§ 7.32 p.m.
§ Earl Howe
rose to move, That an Humble Address be presented to Her Majesty praying that the regulations, laid before the House on 14th August, be annulled (S.I. 2003/2123).
The noble Earl said: My Lords, I begin by making it clear that neither of the Motions standing in my name has been moved with a view to dividing the House. Nevertheless, the regulations provide us with an appropriate opportunity to debate some of the serious concerns relating to patients’ forums and to the emerging shape of patient and public involvement more generally.
At the outset, it is only right for me to give the Government credit where it is due. When we last debated the issues, 1 expressed my grave disappointment that there was to be a gap of three months between the abolition of community health councils and the establishment of patients’ forums—a gap that would make a mockery of the Government's promise of a managed transition from the old system to the new. Since then, the abolition of CHCs has been put back by three months. That was clearly a welcome decision. In addition, I acknowledge the efforts of the Department of Health to consult as widely as it could on the content of the regulations and its willingness to make changes in the light of the comments received.
There are, however, two pivotal issues that the regulations fail to address, and on which the success of patients’ forums depends. The first is the infrastructure from which patients’ forums will operate. The second is the relationship between patients’ forums and other associated organisations. We all believed, when we debated the legislation last year, that the precise way in which the Commission for Patient and Public Involvement in Health would fulfil its role of providing staff, funding and premises to patients’ forums would be set out in regulations. Instead, the regulations effectively give the commission a carte blanche discretion to set about those tasks however it wants.
That, I contend, is not within the spirit of the Act. In practice, we see that it is leading to results that can only be viewed as highly regrettable. On 6th December 1682 2001, Parliament was assured by Hazel Blears that there would be a pathway for staff of CHCs who want to take part in the new system. Nobody understood that to mean a guaranteed meal ticket. But the benefit of such a pathway would be that the expertise and knowledge of CHC staff would not be lost to the local community. Instead, we are now witnessing a wholesale contracting out of the staff support function to the voluntary sector, to be called local network providers.
That decision has, in effect, left CHC staff out in the cold, unless they are prepared to compete in the job market for short-term contracts in small voluntary sector bodies—a far cry from their present terms of employment with the NHS. In other words, there is no pathway for those experienced staff. The commission is recreating the very thing that Ministers told us would be stripped out of the new system—the middle layer of administration standing between the commission and local communities.
There was absolutely no consultation about the decision. It runs contrary to the picture painted by Ministers in Parliament that patients’ forums would directly employ their own staff who would be men and women provided by the commission. It is certainly not the managed transition that was promised so as to make the best possible use of the local knowledge base.
As it is, many of the local network providers have no connection whatever with the communities for which they are to be responsible. Scope, based in Birmingham, is covering forums in south London. The College of Health, based in east London, is covering Essex—rather, it was going to, but it is now going into liquidation.
Local community knowledge for patients’ forums is not just an optional extra; it is vital to counterbalance the increasing trend in the NHS towards larger provider trusts, some of which cover several local authority areas. Some network providers, although expert in one field, have no expertise in others. With the best will in the world, Age Concern Harrow is hardly geared up to provide support on mental health, maternity or children's services. I wonder, too, about the Scouts, another local network provider. Some staff will be answerable to more than one forum at a time. Different forums will find that they have different levels of support, some with a reasonably good understanding of local needs and others with practically none.
All that spells one thing: a less than satisfactory structure for supporting patients’ forums. It is a recipe for patchiness and complexity. It is also a recipe for bureaucracy, as each local network provider will be governed by a contract that will have to be managed. That is the exact opposite of the consistency, evenness and simplicity that we were promised when we debated the legislation.
We were told that ICAS would be delivered through every PCT patients’ forum. That now looks unlikely to happen until 2005. Meanwhile, the PALS service is tasked with advising patients on how to access ICAS. ACHCEW has just surveyed 100 PALS services by 1683 telephone. Only 54 of the 100 received a direct personal response; others got an answerphone or no reply at all. Only 27 out of the 54 were able to direct the caller to the ICAS helpline, which started on 1st September. The survey reflected only those trusts that have a PALS service; many still do not.
We were also promised one-stop shops. It is both surprising and disappointing that the regulations do not cover that. Whether we will get one-stop shops remains to be seen, but the auguries are not promising, judging by the very small offices generally occupied by the network providers. A one-stop shop requires the right kind of premises in the right place. Many CHC premises are ideal for the purpose, but the commission shows no signs of wanting anything to do with them. That is a wasted opportunity and a giant waste of public money. Many CHC premises are newly refurbished and at high street locations, with disabled access and private rooms for confidential discussions. Yet a number of CHC premises are now empty and boarded up. Others, including their equipment, are being made over willy-nilly to the NHS. Others, again, are to be offered to house clearance traders.
