HL Deb 13 February 2003 vol 644 cc884-902

7.42 p.m.

Earl Howe rose to move to resolve, That this House calls on Her Majesty's Government to revoke the regulations laid before the House on 5th December 2002 (S.I. 2002/3007).

The noble Earl said: My Lords, let me begin, if I may, with a health warning. When I tabled the Motions more than a fortnight ago, the Government had not yet made their announcement about the abolition date for community health councils. We now know that CHCs are to disappear on 1st September.

When the Minister came to the House last week to answer my Private Notice Question about the matter, I and others made clear our dismay that the assurances we received from him last year about a seamless transition from the old arrangements to the new, and about prior consultation with stakeholders, had in the event counted for nothing. The abandonment of ministerial undertakings, on the strength of which amendments to last year's legislation were withdrawn, is an extremely serious matter. It is no good for the noble Lord, Lord Hunt, to say, as he did last week, that in the end it is for Ministers to take decisions. Ministers do take decisions, but they should also abide by the assurances that they have previously given.

On the substance of the issue it is, for me, unacceptable that in some areas of the country after 1st September there is likely to be no organisation with a statutory right to inspect the NHS, and that as a result parts of the health service will not be monitored next winter at all. There will be no patient voice on NHS boards, no patient perspective brought to NHS decisions and no patient perspective on public consultations.

I am not sure whether the Minister is prepared to acknowledge that accountability vacuum explicitly, because so far he has not done so. I should like him to comment on it tonight. Every month, some 11,700 patients make a complaint against the NHS. I therefore have to ask: is ICAS to be fully up and running by 1st September or not? If it is not, large numbers of patients will go without the assistance that they need for an indefinite period. Again, that is simply not acceptable, and not in accordance with either the letter or the spirit of the undertakings given by Ministers to Parliament.

The noble Lord, Lord Hunt, is trusted and respected in this House, but I am sure that he will see that we cannot perform our function effectively as a revising Chamber if we constantly find ourselves doubting the validity of the assurances that we receive from Ministers. It will lead to mayhem.

According to the Minister's statement last week, the abolition date for CHCs was chosen because CHCs are losing staff and membership at a rapid rate. I do not know where the Minister's information has come from about the haemorrhaging of staff, because I have been told that the loss of members and volunteers is not happening on any great scale. If staff are leaving CHCs, there is one simple reason: uncertainty combined with a lack of communication. There has been an inordinate delay by the Government in announcing when CHCs would cease to exist. Had the whole exercise been handled more collaboratively and had the Government taken the trouble to ensure that staff and members of CHCs felt wanted and needed, we would not be facing such difficulties.

It is absolutely certain that in areas where patients forums are unlikely to be in place by 1st September there will be a mass melting away of key people. Why should anyone bother to stay? Indeed, anyone with unused holiday entitlement will feel that they may as well take it in August, which would mean that CHCs effectively cease to function at the end of July. Have the Government considered that and do they care?

Against that background we now have to consider the three regulations. I turn first to the Commission for Patient and Public Involvement in Health (Functions) Regulations 2002. During the passage of the National Health Service Reform and Health Care Professions Act we discussed the extent to which the commission would and should be independent of government in its day to day work if it were truly to carry out its job, which is to represent the interests of patients and the public and to hold the NHS to account.

In Regulation 2(1) relating to the commission's functions, there is a requirement for the commission to prepare a work programme setting out its activity for the following year. It is surprising and disappointing to see not only that that work programme has to be approved by the Secretary of State, but also that the Secretary of State has the right to vary the work programme as he or she may determine.

It must be of fundamental importance that the commission should be free to deal with major health related issues as it sees fit without political interference. The involvement of the Secretary of State in determining the work programme in my view is inconsistent with real independence. I hope that the Minister will comment on that because it casts considerable doubt on the Government's previous assurances that the commission will shift the balance of power in the NHS in favour of patients and the public. The way the regulations read suggests on the contrary that the balance of power will be shifted decisively to the Secretary of State.

Furthermore, the commission's ability to take on major health issues throughout the year as they arise should not be stifled or limited in any way. Yet once again we see in Regulation 2(4)(a) that any variations of the work programme must be agreed by the Secretary of State. How is that provision consistent with freedom of action and flexibility? The independence of the new arrangement was something about which the Minister assured us. What status do those assurances have today? What about the ability of the commission to be flexible and responsive? We can well envisage that some issues of importance may be brought to the commission's attention by patients forums; indeed, the whole point of the commission is that it should be influenced by what patients forums find locally.

Are the regulations saying, as they appear to in paragraph 2(2)(b), that the only way in which the commission can respond to such concerns is by picking them up from the annual reports of patients forums and incorporating them into its work programmes? Are we to understand that the Secretary of State has a veto on whether such matters are investigated? That is hardly the model of a responsive patient-centred and independent organisation. What if we were faced with another Bristol heart hospital situation or another Alder Hey? Would it take 18 months before the commission was able to ask permission of the Government to look into the matter?

