. It will then appoint staff to each primary care trust patient forum area. It will then co-ordinate the appointment of patient forum members. I understand what the noble Earl says in relation to numbers. There is a 433 considerable number of people but we shall be assisted by the staff of the primary care trust patient forums at local level to speed that through.
The noble Baroness, Lady Hanham, is not in her place, but we debated a conflict of interest at great length. The point is that the patient forum member will be accountable to the whole board, as are other board members. We shall set out guidance that will help some of the issues that the noble Earl raised. At the end of the day, having been a local authority appointee to a health authority in the 1970s, I do not believe that they will be in a different position from those local authority members then, or university members now. I am sure that there will be tensions but we shall issue guidance to help to accommodate that.
On foundation trusts, it is too early to say how the patient public involvement issues will relate to them because we are still working on foundation trusts. The whole point about foundation trusts is to get greater public health involvement.
On the interesting suggestion that the noble Lord, Lord Clement-Jones, quoted from Dr Taylor—my favourite GP—of a citizens' health council, I have given it the seriousness that it warrants and I have to disappoint him. I believe that we have the correct title already. We have had a good debate and we have come to an acceptable conclusion. I hope that we can agree to the Commons amendments.
On Question, Motion agreed to.