The local network providers are being largely left to deal with the whole matter. I hope that, in due course, the Minister will be able to answer a Written Question from me on the total cost of the abolition of CHCs and the setting-up of the new system, including premises disposal and redundancies. When that figure is available it will stand as a measure of what might have been. In other words, it will be a measure of the properly managed transition that we were promised but have not had. Because the contracts governing the local network providers are managed by the commission, it is very hard to see how the forums themselves will have any control over the quality of service that they deliver. If the forums are unhappy with the support that they are getting, they have no power to question the commission about it, and the commission under the regulations need do absolutely nothing. Yet the forums will be performance managed by the commission as if they did have control over their staff support.
It is true that, under Regulation 8(2), staff in the local network providers must work to the direction of the forums, but the forums themselves have no contractual leverage over the providers and no means of ensuring that they receive a fair share of time and attention from them. If a local network provider is supporting 33 forums—as was going to be the case with the College of Health—what can a forum do if it feels that it is getting short shrift? All 33 forums will be competing for the same limited pool of staff.
The remaining uncertainty is about how patients’ forums are meant to work together. We debated that issue extensively during the passage of the Bill. Patients’ forums need to work together for many reasons, not least to inform the work of the overview and scrutiny committees. There therefore needs to be a coherent joint committee of patients’ forums relating to the same area. Equally, large NHS trusts ought not to find that they are being pulled in different directions 1684 by four or five PCT patients’ forums as well as their own. There has to be a mechanism for getting all those patients’ forums around a table, but there is nothing in the regulations that brings clarity to this issue. Co-operation is mentioned but is nowhere defined.
There will be an awful lot of forums about. One can easily postulate that a single PCT patients’ forum will have to co-operate with an ambulance trust forum, all the forums of the relevant specialised trusts, the forums of the acute trusts from which its PCT commissions services and forums in neighbouring areas. One way or another that is a great deal of co-operation, and if it is to be done well—or done at all— it will require the right degree of support and co-ordination by staff. Frankly, it is difficult to see how such support can be provided by half a full-time post per forum, which in many instances is what is in prospect.
I am sorry to put the Minister on the spot in this way. He was not involved in the legislation or the setting up of the commission and I do not blame him personally for what is now happening. However, ministerial undertakings in both Houses of Parliament given in good faith have not now been met. There has been no managed transition because CHCs have been allowed to disband early and their premises are being disposed of. There has been no harnessing of the skills of CHC staff, as we were promised there would be, and those skills have therefore been lost to the NHS. Not one member of CHC staff has been transferred directly to the commission.
We were promised an ICAS system delivered through every PCT patients’ forum. There is a long way to go before we can be confident that patients can access it, and the promised one-stop shop that we debated so many times in this House is still a pipe dream.
This is a very poor start to an important new system. I look forward to any words of comfort that the Minister feels able to give. I hope that he will be able to take away with him the concerns that I have raised and examine them urgently. I beg to move.
Moved, That an Humble Address be presented to Her Majesty praying that the regulations, laid before the House on 14th August, be annulled (S.I. 2003/2123).— (Earl Howe.)
§ 7.45 p.m.
§ Lord Clement-Jones
My Lords, I rise to support strongly what the noble Earl, Lord Howe, said in his Motion. I thought, if anything, that the noble Earl was quite generous in his opening remarks. However, following them he made a devastating indictment of government policy on patient and public involvement and the implementation of that policy. It has been a sorry tale of government commitments not honoured and of a Gothic divide-and-rule architecture of patient and public involvement. It strikes me that the Government are really rather fond of Gothic architecture—we see that in the opening parts of the latest Bill.
1685 It seems to be a divide-and-rule policy of the Government to split existing institutions in the NHS asunder in a way that makes them unworkable. The ramshackle implementation of even that architecture has been wondrous to behold. I am delighted see the noble Lord, Lord Hunt, in his place. It is rather like him returning to the scene of the crime. He was very strong in his justification of the current architecture and I hope that he has some qualms when he sees the way in which that has been implemented.
The noble Earl, Lord Howe, went through a series of issues such as the absence of managed transition. There has been no managed transition between CHCs and patients’ forums or between ACHCEW and the commission. As I understand it, there has been absolute opposition by the commission to managing that transition. The Department of Health has reneged on its commitment to establish one-stop-shops—the number of quotes that I could present to the Minister on the subject are legion. The noble Lord, Lord Hunt, in reply to a Written Question 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".—[Official Report, 4/ 11/02; col. WA60.]That is a very clear commitment.