After all the warm words of the Minister during the passage of the Bill I am frankly staggered that the regulations should now say the opposite of what we understood to be in prospect. I am beginning to believe that all the assurances given by the Government on patient and public involvement were merely devices to pacify the critics and to ram the legislation through Parliament.

Let us look at ICAS. In Regulation 4 of the functions regulations I might have expected to see ICAS included as one of the bodies prescribed for Section 20(2)(b) of the Act because ICAS will be the key body for dealing with complaints made by patients and the public. The fact that it is not there may be of greater significance than it appears. I would like the explicit assurance of the Minister that there is no question of abandoning the idea of ICAS and that ICAS will be fully established on or by 1st September.

It has been suggested to me—the Minister himself hinted at it during his replies to the PNQ last week—that the PALS service may be presented as a substitute for ICAS. If so, it is a matter of very great concern to me. PALS can be very useful, but we all know that they are not independent of the NHS, nor in many trusts do they exist at all. We were told explicitly by Ministers that every PCT patients forum would have staff to commission or provide independent support for individuals to make a complaint. Does that commitment still stand? ICAS services for NHS trusts must begin immediately after the dissolution of CHCs and as soon as possible after PCT patients forums are set up.

I ask the Minister to confirm that the one-stop shop approach, about which we debated long and hard in this Chamber, has not been abandoned or watered down. Will there be a one-stop shop in every PCT to enable patients and the public to get effective and easy access to the new system by 1st September? We were told by Ministers that there would be over 300 patients forum offices across England. Is that still the plan?

At the root of these doubts is of course the question of funding. I have voiced my concern on a number of previous occasions that there may not be enough money on the table to set up properly staffed patients forums in every PCT and NHS trust. The Government's silence on that issue is alarming. On 10th December the Minister said that he would write to me "shortly" on the matter. He has not yet done so. Will the Government publish a detailed funding breakdown for the commission explaining how the agreed levels of funding match the designated functions of the new bodies? I hope the answer to that will be yes, and soon.

If the new arrangements are to work one thing above all needs to happen, which is that the skills and knowledge of CHC staff and members are harnessed and directed appropriately. There simply is no other group of staff with comparable expertise. There are currently 700 staff to support 184 CHCs. I understand that these individuals have not been offered TUPE arrangements into the new system. What are the Government's intentions on that matter? The best of these people must be transferred into the new system to get it running smoothly and effectively. We also received undertakings to that effect. Yet the commission's current plans suggest that the transfer of expert CHC staff to patients forums may not happen at all. That only compounds my apprehension that a smooth transfer to the new system will not happen either.

The answers we received last week from the Minister all pointed one way: to a significant weakening of patient and public involvement once CHCs have been abolished. Contrary to previous undertakings, we now know that there will be gaps in the system; and that those gaps may well last for several months. But gaps will appear in other ways as well.

At patients forum level, the delivery of a service will depend on the availability of appropriate numbers of staff and volunteers. My understanding is that in order to support patients forums the commission plans to set up formal partnerships with local networks. Those partnerships are expected to consist of consortia of voluntary sector bodies or other local groups, and each partner will support a number of patients forums by drawing on the local networks and knowledge within the community. I must ask the Minister how those arrangements square with the previous undertakings of Ministers, that the commission would employ and appoint staff to man patients forums? Will the commission do that or is this yet another assurance that has been jettisoned?

Local networks are not a reassuring concept. We debated, and I thought disposed of, the idea of local networks when the Bill was passing through the House. What is the Minister's level of confidence that such arrangements will work? Looking at the country as a whole, the coverage and quality of the voluntary sector is patchy and uneven, yet patients forums are supposed to operate to a universal standard.

How are outsourced networks supposed to be a substitute for in-house staff? How can one use voluntary organisations to monitor services when many of them are providers of services as well? How can one avoid conflicts of interest if an organisation is asked to comment on changes that will bring about cuts to its own income? It is not tenable. It is ridiculous. The public and patients will be the losers.

A piece in the jigsaw of patient and public involvement is overview and scrutiny committees. When she was the responsible Minister, Hazel Blears, said: A key principle for this government is the right of the public to expect its concerns over major changes to health services to be expressed through a formal statutory process".

I have to say that is yet another instance of ministerial words sounding pretty hollow. OSCs were the mechanism chosen by the Government to fulfil the role of representing the public's views on major changes. However, what have we got?

When the Bill was going through this House, the noble Lord, Lord Hunt, steadfastly resisted the suggestion that local authorities should be obliged to undertake scrutiny of the NHS. They have merely been given a power to do so. In the first place, it is more than possible that some areas may be left without any scrutiny at this level. If there is no health OSC, it will not be possible to oblige an NHS trust to undertake a statutory consultation because there will be no body for it to consult.

The duty to consult under Section 7 of the Health and Social Care Act 2001 would be legally unenforceable. Even where an OSC does exist, Regulation 3 does nothing more than enable it to make reports and recommendations to local NHS bodies. It does not oblige it to do so. Contrary to what Hazel Blears implied, there would be nothing that a local community could do if it wanted an OSC to protect the public interest in a particular way on some health issue.

