Local Government and Public Involvement in Health Bill

My Lords, I wind up for these Benches in this debate because of the unavoidable absence of my noble friend Lady Scott of Needham Market who cannot be with us because of a family bereavement. Therefore, I will concentrate as I would have done in other circumstances on the patient and public involvement section, as I am no expert on local government. Before I do that, I should like to welcome the maiden speeches and congratulate those who made them, particularly the noble Baroness, Lady Campbell of Surbiton. She made a wonderful speech, but also I think that the whole House would like to pay tribute to her for all her wonderful work throughout her career. The noble Lord, Lord Mawson, is an old friend, colleague and sparring partner from my days at the King’s Fund. He made a terrific and wonderful speech, which I am sure we will all take on board. I am sure that I also speak on behalf of the whole House in wishing the noble Baroness, Lady Andrews, well. I thought that when we acted as a whole House in a cross-party manner and tried to persuade someone to go home, they might take some notice, but she has not. I still wish that she would, but I imagine we do not have long to go. Before I move on to the patient and public involvement part of the Bill, I should like to echo the sentiments expressed by the noble Lord, Lord Dubs, about the role that voluntary organisations should be playing in local area agreements. As someone who has worked all my professional life in the voluntary sector—other than when I have chaired organisations in the statutory sector—unless it is taken seriously, it will not really work. It puts the voluntary sector, which plays such a major part in our society, at a considerable disadvantage. I hope that the Minister will be able to say something about that. I come now to the question of patient and public involvement in health. Like the noble Lord, Lord Low of Dalston, we on these Benches have considerable reservations about the Government’s proposals. Noble Lords will have received many letters on the issue. The Government propose to abolish the Commission for Patient and Public Involvement in Health and the patients’ forums that now exist around the country and replace the system, itself only just four years old, with a new one—that of LINks, or local involvement networks. They are to be fairly loose networks of a variety of people who have an interest, but whose budgets will go to the relevant local authority which in its turn will give the money to a host organisation to manage on its behalf, so that the LINks themselves will have few powers and duties of their own. I am sure that the Minister will tell noble Lords that this is at least in part to save LINks the huge administrative burden of employing and managing relatively few staff. While I understand the point, I do not believe it is possible, from my experience in both the statutory and voluntary sectors, for an organisation to be able to function seriously and effectively if it does not have the capacity to choose who it hires and, occasionally, who it fires. The idea of the local authority choosing the host organisation, and LINks having little power to reject that choice, does not appeal. I have read the draft policy statement kindly provided by the Minister describing the LINks powers to be established in regulations, and I am grateful to him. But although it gives us some detail about the right to enter and inspect premises—or otherwise, the ones that cannot be visited—it fails to clarify: the very nature of the LINks, which is their statutory standing, as the noble Earl, Lord Howe, said; their ability to hold local health and social commissioning to account; and their ability to make decisions about their future, including the host organisation. I would be grateful to the Minister if he could respond to the very considerable concerns felt by large numbers of people, members of present patients’ forums and others, who have been in touch with many of us around this House. I am also grateful to Malcolm Alexander of the National Association of Patient and Public Forum Involvement Organisation for all his advice. I thank also the Royal College of Nursing, Elizabeth Manero of Health Link and others who have written. But there is more. One role that patients’ forums have carried out, and CHCs before them—as the Minister will know all too well from the days when he and I first met and he was a CHC secretary—is spot checks and general inspections of NHS premises. The NHS organisations concerned—I speak as a former chair of Camden and Islington Community Health Services NHS Trust—have not always liked or appreciated those visits. Yet for local people they have played a key role, and if a patient and user-centred service is really what we want to achieve, some rights of inspection are needed if those patients are to feel that they are being taken seriously. For the most vulnerable, this is absolutely essential, as was made very clear by several noble Lords, including the noble Earl, Lord Howe, and the noble Lord, Lord Walton. The 2006 White Paper, Our Health, Our Care, Our Say, states: "““The challenge to commissioners is how to make greater local voice, choice and control a reality””." It continues, "““systematically