On the commitment to staffing, the noble Lord, Lord Hunt, said:
Staff will be provided by the Commission for Patient and Public Involvement in Health to primary care trust patients’ forums".—[Official Report, 4/11/02; col. WA 60.)What do we now see? Local network providers, which involve a very new different concept that was not heralded in ministerial statements at all.
We now find that the Charities Commission has had referred to it the whole issue of whether it is proper for charities to act in this way. We await the outcome of that with considerable interest.
On the commitment on ICAS, Hazel Blears said:
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 Patients’ Forum, ensuring that the local public have a vehicle to express their view about matters relating to health".—[Official Report, Commons Standing Committee E; 22/5/02; col. 325.]That has not happened.
On the transfer of skills and knowledge, as the noble Earl, Lord Howe, made a clear point. David Lammy MP said:
The Government takes the view that community health council (CHC) staff have valuable skills which are important to the smooth running of the National Health Service".—[Official Report, Commons, 2/12/02; col. 610W.]That smooth transition has not taken place.
A great many commitments have not been fulfilled. The noble Earl, Lord Howe, described the survey carried out by ACHCEW—and it is a good thing that we still have ACHCEW in order to at least carry out surveys at this juncture. We will not have it for very much longer. It carried out surveys in April and October 2003. April 2003 was a year after PALS were meant to have been set up in every trust, and October 1686 2003 was 18 months after that date. The results in April 2003 were totally unsatisfactory as the noble Earl, Lord Howe, mentioned, and the results in October 2003 demonstrated absolutely zero improvement. That is the bottom line of that survey— totally unsatisfactory.
I have a few minor questions. I could probably go on for about 20 minutes on all the regulations, but, perhaps unusually, I am not going to torture the Minister. However, I am going to go through a number of the different regulations. I turn first to No. 2124—The Patients’ Forums (Functions) Regulations. Why must patients’ forums have to have regard to any advice given by the commission? That seems a pretty heavy hand. What is meant by "shall have regard"? Is that a directive? Does it effectively mean that patients’ forums have to respond in those circumstances?
We have issues about access under Regulation 3. It is unfortunate that access for patients’ forums to prison health services and health facilities in detention centres for asylum seekers is not explicitly included in the regulations. Also, as we know, we have a mixed economy. NHS patients will be treated in private hospitals and clinics. I see no right of access there.
The Department of Health has strengthened Regulation 5 by creating a requirement for NHS bodies to provide information within 20 working days, but there is no mention of the quality of the information or of information required on national and regional NHS services, prison health services, private providers, local authorities or primary care providers.
Regulation 6 deals with restrictions on the disclosure of information. There is no provision that deals with the sensitive issue of doctors or nurses who may have been referred to the National Clinical Assessment Authority or are otherwise regarded by the trust as having displayed weaknesses in their practice. It should be possible for patients’ forums and trusts to share sensitive information in that way.
Regulation 7, relating to referral to the overview and scrutiny committee, is too narrow and weak. It represents a missed opportunity. It should have included general encouragement to refer any key issues to the OSC, and it should have referred specifically to Section 19(2) of the National Health Service Reform and Health Care Professions Act 2002, which allows the patients’ forum to refer any matter to the overview and scrutiny committee concerning the health of local people. That signpost is not in the regulations.
Regulation 8(3) fails to include overview and scrutiny committees in the list of organisations to which the patients’ forum should send reports on service reviews.
SI 2003/2123, the Patients’ Forums (Membership and Procedure) Regulations 2003, is equally full of flaws. The bit relating to the membership of patients’ forums, NHS trusts and PCTs is, perhaps, the worst bit of the regulations. We have a basic patients’ forum of seven members, and we have a PCT patients’ forum 1687 of, potentially, nine. There are provisions about sub-committees involving two members. That is a very small base on which to build a patients’ forum. What happens if members of a patients’ forum are away or on holiday or are sick? Instantly, we are emasculating the power of patients’ forums. The small size envisaged for patients’ forums is a major problem.
Regulation 3(1) does not require that the powers will be exercised. I will be happy if the Minister can give an indication that they will be required. The regulation says that the patients’ forums "may" appoint a chair; it does not say that they "shall" appoint a chair. Given that, in Regulation 8(2), it is the members who are described as directing staff provided by the commission, the risk of confusion could be a major problem. How can the members exercise proper control collectively over the staff provided for the forum?