Patients forums have no right to demand a consultation because they will not be statutory consultees. If we read on, we find in Regulation 4(2) a most extraordinary exclusion. OSCs are not to be consulted by the NHS on the establishment or dissolution of NHS trusts or PCTs. Why on earth is that? Community health councils currently have the right to be consulted on such matters. The establishment or dissolution of a PCT or acute trust is likely to have a major impact on provision and access to services. The loss of the powers held by CHCs is irrational, onerous for an OSC and very damaging to the rights of patients.

Regulation 4(4) places no time limit on the length of a consultation. Under the present system, bodies that are consulted must be given a reasonable time for consultation, which is usually three months. l am concerned because NHS bodies in a hurry may want to consult quickly—perhaps very quickly. That should not be permitted. The local community must be given a reasonable chance to assimilate the proposals and express its views. Will the Government think again about that?

The net result is that Section 7 of the Health and Social Care Act 2001, which provides the legal underpinning for OSCs, is likely to result not in an enhancement of local accountability but in a diminution as regards consulting on substantial variations in the NHS. What action will the Minister take to prove me wrong? In particular, if a local authority fails to set up an OSC, what mechanism can be invoked to enable local objections to a major variation in health services to be registered with the reconfiguration panel? Is there to be such a mechanism? And where an OSC does exist, what performance management levers are there to ensure that it does its job as it should?

I tabled the Motions to protest in the strongest terms at what the Government now appear to be doing. I strongly suspect that they are starving the new system of the necessary funds and therefore of the necessary personnel and offices. The Government are not committed, as they said they were, to a smooth transition from the old system to the new. They are not committed to the independence of the commission. Nor apparently are they concerned that the new organisations, once in place, will be able to perform their functions effectively.

That, in a nutshell, is the list of charges against the Government. It is a very grave list and one is tempted to conclude that the whole system is being set up to fail. The credibility of Ministers is really on the line. I beg to move.

Moved, That this House calls on Her Majesty's Government to revoke the regulations laid before the House on 5th December 2002 (S.I. 2002/3007).—(Earl Howe.)

8 p.m.

Lord Clement-Jones

My Lords, I congratulate the noble Earl, Lord Howe, on securing the debate and on the high quality of his forensic deconstruction of the orders and the current state of play as regards patient consultation.

There is growing suspicion that, despite the pledges that they gave and the defeats that they suffered during the passage of the National Health Service Reform and Health Care Professions Act 2002, the Government are now engaged in a cynical exercise to use the current legislation to put into effect the scheme that they wanted all along but about which they failed to persuade Parliament.

I shall not cover the same ground as the noble Earl, Lord Howe; there is enough evidence to fill several debates, let alone today's. First, let us examine the issue of independence. I share the noble Earl's worries about the work programme being subject to the Secretary of State's approval and that he may vary it. Those requirements fundamentally undermine the commission's independence.

I remind your Lordships of our debates on the question of independence on Schedule 6 to the parent Act last year. The Minister gave us specific assurances on that score. He said: The independence of the system for patient and public involvement is critical to its success".—[Official Report, 21/01/02; col. 355.] When we were discussing direction-making powers under the schedule, he said: I understand why noble Lords may believe that a direction-making power might diminish the independence of the commission, but in a sense we must return to our debates yesterday: it is not envisaged that that direction-making power will be one that will come into play on a frequent basis".—[Official Report, 30/04/02; col. 629.] What is this but effectively a direction-making power over the commission's programme? For instance, could the Secretary of State intervene on a particular survey programme to be undertaken by the commission—on the same lines as Casualty Watch—if it was not planned as he thought appropriate? The Secretary of State has a clear conflict of interest in such circumstances. The Minister should take that on board.

From discussions held by the commission, it is clear that it will contract out the staffing of patients forums to voluntary organisations. The involvement of the voluntary and community sector is essential in the work of patients forums, but giving the sector the leading role of patching the unevenness that the new system sought to avoid seems to have been built in to the core of the new system. As the noble Earl, Lord Howe, described, the commission plans to set up formal partnerships with consortia of voluntary sector groups. That will create an extremely uneven pattern across the country, with inconsistency between patients forums.

However, the primary objection to the regulations is that they do not fall within the spirit of the original debates. Is it "providing" staff within the terms of the National Health Service Reform and Health Care Professions Act 2002? Surely, contracting to provide is a very different concept from providing.

I remind the Minister of his colleague's comments. Hazel Blears said: There will be staff employed by the Commission for Patient and Public Involvement in Health who will work with PCT patients forums, supporting all of the forums in the area, commissioning and providing independent complaints and advocacy services".—[Official Report, Commons, 22/5/02; col. 349.] The word used was "employed", not engaged, contracted or any other word. "Employed" has a clear legal meaning.