and rigorously finding out what people want and need from their services is a fundamental duty of commissioners … organisations commissioning NHS-funded care must ensure local people play a full part in the planning, design and delivery of their services””." I argue that local people cannot play that role with commissioners in partnership if the right to visit and inspect is all but removed. I know that the Minister will say that authorised people from LINks, provided they have checked with the Healthcare Commission or the Commission for Social Care Inspection, or whatever merged body succeeds them, will be able to visit despite the burden that that places on organisations. We all recognise the problem of over-inspection and over-visiting, as the noble Lord, Lord Walton, has mentioned, but if the Government were serious, they would go further and say that a member of a patients’ forum now or a LINk in the future should be included in every inspection team that visits from the Healthcare Commission or CSCI—and I do not believe that the Healthcare Commission would be totally opposed to that. It would add to the teeth of the local forums or LINks, but their ability to visit for spot checks should not be so summarily dismissed or hampered, as the present proposals suggest; that their capacity to really listen, feel and engage with services is seriously limited. That is all the more serious because of the report from the Picker Institute, which came out today. It shows that the majority of PCTs are themselves not ready to meet the new challenge of integrating patient and public involvement into all aspects of their commissioning strategies. Few trusts have finalised plans for the new elements of patient and public involvement they are expected to use, and that includes LINks, patient-initiated petitions and the patient prospectus; nor have they integrated patient and public involvement into commissioning at high management or budgetary levels; they have not built in experience of deliberative processes with the public, as opposed to taking snapshots of opinion; and they have not used patient and public involvement in parts of commissioning other than service redesign, such as assessing needs, determining priorities and evaluating services. Moreover, the Picker survey shows that the majority of PCTs have low expectations of the outcomes of patient and public involvement. They do not expect patients’ forums, voluntary organisations and patient groups to be ““highly influential”” in commissioning decisions, and they expect the new patient and public involvement mechanisms to affect the process of making commissioning decisions more than their substance. The survey identifies various challenges faced by the PCTs, including reaching seldom-heard groups, getting reliable data on patient experiences, and the public’s lack of knowledge of what commissioning means. PCTs also often cite the lack of support from senior executives and the lack of conviction of senior clinicians as among the greatest barriers. The noble Baroness, Lady Meacher, was right to say that patient and public involvement in commissioning is essential, and she is also right to point out that some of the roles in this new legislation appear to overlap considerably with those of the governors of foundation trusts. We really have to sort it out if, as the Picker Institute has pointed out today, the trusts do not quite understand what the role is. As if that is not enough to suggest that we should be cautious about limiting the powers of patients’ forums or LINks, as many noble Lords know, there was a major King’s Fund and Age Concern event last Saturday—here I declare an interest as a former chief executive. I was not there, but I know people who were. The Chancellor and Prime Minister-elect attended to listen to the views of the public and healthcare professionals on the key issues facing the NHS. At the end, the Chancellor said: "““You cannot have a Government that just tries to pull levers. You have to talk to people and take their views into account. We need a better way to listen to people and act on what they say. If we don’t listen, we’ll get things wrong. Bringing patients and NHS employees together is the way forward””." The future Prime Minister is right. Bringing patients, the public and staff together is an important way forward. Thus far, the Government’s proposals do not achieve that. Instead, they have upset the very people they need to encourage as the core of any new system. We are not saying from these Benches that patient and public involvement could not be done better. The noble Baroness, Lady Campbell of Surbiton, in her maiden speech made a strong play for how many things could be done better. We believe that there are excellent arguments for bringing health and social care public involvement closer together. Like the right reverend Prelate the Bishop of Peterborough, we believe in evolution rather than revolution and, like the future Prime Minister, we believe that it could get better. We would like to see far greater democracy within local health services to help it do so. However, we are where we are, and that is rather unsatisfactory. LINks have unclear powers, no control over their funds, limited access and an insufficient role in enabling people