I mentioned the problems with sub-committees. They could be major problems. Even in Regulation 10, which relates to meetings and proceedings, there is no requirement to hold a minimum number of meetings. It appears that a patients’ forum can meet whenever it wants and with a regularity chosen by the members. On the basis that the Bill that we are debating so frequently and nocturnally appears to envisage the withering away of patients’ forums, Regulation 10 is an open invitation to have the patients’ forum meet rarely, if at all.
I have said enough to demonstrate not only the flaws in government policy but the sheer lack of commitment demonstrated by Ministers to genuine patient and public involvement and the flaws that are inherent in the regulations.
§ Lord Hunt of Kings Heath
My Lords, this brings us back to the happy days when we discussed the setting up of the new arrangements and the abolition of community health councils. I probably delight more in Gothic architecture than the noble Lord, Lord Clement-Jones, and I remain convinced that the proposals and the new structure will produce a greater scale of patient involvement and more effective handling of patient complaints than we ever had from community health councils. The evidence is that, over 30 years, some did excellent work, while others did not. I remain convinced that the establishment of patients’ forums and of powers of independent advocacy will lead to a stronger, more user-friendly NHS.
The noble Earl, Lord Howe, and the noble Lord, Lord Clement-Jones, mentioned statements made by Ministers, including me, during the passage of the Act that set up the new arrangements. Those statements were made in good faith. It was my firm intention that the arrangements would be established in the way that I described. I regret that, as it turned out, the arrangements were, unfortunately, not made in time. I apologise to noble Lords for that and accept any responsibility that I must take for that situation. There was no malevolence involved. The task was great, and the commission was slow to get off the ground. I suspect that it spent too much time talking to the 1688 department about money rather than getting on with the job. The commission must also share some responsibility.
The question now is how we ensure that the new arrangements are effected as efficiently as possible. I share some of the concerns about the performance of the commission. Reports have reached me from the health service of a certain inflexibility of approach. I regret that. Like the noble Lord, Lord Clement-Jones, I wonder why, for instance, SI 2003/2124 says that the patients’ forums "shall have regard to" the advice of the commission. The commission has an important role to play in ensuring and reviewing the performance of each patients’ forum, but it is not there to manage the patients’ forums. They are not local branches of the commission. It is important that they are seen to be independent. I give notice that I shall return to the matter, if I detect signs that the commission is seeking to have too much influence on the activities of individual patients’ forums.
On the question of local network providers, I do not think that the principle is unreasonable. It was a good decision by the commission to recognise that, given the huge number of people to be appointed, using local providers seemed sensible. However, those local providers must have local knowledge. They have a great responsibility to ensure that the people appointed to patients’ forums are up to the job. I worry about those who provide the service but are not based in the locality for which the patients’ forum is being appointed. I hope that my noble friend might take that message back to the commission.
I have two or three issues to raise. The first is that it was always the intention that patients’ forums would appoint one of their number to be a non-executive on the board of NHS trusts. Word reaches me that that has been put into abeyance. I would be grateful if my noble friend could tell me the position on that. I always thought it to be a very important provision that patients’ forums would have that direct connection with the board of each NHS trust and primary care trust.
My second question is about foundation trusts. I suspect that the noble Lord, Lord Clement-Jones, for one, will not agree with me. We are discussing legislation that would not require a foundation trust to appoint a patients’ forum. Yet word reaches me that the commission, none the less, is insisting that those NHS trusts which are going forward as applicants are establishing patients’ forums for those trusts. The noble Lord will no doubt move an amendment on Report to require that but at the moment they are not required to do so. I suggest to the commission that, surely, there is room for some flexibility in relation to the first wave of foundation trusts. Surely they should hold off the appointment of those patients’ forums until the matter has been decided by Parliament.
Parliamentary involvement brings me to another issue. In the Bill, the Act and the regulations, there are references to patients’ forums, not to patient and public involvement forums. I ask my noble friend: why are these organisations to be called patient and public 1689 involvement forums? That may be a minor point, but as my noble friend knows, I have raised it in relation to the Health and Social Care (Community Health and Standards) Bill where governing bodies are named as governing bodies. Yet my good friends in many applicant foundation trusts have produced consultation documents which refer to them as member councils.
Either Parliament is here to determine what happens in the NHS or it is not. If Parliament determines that governing bodies are called governing bodies, it is not for the NHS or the department to suddenly say, "You can use another name". We did not establish patient and public involvement forums; we established patients’ forums. My concern is that the commission has ordained that the name should be changed because it considers these local organisations to be branches of the national commission. That is not what the legislation intended. They are not local branches of the commission. The commission has an important role to play in ensuring that patients’ forums are given the right advice and information and that they are enabled to do their job properly.