Voluntary organisations will have mixed feelings about the current system, but they will face a conflict of interest. Surely the role of patients forums will sometimes require them to make themselves unpopular with government. Will not voluntary organisations be rather fearful for their contract? Will the staff provided by them have genuine independence because of those contracts? If staff were employed to support forums and facilitate patients forum opposition to controversial changes or cuts in services, the employing organisation—that is, the voluntary sector organisation—may well feel that its contract is at risk or subject to pressure not to oppose such changes. In those circumstances, it would be difficult for it to support the independence of patients forums if to do so would compromise its own source of income. There is a clear conflict of interest.

Will not there be inconsistency between more services being provided by the voluntary sector, as envisaged by government policy, and the voluntary sector's role in monitoring that provision? If the voluntary sector is increasingly to become service providers, it is inconsistent that it should also have an enhanced role in monitoring those services.

As regards staff who could be used by the commission or the voluntary organisations, the Department of Health seems deliberately to be constructing a system designed to exclude current staff of CHCs. The Minister made a precise pledge on 11th April 2002, at col. 629 on the fourth day in Committee, that CHCs will not be abolished, until we arc confident all their functions have been picked up in the new system: independent advocacy by independent complaints advocacy providers; scrutiny by OSCs; and monitoring of local services by patients forums. There will be a managed transition to all parts of the system". The noble Earl, Lord Howe, quoted that to the Minister only last week. Many of us were flabbergasted by the decision to abolish CHCs on 1st September on the ground that people are leaving. It is a completely circular argument. We should be striving to retain them. Contrary to the Minister's commitment, there is expected to be a six month period between 1st September 2003 and 1st April 2004 when the substantial amount of patient and public involvement work currently carried out by CHCs will be terminated. I refer to Casualty Watch, NHS monitoring and the CHC complaints service.

Staff are not being managed into the new system: they are being manipulated out of it. They will be issued with their redundancy notices by 31st May. They will be made redundant on 31st August. Senior staff heard today from department officials that all that is being offered to them is a clearing house through which they can apply for general health jobs. There is no undertaking being given about when jobs for the commission will be advertised or when the arrangements with the voluntary sector for the staffing of patients forums will come into being. In short, there appears almost a deliberate desire to exclude the current CHC employees from the new system. Why is the commission not being more proactive in securing these valuable skills?

Perhaps I may quote more ministerial statements. On 6th December 2001, at col. 280 of the Official Report, Hazel Blears said: I am absolutely determined that we find a pathway for staff of Community Health Councils who want to take part in the new system, members of Community Health Councils and members from all other communities that I identified on Tuesday. I genuinely believe that it is important to hear from all of them if the NHS is to respond properly to the whole of our community". There are various other statements about wishing to bring through CHC staff into the new system. But even if by some miracle a former CHC employee manages to get a job with or through the commission, again there will be deliberately no continuity of employment.

If that were not enough, as the noble Earl, Lord Howe, pointed out, there is even more uncertainty about ICAS than about patients forums. Even less information has been vouchsafed by the Government. As the noble Earl pointed out, it looks as though PALS may be the way into ICAS and, in the short term, may perform its functions. That, again, is not as forecast by Ministers when we believed genuinely that it would be an independent service accessible separately by the public. ICAS, too, it appears will not be off the ground until after 1st September.

Let me again remind Ministers of their statements on previous occasions.

On 22nd May 2002, Hazel Blears said at col. 325: To summarise, every NHS trust and PCT will have a patient advocacy and liaison service, ensuring that concerns are dealt with before they become a serious problem", and so forth. She said that, the staff of the PCT forums will be able both to provide and to commission independent advocacy support. During various stages of the Bill's consideration many Members have talked about incorporating the duty to represent the views of local people, and the provision of independent complaint and advocacy support would make sense. We genuinely picked up on that idea".—[Official Report, Commons, 22/5/02; col. 320.] And so it continues—more commitments from Ministers which appear to be at least tenuous at present.

Even at this late stage, it is not clear who will be funding the ICAS service. Will the funding be provided by patients forums, the Department of Health, NHS trusts? Perhaps the Minister may cast some light on that.

I turn now to one-stop shops, as mentioned by the noble Earl, Lord Howe. Do we any longer have commitment to these? Once again, I remind the Minister of his commitment to one-stop shops. On 4th November 2002, in reply to a Question for Written Answer, at col. WA 60 he said: Patients forums in Primary Care Trusts will act as one-stop shops by advertising locally their presence and the services they provide in person, over the phone or over the Internet and by being based in premises that are accessible", and so forth. Those are the commitments to a one-stop shop.

In summary, the Minister and his colleagues appear to be in the process of ripping up a number of hard-won undertakings made during the passage of the Bill. I am not sure, but I believe that the Department of Health, rather stung by criticisms of its current policies on the abolition of CHCs, is actually constructing a register of commitments made in both Houses relevant to its activities. It is high time that it did, because unless it can plead ignorance its behaviour to date has every sign of being conducted in bad faith. I entirely endorse the comments made by the noble Earl concerning the Minister. However, the Minister needs to backtrack and ensure that current implementation follows the commitments made.