to take responsibility, as the noble Lord, Lord Mawson, made clear. They will also have a poor capacity to hold services to account. Accountability is a key question, as many noble Lords around the Chamber pointed out. The UK scores badly both in its patient and public involvement, as the Bristol inquiry made all too clear. The noble Earl, Lord Howe, mentioned that. But the issue of patient involvement often slips to the bottom of the heap despite the clear evidence that Angela Coulter from the Picker Institute gave to the Health Select Committee inquiry, which shows that engaging patients in treatment decisions and in managing their own health improves the appropriateness of care, improves health outcomes, reduces risk factors and prevents ill health; it leads to more cost-effective outcomes, moderates demand, improves safety and reduces complaints and litigation. Patient involvement changes behaviour in the whole health community, but behaviours in the wider agenda of patient and public involvement need to change in order to allow it to take place properly. Patient involvement will not be the norm until the whole system faces outwards to patients more successfully. LINks as presently proposed do not appear to have the powers to enable them to do that. There is one further issue I wish to address before moving to some questions for the Minister. In Clause 232(1B) the word ““significant”” has been added to the Bill, reducing substantially the opportunities for individuals and communities to influence service provision and the commissioning of services. As other noble Lords have said, who is going to define ““significant”” and to what extent do the Government believe that this will even further limit the ability of communities to influence the commissioning of services, given that LINks are not to have any power to do so? I am left uncomfortable with the lack of clarity, the lack of powers, the lack of ownership of their own destiny and the lack of a sense of serious commitment to patient and public involvement. I regret that the forums have not had longer to carry out their work and I am highly dubious about the pace of this change. I feel that all the more strongly after conversations with many forum members, including Robin Tuck, chair of Kensington and Chelsea patients’ forum, the only ““early adopter”” in London. He made several important points in his conversation with me. His key concerns, as they are of many others, are about who holds the money. You cannot have LINks being asked to be in touch with patients and the public to find out their views without doing research, but it is the host, not the LINk, which has to commission the work because it holds the purse strings. He also cites, as does everyone else, the issue of entry to NHS premises and suggests that LINks must be able to suggest remedies where things go wrong as well, for local voices often do know about local situations and local solutions. But, above and beyond all this, he and others all raised the question of the pace; evolution, not revolution, as the right reverend Prelate has said. What is the hurry here? The early adopters are not ready; the system is clearly not ready; the future Prime Minister is suggesting that we need to think hard about how we have these conversations; and the Health Select Committee has major concerns. Few are suggesting that patient and public involvement could not be improved. The patient forums could get together on an area basis informally; they could work differently. The present forums are full of volunteers—people who give their time, energy and commitment. They feel upset, angry and betrayed. The Government want to encourage volunteering. I chair the commission on the future of volunteering in England and I welcome the Government’s commitment to volunteers and volunteering, but you do not encourage volunteers by riding roughshod over their concerns, and there are simply too many people writing and speaking out for this to be a fringe interest. Some of those people, as the noble Baroness, Lady Cumberlege, said, came originally from the community health councils, which were abolished, and they volunteered for the patient forums, which are now to be abolished. Forums were not included in the Government’s review of patient and public involvement—a mistake, in my view— although the members of that expert panel were very good. Some of them were my former colleagues from the King’s Fund. But the members of patient forums rightly feel disaffected and unthanked. We on these Benches will want to see significant changes to the proposals and significant delays in the change to the new system if we—the present forum members and many others—are to have confidence in the new system. Transitional arrangements are barely there, as many noble Lords have said, and the need for training and support is simply unrecognised. Unless we see considerable changes as well as clear powers and accountability structures for LINks on the face of the Bill, we will have considerable difficulty in supporting this section of it. My noble friend Lady Hamwee very charmingly said at the beginning of her remarks that I was neither old nor grumpy. On this Bill, without clarification and changes, I might well become quite grumpy and probably quite old in the process.