I get very concerned when the commission takes it upon itself to change wording that is in the legislation and seeks to over-manage what those patients’ forums do. 1 do not hold my noble friend responsible for that at all. We set up the commission as an independent body; it is right that they should be independent. My goodness—the commission has a responsibility, too, to Parliament, to act in the way that Parliament intended and ordained.
§ 8.2 p.m.
§ Baroness Masham of Ilton
My Lords, I should like to thank the noble Earl, Lord Howe, for giving your Lordships the chance to hear about the progress of setting up patients’ forums and for his interesting speech. With the demolishing of community health councils, several of your Lordships, including myself, were concerned that there would not be an independent voice for patients and the public. Community health councils have closed down or are closing down before, it seems, the forums are set up and in place.
With the fragmentation and confusion to the public while the many different professional bodies are sorting themselves out, the patients’ voice, which was supported by the CHCs, seems to be left in limbo. Because he has been a director of social services, I am sure that the noble Lord, Lord Warner, the Minister replying, will understand how confused and vulnerable patients or their relatives need support and information.
I hope that the noble Lord will give us some assurances today that suitable patient support bodies will be set up. CHCs were able to delay the closure of hospitals—in a way, rather like the House of Lords— giving the Government a chance to think again. CHCs could give the Secretary of State for Health a chance to listen to the public and think again. Will there be any body which will be able to do that now? What functions are the patients’ forums to have?
1690 It was of great concern to read this week about the epileptic children in Leicestershire. There seemed to be no mechanism for patients and health workers to get any satisfaction about the deplorable situation which was going on around them. No one seemed to want to listen. The Minister will no doubt say that he cannot comment on an individual case, but there were more than 600 young lives being damaged, having been given unnecessary drugs.
The noble Earl, Lord Howe, is to be congratulated on bringing up this matter. What is to be the membership and procedure of the patients’ forums? Will they really represent patients? What will happen to all the information gathered over the years by CHCs? Is it to go into a bin? I should like to ask the Minister: why will foundation hospitals not need to have a forum? While other health bodies and hospitals will have them, will that not add to the present confusion? Are dentists to have forums?
I hope that the Minister will be able to take up the challenge and put in place a satisfactory, supportive and independent body which has time to help patients and advise managers on the needs of their communities. The present forums, as stated in the statutory instruments, do not seem satisfactory, as stated by your Lordships tonight. The criticism of CHCs was that they did not have enough teeth: these forums seem to have none.
§ 8.6 p.m.
§ Lord Harris of Haringey
My Lords, I should declare an interest as a former director of the Association of Community Health Councils. However, on this occasion I have not had the benefit of sight of the interesting review and survey carried out by the association. None the less, that will not stop me commenting on the regulations.
I am grateful to the noble Earl, Lord Howe, for his commitment not to divide the House on these regulations because we must get on with establishing patients’ forums. If the Prayer were to succeed, the consequence would be even more confusion, even more of a hiatus and even more of a gap than might otherwise be the case. Nevertheless, it is valuable to have an opportunity to discuss and debate some of the rather interesting issues that appear to be in the regulations.
I speak as someone who is not a lawyer, something of which I am inordinately proud. As a lay person, it seems that there are a number of issues in the regulations that it would be helpful for the Minister to clarify.
In SI 2123 on membership and procedure, for example, Regulation 2(4)(b) on membership seems to suggest that the commission may decide that all kinds of other bodies might be represented on the patients’ forum. That could be very helpful, but it would be interesting to be given some sense of what Ministers have in mind here. It is self-evident that local authorities or parish councils within the area of a PCT are bodies that represent members of the public. Perhaps they might have a representative on the 1691 forum. It could even be argued that Members of Parliament represent the people in the area and therefore might be allowed to send a member of their staff to become a member of the patients’ forum. That is an interesting concept, but I am not sure whether it is quite what was in mind. Local neighbourhood watch schemes may even seek representation. What exactly does this part of the regulations intend to achieve?
I turn to Regulation 10(5). The noble Lord, Lord Clement-Jones, drew attention to some of the issues surrounding meetings and proceedings. However, this regulation provides that the only meetings which must be held in public are those dealing with the items set out in paragraph (4). The much-maligned community health councils were subject to access to information provisions and there was a presumption that all meetings would take place in public. Given that such a body is considering the services being provided for local people, it is an important provision. I am not sure what is to be gained by allowing this potential restriction.
Regulation 8(1) and (2) address the central questions of funding and resources. I would welcome a clear statement from the Minister that Regulation 8(2) would apply even if staff are associated with supporting a patients’ forum only on a part-time basis. Do they then come under the direction of the members? What will define the point at which they would stop being under the direction of the members and under the direction of someone else?