As the noble Earl, Lord Howe, pointed out, unless the new bodies are put in place by 1st September there will be major gaps. There will be a complete vacuum. If the CHCs are abolished and patients forums are not established immediately, there will be no patient perspective brought to NHS decisions; no patient voice on NHS boards; no monitoring or inspection of the NHS; no referrals to OSC committees; no patient perspective on public consultations; no competent informed support for complainants; no "early warning system"; and no organisation to take action on failing PALS.

That does not seem to have been the intention of those who were present at the passing of the Bill of 2002. In the light of those criticisms, and when allied to what is likely to be a very low budget for the commission and patients forums, there is only one conclusion to be drawn: the department is determined that the new bodies will be ineffective. No indication has yet been given about the resourcing of the new system—certainly no official indication has been given—in terms of levels of staffing, funding and volunteer requirements. However, the auguries are not good. We need assurances from the Minister on the points raised today, failing which there will be a total lack of confidence in the new system. Certainly, the skills of those staff currently employed in CHCs will not be employed to the optimum.

8.15 p.m.

Lord Rea

My Lords, my noble friend will remember well that I was never convinced of the need to abolish community health councils. They did not seem to be broke in the sense that they did not work. Certainly, they were not so badly broken that they needed to be totally written off and replaced. However, they were broke in the sense that they always had been under-funded and under-staffed. But, of course, that was last year's discussion.

Now we have these regulations which spell out how the new system will work. The noble Earl, Lord Howe, ably supported by the noble Lord, Lord Clement-Jones, has called for their revocation simply to ask a series of cogent questions, which has been done extremely eloquently. It is not my intention to follow-up those questions, but only to say that I believe they are questions which need to be answered. The whole purpose of bringing forward this Motion was to allow my noble friend a chance to hear the serious concerns of those who work in the CHCs—so well expressed by noble Lords—and to give him a chance to spell out how the new arrangements will operate. My main concern, as expressed by both other noble Lords, is whether the new structures will be in place when the CHCs are abolished on 1st December. It seems extremely unlikely at present. Will my noble friend assure us that, if they are not in place, the abolition of the CHCs will be postponed? It would be ideal if the operation of the two organisations could overlap while one is phased out and the other phased in. That, I hope, would make it easier for CHC staff, whose skills we want to retain, smoothly to move over for the new bodies. That is what a "managed transition" involves, to quote my noble friend. I shall be interested to hear how he answers some of the extremely searching questions that other noble Lords asked.

Lord Hunt of Kings Heath

My Lords, I am overwhelmed by the warmth with which the regulations have been received in this debate. I hesitate to reopen the debate that we have had over the past few years on the issue. But both the noble Earl, Lord Howe, and the noble Lord, Lord Clement-Jones, seem to have misunderstood completely why the Government wish to make changes to improve patient and public involvement in the National Health Service. If we had really wanted the kind of weak, patchy patient representation that they both accused the Government of seeking, we would not have proposed the new arrangements. Instead we would have retained community health councils—the very bodies that have produced such patchy performance in their 25 years' operation and that have had such little influence in improving the outcome of care for patients. We made the changes because we wanted enhanced patient and public involvement.

When we first debated the issues, I said that I would not have brought legislation before your Lordships' House if I did not believe that the new arrangements would be profoundly more powerful for patients and the public than the current ones. Arrangements including the architecture of patient advisory and liaison services within each trust; the establishment of patients forums; the powerful new role being given to local authorities through overview and scrutiny committees; the independent arbitration service; and the role of the national commission—which will have an enormously influential role in ensuring that patient forums, in particular, perform strongly and effectively—will be far more powerful than those provided by community health councils at present.

Listening to some noble Lords, one would imagine that CHCs provided a golden age of public involvement in the health service. The evidence is very different. Surveys have found that only 3 per cent of the population have ever heard of community health councils. I am convinced that the new arrangements will touch many more people in this country than CHCs ever did. I do not detract from the hard work of many staff and members of CHCs. But the cumulative impact of CHCs over 25 years has been disappointing and patchy. Noble Lords will know that I was one of the first CHC secretaries to be appointed in the early days of the system. But I do not believe that they ever achieved the role that they were given.

As regards the date of abolition of the CHCs, which was announced a few days ago, the intention is that they will cease on 1st September. I say to my noble friend Lord Rea that that is a firm government decision. As I said during the debate on the Private Notice Question from the noble Earl, Lord Howe, it was the firm intention that there would be no gap between the abolition of CHCs and the appointment of patients forums. But we have had to make changes in the light of experience. I am satisfied that the problems currently faced by many CHCs, with staff and members leaving, are genuine. Because of uncertainty it was best to give people a clear date when CHCs would be abolished.

I would have wished to assure noble Lords tonight that there would be a patients forum in place in all parts of the country on 1st September. I regret that I cannot do that, but I do know that the commission will be working very hard indeed to establish patients forums as soon as possible. I say to the noble Earl, Lord Howe, that there will be continued inspections by other bodies such as the Commission for Health Improvement and the patient, environment and access teams. I hope that patients forums will be established very quickly so that inspections by them can be maintained and continued, but I cannot at the moment give a firm date by which all patients forums will be established. I know that the commission hopes that it will take place certainly by the end of the year and as soon after 1st September as possible. I have no doubt that the commission will have more to say about that in the weeks ahead.