Regulation 2 of Statutory Instrument 2124 covers functions. I suspect that those lawyers drafting these regulations may have raised a number of issues which they did not intend—or perhaps they did intend to do so, in which case the aim may have been to make the job of the new patients’ forums almost impossible to complete. Regulation 2(2), for example, states:
Where an NHS trust provides services under arrangements made by more than one Primary Care Trust, the Patients’ Forums established … shall co-operate".The word "shall" is powerful. Presumably every PCT in the country receives services from Great Ormond Street hospital or from one of the other national institutions. Does that mean that no comment can be made unless every patients’ forum in the country has co-operated? That seems to be the implication here. I do not understand why the word "shall" as opposed to "may" has been used. No doubt there is a good reason and the Minister will share it with us.
Regulation 3( 1 )(a) is excellent stuff, giving the PCT patients’ forum the most impressive powers of entry and inspection. If I read it correctly, where it states,
any body mentioned in paragraph 3",that would mean access to any primary care trust, any local health board, any local authority—presumably anywhere in the country—any NHS trust—presumably anywhere in the country—and so forth. That is an incredibly wide power which, while extremely useful, no doubt could lead to all kinds of fishing expeditions being made by patients’ forums if they have the staff and the 1692 members to do so. That might mitigate against some of things that apparently concerned Ministers about the CHCs.
A similar point arises in respect of Regulation 5(1) on information. Subject to Regulation 6, which covers not disclosing personal information about individuals, it seems that any of the bodies referred to in Regulation 5(3) must produce for the patients’ forum any information,
which appears to the Patients’ Forum to be necessary".Again, I commend that power. It is absolutely wonderful that patients’ forums may require such information from any of these bodies; that is, any strategic health authority, any NHS trust, any primary care trust and, indeed, the commission itself. That would be interesting, because it is one of the most open of bodies. No doubt it will be happy to make available all this information. Again, these are wide powers and no doubt the Minister will want to commend and support their use. I look forward to hearing his explanations.
However, the fundamental issue that must be addressed, and to which no doubt my noble friend on the Front Bench will respond, is that there are some real weaknesses in what is actually happening. The point has already been made about the commission's decision to contract out some of the staffing and administrative arrangements. I thought that the real strength behind establishing the Commission for Patient and Public Involvement is that it would enable common standards to be set, along with a common set of procedures and common arrangements across the country. That was a strength and would mark how these new arrangements would be better than those for the CHCs, but that has been thrown away. I would be interested in the Minister's views on that, and whether he thinks it is working well in the light of experience so far.
I turn to the question raised by the noble Lord, Lord Clement-Jones, and my noble friend Lord Hunt of Kings Heath. Both noble Lords are suspicious about the phrase "will have regard" to the points made by the commission. I am rather more sanguine about this because it seems to be precisely the role that the commission should play. Again, however, I would be interested to know the Minister's views about how that will apply and whether it is about achieving common standards and enabling common information from patients’ forums in relation to their work to be made available.
My final point comes back to the question of funding. When the Bill passed through the House it was quite clear that what was being proposed could be a better system than previously existed, but it would always have been naïve to assume that it could have been achieved on the same level of funding as CHCs or even on an enhanced level of funding. The messages I am getting from all around the country is that an attempt is being made to do this on the cheap. I will be interested to hear from the Minister, not so much about the costs of winding up and start up but about the real, expected resources that will be available for 1693 patients’ forums in the future and, again, my noble friend's judgment of whether they will be sufficient to enable the patients’ forums to do the job that the House and the public expect them to do.
§ 8.15 p.m.
§ Lord Warner
My Lords, I am grateful to the noble Earl for giving the House an opportunity to debate this issue. After listening to the speeches, I have a slight sense of being someone who has blundered into a reunion party without having paid his dues. I shall do my best to earn my entrance fee. I was quite touched by the suggestion of the noble Lord, Lord Clement-Jones, that I might have something of the night about me.
Before responding to the points raised by noble Lords, perhaps I may start by paying tribute to the staff and members of CHCs for all that they have contributed over the years to protect and promote the interests of patients. None has done so more than my noble friend Lord Harris, who made a typically robust contribution. He will not be surprised to hear that I shall not be able to answer all his detailed questions tonight, but where I do not pick up on points I shall reply to him. I was grateful for his statesmanlike approach in encouraging us to think about the future rather than dwell too much on the past.
I recognise that the noble Earl, Lord Howe, and the noble Lord, Lord Clement-Jones, have made great contributions in trying to improve the arrangements we have in place for patients. I am grateful that I have been found personally not guilty and for the fair-minded tone of many of the noble Earl's comments.
I accept that he and others have reservations about the process by which we have reached the present position. But we have a new structure in place which comprises 570 patient and public involvement forums—we can discuss later whether that is the right title—serviced by 68 local network providers. We are reliably assured by the strategic health authorities that patient advice liaison services now cover 98 per cent of NHS trusts and PCTs. There is a new regional independent complaints advocacy service offering support across the whole of England to those who wish to complain. It may well be that an easier road to reform could have been taken, but we are where we are and it is important that we look to the future as well as thinking about what went on in the past.
I have listened to the comments made about the commission. We should recognise that a huge effort has been made in the past 10 months by the Commission for Patient and Public Involvement in Health and others to put the new arrangements in place and that there are some good early signs as well as problems. We have to give these new arrangements a chance to flourish. Certainly having been a change manager in the public sector in a number of areas, I fully recognise that transition is never easy. In the transitions in which I have been involved, I have observed that there is a tendency to don rose-tinted glasses about the past and to be suspicious about the future. I am not making accusations, but there is a tendency somehow to see the past as a little better than it might have been.
1694 A number of noble Lords referred to the issue of money. I do not have detailed evidence of the cost of the transition. What I can say—I hope that noble Lords will find this reassuring—is that the money spent on patient and public involvement last year was around £23 million and we are expecting to spend a little more than £35 million this year. So a penny-pinching approach is not being adopted in this area. I acknowledge that that does not deal totally with the issue of whether in the past people would have spent the extra money in this particular way, but we are certainly not doing this on a wing and a prayer. We are certainly putting in resources to make it work effectively.
Noble Lords have raised a number of issues with which I shall attempt to deal. 1 would like to deal head-on with the idea and the setting up of local network providers. While acknowledging that this was not the Government's original idea, it is possible to see the commission as having been rather creative and innovative. It is also possible to see this as a genuine effort to work with and involve the voluntary and community sectors more effectively. Given my background, I have a lot of sympathy with that approach.
Our job in the department—I do not want to distance it from the commission—is to ensure that the commission carries out its functions within the scope of the legislation. The local network providers’ approach does this, even though it is probably not the approach people would have thought would emerge when this was being discussed at an earlier stage. It is different from the Government's original thought that the commission would employ staff locally, but we have to respect its independence. It has produced an alternative approach of achieving its main goal, and we have to give that a chance to work before we rush to criticise.
It is worth bearing in mind that in a 10-month period the commission has managed to get in place this series of networks by awarding 140 contracts by 1st September. That is a very considerable achievement. Network providers will undoubtedly work differently from the staff support arrangements that were provided to CHCs. But not all CHC arrangements were universally popular. There were some great success stories but there were some areas where things did not work quite as well, and we must bear that in mind.
Staff of the local network providers may support more than one forum. That does not mean that the forums will be in any way less supported than CHCs have been; the approach can encourage forums to work with other forums where they share a network adviser, something that people were concerned about in the debate. They can work to promote the sharing of ideas between forums. There will be local network providers which have an overview about groups of forums and the way in which they are working.
I detected, once or twice, a kind of enthusiasm for a traditional public sector committee structure, and a feeling that something was not quite right in these 1695 arrangements. It is fair to say that we do not necessarily want all patients’ forums to work like old-style committees, with a rather static secretariat support. We want them to be flexible; we want them to use modern technology to generate and sustain interest.
We have been rather programmed—rather institutionalised—when it comes to always having a chair, but we think that should be left to local forums. I am sure that the noble Lord, Lord Clement-Jones, does not like me even implying that he might be a bit fuddy-duddy about this, but we want to leave this to local decision-making. From time to time I am accused of being one of the great centralisers, but we are trying to devolve responsibility down to the local level. The local network providers can provide services by making more use of telephone and Internet services and disseminating good practice information. I mention these points to show that there is another approach and another point of view.
Let me turn to the specific points raised. On one-stop shops, local providers will provide support to PCT forums to carry out this role. There has been no change of heart; the commission is committed to one-stop shops. Rome was not built in a day, we have not got there yet, but there is no backtracking on that issue, as I understand it.
Why do patients forums have to have regard to commission directions? One criticism made of CHCs was that there was unevenness of standards across the country. That provides for the commission to ensure that standards are adhered to and there is greater consistency across the country—consistent with a fair degree of local devolution. One wants to be able to ensure that most parts of the country receive a consistently good and supportive service.