As regards ICAS, it is for the Secretary of State to establish it through commencement of Section 12 of the Health and Social Care Act 2001. ICAS will be covered by the commission's work programme. It will be funded by the commission. I give an assurance that there will be an ICAS service up and running on 1st September and that it will be provided to all who wish to use its services from all over the country. The commission will be providing a national helpline so that it will be very straightforward for patients, relatives and carers to access that helpline and the ICAS service.

I recognise that as regards complaints and case work, it is essential that there should be no hiatus at all between CHCs being abolished and the new arrangements being put into place. I give an assurance that case work will be carried over.

I also refer to the comments made about patients' advocacy and liaison services. I have always been a keen advocate of the PALS service. The indications that we are receiving from the field are that they are having an enormously beneficial impact both in terms of being able to deal with problems as they arise when patients, relatives or carers raise them, but also on the way NHS services are run. I am absolutely determined to ensure that the NHS recognises the value of those services.

As to the issue of the independence of the commission and its work programme, we discussed this when the legislation was passing through the House. This kind of situation is not out of the ordinary in similar bodies where the Secretary of State has to approve the work programme. I wish to make it clear that if the work programme did not need to be agreed by the Secretary of State, or if changes could be made without his consent, that would detract from the commission's overall accountability to Parliament and the public for its actions and use of public funds.

We have got the balance right between the necessary accountability and the freedom of manoeuvre that the commission wishes to have, and which I am sure it will operate.

Lord Clement-Jones

My Lords, I apologise for interrupting the Minister but he seems to have substituted "freedom of manoeuvre" for "independence". Is the Minister redefining the remit of the commission?

Lord Hunt of Kings Heath

My Lords, not at all. I am trying to describe the appropriate balance for public bodies that are ultimately accountable to Parliament. Far from the commission being inhibited and under the control of the Government, I am confident that it will be in a strong position to operate in the way it wishes and to develop its work in the light of experience.

Lord Clement-Jones

My Lords, can the Minister confirm that the commission will be independent, as pledged by Ministers during the passage of the Bill through Parliament?

Lord Hunt of Kings Heath

My Lords, of course the commission will act independently. There is no suggestion that it will not. Frankly, when I look at the members of the board, who are led by Sharon Grant, the chair of the commission, the idea that the commission will act as a kind of government poodle is ridiculous. Indeed, there have already been extremely vigorous discussions between the chair of the commission and Ministers and officials in my department. I have no doubt whatever that the commission will act vigorously. That is what we want it to do.

The noble Lord and the noble Earl raised the issue of casualty watch. We have debated this time after time. I have made it consistently clear that the commission has the power to ask forums to undertake work on specific themes, based on reports it receives from patients forums. It will be able to instigate reviews on what is important to patients over a wide range of subjects. This could include surveys of accident and emergency departments and the implementation of national service frameworks.

The one-stop shop is important. It will be built around primary care trusts because they are population based. I am absolutely assured that the patients forum in each primary care trust will be able to provide access to all who require its use. In addition to helplines and the other ways in which it can be accessed, as I suggested in our debates, there will be a physical presence, either in the form of members of the patients forum going out to meet people in their own homes or the public coming to meet them to discuss their concerns.

We do not want to tie the whole situation down by saying that there must be, say, a high street shop for every patients forum. Clearly that must be decided at local level. The point about ready access is crucial h ere. It will be provided.

I said that I would tell your Lordships as soon as I knew the position on funding. Details on that have been sent out to the health service today. The figure will be £34 million, compared with the £23 million currently received by community health councils. The commission assures me that it can deliver a meaningful and effective system of patient forums and ICAS for that figure.

Lord Clement-Jones

My Lords, will the Minister clarify that? Is that £34 million purely for the commission or does it also include the money available for ICAS?

Lord Hunt of Kings Heath

My Lords, it will be for the commission, for patient forums and for ICAS. However, I am sure that the noble Lord agrees that it is significantly more than the sum currently being spent on community health councils.

Lord Clement-Jones

Yes, my Lords, although the estimate made for a meaningful figure for the structure set out in the original Bill was £100 million.

8.30 p.m.

Lord Hunt of Kings Heath

My Lords, I am confident that the figure we have given will certainly be sufficient to ensure that a very effective service is put in place.

The commission will have a small staff at national level. It also intends to have nine regional offices located in government office regional areas. I understand that they are likely to have around 18 staff per office, on average. Those will be directly employed. It will also contract out support for PCT patients forums to 150 consortiums of voluntary organisations—one operating in each locality. The 150 areas will be broadly modelled on local authority areas, with some boundary tweaking to ensure coterminosity with NHS boundaries.

I listened with care to the comments of the noble Earl and the noble Lord about the direct employment of staff. The question is whether they are good and will provide an effective service rather than whether they are directly employed by the commission or by the consortium. We have debated the role of the voluntary sector many times in this House. The commission has come up with an imaginative solution to the issue of where people should be employed. It is fantastic that they are to be placed within the voluntary sector. I know that many people in the voluntary sector welcome the fact that they will be able to forge just the right kind of partnerships at local level, but based on a contractual arrangement so that the commission can assure the quality of the service to be provided. I hope that noble Lords accept that it is an imaginative approach that deserves to succeed.