My noble friend Lord Hunt became very concerned about whether the commission has changed the name agreed by Parliament. One can argue that there is something rather respectable about patient and public involvement. The commission has used its own title in effect to brand that work. I am not versed in the background to the issue. I do not promise to change things, but I shall reconsider the matter so that I, at least, understand it. I shall return to the issue of how I might communicate with noble Lords after the debate.
The policy on patients forum members as NEDs has not been changed. We are agreeing a timescale and will amend membership later next year. The regional offices are trying to ensure that local network providers cover adequately the country as a whole, which raised some concern.
I share the views of the noble Baroness, Lady Masham, on vulnerable people. I cannot comment on the tragedy of epilepsy that she raised, although I can understand her concerns.
A question was raised about why there was no mention of prisons in the regulations. There is no need for that; from next April, healthcare in prisons will begin to be commissioned by primary care trusts and, as such, will be a service that can be monitored and 1696 reviewed by patients forums. There is no bar to entry. Arrangements will have to be agreed with the Prison Service on the way in which prisons are entered, but there is no intention to exclude prisons in any way.
The primary legislation does not give rights of entry to patients forums in respect of care provided in the private sector, but we recognise that, increasingly, care is provided outside NHS settings. We shall be issuing directions to primary care trusts requiring contracts that they have with the independent sector to cover arrangements for dealing with patients forums.
Some noble Lords expressed concern about whether PALS have adequate coverage. As I said earlier, we are assured that 98 per cent coverage of PALS is in place.
Much concern was expressed about whether the Independent Complaints Advocacy Service was answering the phone adequately and properly. Such services are often difficult in the early days. However, our understanding is that, although the service was very busy in the early days, things are working much better now. Demand has stabilised and the phones are being answered reasonably. However, I shall check again on that to reassure noble Lords.
I do not want to go over future ground. We shall come back to patients forums and foundation trusts in the debates on the Bill, and I have given a commitment to consider again some of the issues on those matters. The debate has been useful, and I am grateful to noble Lords for their contributions. I have not been able to respond to all the points that were made, but I shall write to noble Lords about many of the points I was unable to deal with in detail.
We have a new structure in place, and it is important that it should be allowed to work effectively to improve patient and public involvement in the NHS. I am sure that the commission will heed the concerns and criticisms voiced by noble Lords. Without in any way wishing to sound as if I were reverting to a traditional centralism, I shall ensure that the commission is aware of the concerns that have been expressed. I will want to seek some reassurances from it on some points that noble Lords have raised.
Given the work that the House has done in this sphere, I think it fair that noble Lords should know and be confident about how we are moving forward. However, I hope that we can avoid rushing to judgment on how well the new arrangements will work. The commission knows that it will be judged by results, and we have to give it time to demonstrate those results. I hope that we do not dwell too much on the past. I think that we can put that past behind us. We need to give these new arrangements a chance to show their worth and what they can do. With that reassurance, I hope that we can successfully move forward.
§ Earl Howe
If I may, in the two minutes available to me, I should like to thank the Minister very much for his constructive response. I thank all noble Lords who have taken part in this extremely useful debate. I agree with the Minister that it is the future that is important. I also agree that transition is not easy. I think, though, that he will have gained a sense from the contributions this 1697 evening that, without too much more effort, the transition could have been made a lot easier than it has turned out to be.
The commission is to be applauded in many ways, not least for taking what I acknowledge is an innovative approach to supporting the patients’ forums. The voluntary sector has a great deal to offer the patient and public involvement system, just as it has been an intrinsic part of the CHC system, although its role will now be more as a provider than an impartial contributor. Nevertheless, it is an imaginative idea.
The commission has, however, to be set up properly. I think that the noble Lord, Lord Hunt, was absolutely right. Those who support the forums must have local knowledge. While the noble Lord, Lord Clement-Jones, might be accused of being a fuddy-duddy, I had great sympathy with what he said about the committee structure. The fact is that having one person serving a number of patients’ forums is a recipe for muddled accountability and potentially for conflict of interests. I think that that has to be guarded against and, if I may respectfully suggest, at one remove to the commission. I hesitate to criticise the commission openly in the House when it has no means of answering back directly, but it does have to pay close attention to the decisions that Parliament took. The noble Lord, Lord Hunt, was right to highlight that, especially its own relationship with the forums once they begin. The forums are independent entities. They are not to be line managed, nor are they local branches of the commission.
I am sure that I speak for all of us here in wishing the patients’ forums well, and indeed the commission, as they go about their important task. I beg leave to withdraw the Motion.
Motion, by leave, withdrawn.