As for the conflict of interest question, let me make it clear that voluntary organisations are simply providing staff to support patients forum members. It is the members who will monitor NHS services and make recommendations, not the staff. It is important to recognise that this is not a staff-led but a member-led approach, and the members will make the judgments and recommendations and be the engine room of patient and public involvement at local level. The staff are there to support that function.

I listened carefully to the question of the staff position. I always said that I hoped that there would be room for many of the good people working in community health councils in the new structure. There is a great deal of room and enormous opportunity in local government, with the overview and scrutiny committees, in the NHS, with the PALS, with the independent advocacy services and in patient forums. However, we have never envisaged that we could guarantee employment. I never at any stage suggested that we could do that; we never believed that we could deal with CHC staff differently from the way in which we deal with other staff in the NHS when they are affected by restructuring.

I have seen some work from overview and scrutiny committees, not least in Birmingham City Council where the committee produced an excellent report on breast-feeding which had strong recommendations from the NHS and local government. I should declare an interest, as my mother-in-law chaired that committee. That impressed me because it showed how influential those committees will be in future.

The noble Earl, Lord Howe, asked about the power to scrutinise, as opposed to the duty. We argued about that when the Bill was debated, and, as I said at the time, the Government want local authorities to have discretion. They should have discretion because they are democratically elected at local level. Therefore, I do not accept that we should have put a duty on them. That said, I find it almost inconceivable that a local authority would not establish an OSC when making a major change in service. That is when representations may certainly be made to the Secretary of State. If it were ever the case that a local authority did not establish an OSC, it would be up to the local community to make representations direct to the Secretary of State. However, that is a very remote suggestion.

The noble Earl, Lord Howe, asked why OSCs were not given a role in relation to the establishment and dissolution of trusts. That is not a major change in service but a structural issue. With the greatest respect, we should not accord structural issues the importance of a service issue, in which case the change could have a big impact on the country. Indeed, having lived through any number of structural reorganisations, I can say that most of them pass the public by. I still meet doctors and members of the public who refer to area health authorities, which were established in 1974 and abolished six or seven years later.

I say in conclusion that I do not doubt the sincerity of all noble Lords in wanting to ensure that the new arrangements work. Nor am I complacent about the need for patients forums to be established as soon as possible so that there is as small a gap as possible between the abolition of CHCs and the establishment of patients forums throughout the country. I am optimistic. I believe that in the chair of the new commission we have someone who has already shown great leadership skills. The commission will clearly be determined and will not be backward in making its views known. I imagine that within a very short space of time the noble Earl, Lord Howe, and the noble Lord, Lord Clement-Jones, will gladly use the ammunition and evidence that they put forward to have a go at the Government, and that is absolutely right. I am absolutely convinced that as the new arrangements bed down they will be seen by the public, patients and the NHS to be much more powerful than what we have at the moment. On that basis, I commend the regulations to the House.

Earl Howe

My Lords, I thank the Minister for his reply which I have to say I found far from reassuring in many, if not most, respects. A good proportion of the early part of his speech was devoted to rehearsing past debates about CHCs. I do not think that there was any need for him to do that. I accept that CHCs are about to come to an end. My concerns are purely for the future. I remarked earlier that the credibility of Ministers on these issues is on the line. As far as I am concerned, it still is.

The Minister essentially implied at the end of his speech that it is for the commission to get on with the job of setting up the new arrangements and that Ministers can effectively stand back from that process. I simply raise again the issue of the raft of ministerial undertakings. We were told that there would be consultation. What seems to be in store for us is a model for patient and public involvement on which no one whatever has been consulted. How is it credible to set up a system to service the interests of patients and the public if neither patients nor the public have been asked what they want? It seems to me an absurdity.

I turn to the issue of the commission's independence. What we have in these regulations is not what I would view as a reserve power; it is a licence to micro-manage. I think that I know a reserve power when I see one. A reserve power, which I quite understand is needed in certain circumstances, takes the form of a power of direction. That power of direction was indeed in the Bill. If the Minister wishes us to believe that a power for the Secretary of State to approve, alter and veto the commission's work programme is necessary to enable him to fulfil his accountability to Parliament, then I say that that is palpable nonsense. What other non-departmental public body is subject to the same restrictions? I cannot think of one and I challenge the Minister to name one. I do not accept his explanation. I do not accept that a power is needed to dot every "i" in the work programme.

Lord Hunt of Kings Heath

My Lords, I give the example of NICE. No one suggests that NICE is anything but independent in the technology appraisals or the clinical guidelines that it undertakes. But Ministers approve its work programme.

Earl Howe

My Lords, is not NICE a special health authority? I think that that falls into a different bracket altogether.

Lord Hunt of Kings Heath

My Lords, let me give another example—the Commission for Health Improvement, which I think is a non-departmental public body. There is no suggestion that Ministers have ever sought to intervene in the way it carries out its reviews. But I as the responsible Minister have regular meetings with the commission and have agreed issues to do with a number of reviews that it undertakes. That is a perfectly satisfactory arrangement.

Earl Howe

My Lords, but is there a power for Ministers to approve or vary the work programme of the Commission for Health Improvement? I do not believe that there is. I think that the commission can act perfectly freely as it sees fit. What we are talking about here is something of a different order altogether. I simply do not accept that Ministers need a power to dot every "i" in the work programme. The Minister's words of 21st January last year were: The independence of the system for PPI"— patient and public involvement— is critical to its success". How strongly I agree. I do not think that to talk about acting vigorously and being in a strong position to promote a programme is any comfort.

I see the flexibility and responsiveness of the commission as very important in the way in which it operates, but I am not sure that anything that the Minister said on that gave me any comfort either. For example, will the commission be able to undertake legal action against the NHS and to fund patients forums to do so? Will the commission and patients forums be able to campaign to change government policy? From what the Minister said, I doubt very much that that will be the case.

The Minister referred to the transfer of staff from CHCs and said that there would be room for the best staff. I quite agree that there was never any guarantee or indeed a suggestion of a guarantee of a passport to further employment after CHCs came to an end. However, how many of the staff can now look forward to a continuing role in representing patients and the public? It is clear that the answer is very few. That is a grave disappointment, and I am sure will be met with dismay by the hard-working staff of CHCs.

We come to the concept of consortiums and networks. It may well be an imaginative approach that the commission has adopted, but I am still just as negative as I was and, indeed, not a little confused. How exactly is it suggested that consortiums will be involved in the running of patients forums? What does that concept actually mean? Has the Minister thought about the practicality?

Lord Hunt of Kings Heath

My Lords, it means that the consortium of voluntary organisations will employ staff who will provide the infrastructure support to patients forums to undertake their work.

Earl Howe

My Lords, let us see how that works. I think that it will be enormously bureaucratic and complicated. For a start, we are in for a huge tendering exercise. There will be a vast array of bids, all needing evaluation. All the contracts will need to be monitored. Arrangements will have to be put in place for that, and all that is before anyone has even set foot in a hospital. It is a guaranteed recipe for bureaucracy.

We understand that the local consortiums are to be in place by 1st September, or at least that that is the aim. What one gathers from that—the Minister admitted it—is that patients forums will not be. That is deeply regrettable and contrary to the understanding that we had during the passage of the Bill.

I thank the Minister for his comments on a one-stop shop, although I am not sure that I fully understood them. He spoke about patients forums providing access to all and providing a physical presence. I do not know whether that is or is not a one-stop shop. It seems to me a roundabout way of saying that it might not be, which I again find deeply regrettable.

Lord Hunt of Kings Heath

My Lords, I think that what I said was consistent with what I said in debate. There must be discretion to decide the arrangements at local level. What I cannot say is that every patients forum PCT will set up a high-street shop. They will have to ensure ready access through various means. One of those forms of access will be physical access.

Earl Howe

My Lords, I do not think that a telephone line, for example, is what most of us have been led to think of as a one-stop shop.

Lord Hunt of Kings Heath

My Lords, that is what I meant by physical access. Clearly, it will be important, if a member of the public needs the services of a patients forum, that they can meet representatives of the patients forum and that there is not simply a telephone line.

Earl Howe

My Lords, I thank the Minister for that reply. The issue hinges on practicalities and accessibility for patients and the public. The Minister gave the overall budget figure for the commission, for which I am grateful. I am frankly amazed that the commission believes that a comprehensive patient and public involvement service can be provided for £34 million, bearing in mind that there will be 571 patients forums, if I have the figure right. We must have a strong, rigorous system for patient and public involvement in which all elements are properly resourced. I know that the Minister believes that too as I have quotes from him saying exactly that. However, I do not share his confidence that it will be forthcoming. That is no criticism whatever of the chairman of the commission.

The Minister addressed the accountability vacuum. I do not see CHI as a substitute of any kind for the involvement of patients in the monitoring and scrutinising of the day-to-day work of the NHS. It cannot possibly be a substitute. I am surprised that the Minister should suggest that. As to the date for establishing patients forums, that is still a matter of hope and vague guesses. The Minister has done his best, but I am not reassured.

Turning to overview and scrutiny committees and the establishment and dissolution of trusts, the Minister suggested that structural issues did not constitute a major change to the health service. The closure of a facility, even temporarily, is well established by case law as amounting to a substantial variation of services. I hope that the health service will bear in mind that point and that it will be included in the relevant guidance.

I am most grateful to the noble Lord, Lord Clement-Jones, for his sterling and cogently argued speech which dovetailed neatly with my own without any prior consultation between us. I do not intend to divide the House on these Motions. There would be no point in doing so. The reason for the debate has already been stated. I thank the Minister for his reply, which I shall study carefully in Hansard. I give him notice that we shall return to these matters. In the mean time, I beg leave to withdraw the Motion.

Motion, by leave, withdrawn.