Local Government and Public Involvement in Health Bill

My Lords, Part 14 of the Bill deals with patient and public involvement in health and social care. In thanking the noble Baroness, Lady Morgan, for presenting the proposals foreshadowed last year in A Stronger Local Voice, I am sure we all wish the noble Baroness, Lady Andrews, a stronger ministerial voice in very short order. It seems like only the other day—in truth it really was only the other day—that we debated long and hard the Bill which created patients’ forums in place of community health councils and simultaneously set up the Commission for Patient and Public Involvement in Health. I venture to think that the Minister who took that Bill through this House, none other than the greatly respected noble Lord currently sitting opposite me, the noble Lord, Lord Hunt of Kings Heath, would have described its passing as hard fought for and hard won. It is therefore well nigh incredible that we should be debating yet another complete transmogrification of patient and public involvement in healthcare; not a set of evolutionary amendments to the present structure, but wholesale organisational change. I remember the noble Lord, Lord Hunt, telling your Lordships in 2002 at the conclusion of the Bill’s passage that this, "““is as good as it gets””.—[Official Report, 13/6/02; col. 419.]" It was only a few years ago that the noble Lord, Lord Warner, told us that patients’ forums would remain, "““the cornerstone of the arrangements we have put in place to create opportunities for patients and the public to influence health services. We are completely committed to those forums””.—[Official Report, 5/7/04; col. 516.]" Honestly, what are we meant to believe? Patients’ forums have been going for about four years and they are making their presence felt, in many cases quite effectively. The Government now want to abolish them. The obvious fear I have is that this will achieve the very thing Ministers say they do not want to happen, which is to make patients’ forum members feel so demoralised that they just want to give up in despair and go home. We saw exactly that when CHCs were abolished. Many of the people with real expertise and who had committed themselves for years to making patient and public involvement a living reality threw in the towel. The noble Lord, Lord Hunt, always assured us that the Government did not want this to happen, but it did so nevertheless, and it is going to happen again. If the Government really mean it when they say that they want to strengthen public involvement in healthcare through these new arrangements, the one thing they can do now is to convey to patients’ forum members that they are needed, wanted and valued both today and for the longer term. So far, frankly, I do not see much sign of this. No patients’ forum member sat on the expert panel that reported to Ministers last year. In the whole process leading up to the publication of this Bill, patients’ forum members have been sidelined and ignored. So if I were a member of a patients’ forum, it would stretch my credulity to be told that actually I had an important part to play in making the proposed new structures work effectively. What are the new structures? The Bill gives us no clue whatever. Local involvement networks are not described, or at least they are described only by reference to what they are not. We are told that the Government do not want to be prescriptive and that it will be up to each LINk to set itself up in the way it wants. In Greek legend, I think it was Proteus who was able to assume any shape or form that he liked. The reason why he did this was in order to avoid foretelling the future. For us debating this part of the Bill, it is almost impossible to foretell the future because neither the governance arrangements of LINks, nor their structures, nor their powers, nor even the precise scope of their activities, are set out here. In a real sense, as with Proteus, we do not know who or what we are dealing with. As I understand it—the Minister may correct me—because LINks are not defined they are not classifiable as statutory bodies. We may know a LINk when we see it—although I am not completely sure about that—by virtue of the things that it does. The Bill refers to activities being ““carried on””. In fact, in one way or another, there is quite a lot of carrying on in this part of the Bill. There may be a joke there somewhere but I shall refrain from trying to find it. But that nebulous form of drafting is as far as we get. It will be incumbent on us in Committee to try to flesh out some of this unsatisfactory vagueness. That brings me on to something fundamental: what we are meant to understand by the term ““patient and public involvement””. Involvement can amount to a little or a lot, but it cannot, surely, count for a great deal unless patients and the public are able to exercise some real influence on the commissioning or provision of local services. The main problem with the Bill is that because LINks have no identity or definition, they can be seen neither as bodies whose independence is guaranteed, nor as bodies which have the power to hold local health and social care commissions to account. Such powers and duties as there are in the Bill are vested mostly in providers and commissioners rather than with the LINks themselves. That, in my view, is a retrograde step. We need to remember what led to the Government reforming patient and public involvement in healthcare six or seven years ago. One of the 198 recommendations of the inquiry into children’s deaths at Bristol Royal Infirmary was this: "““The involvement of the public in the NHS must be embedded in its structures: the perspectives of patients and of the public must be heard and taken into account wherever decisions affecting the provision of healthcare are made””." The sad events at Bristol showed that accountability of the NHS to patients can be poor. There is surely no case for weakening that accountability. Accountability has to be, as the Bristol report stated, embedded in NHS structures, yet this Bill takes us away in diametrically the opposite direction from that aspiration. The way in which the Bill is worded does not give the impression that the Government are seriously committed to the NHS developing as a patient-centred service. To be a patient-centred service means a system in which patients and the public can participate nationally and locally in setting and reviewing standards and monitoring the way in which those standards are observed. I challenge the Minister to show me how the Bill gives LINks any real power, real leverage, to influence commissioning decisions. Instead, what we are being asked to approve is a weakening of the powers contained in Section 11 of the Health and Social Care Act 2001. Under that section, local communities have a right to be involved in and consulted on the planning and provision of services and proposals for change. Clause 232 of the Bill removes the word ““involved”” and keeps merely the word ““consulted””. Being consulted on plans that may already have been formulated is a very different thing from being involved from the outset in shaping and developing those plans. On proposals for change in health and social care services, Clause 232 would restrict the right of consultation to changes that are significant. What counts as significant is again far from clear, but we are looking at a dilution of influence on the part of the citizen. On the provision of services, we are told by Ministers that LINks members will be held at arm’s length from the most vulnerable service users of all, including children and those with learning disabilities—the very people whose interests need promoting and safeguarding. To monitor services properly, you need to talk to patients and staff and have the freedom to enter premises as of right. LINks will not be able to carry out unannounced spot visits. To say that that is the job of the regulator misses the point that neither the Healthcare Commission nor CSCI is able to visit any given set of premises on anything other than an infrequent basis. They are not resourced to do so. Inspectorates may be able to oversee governance arrangements perfectly adequately, but they cannot hope to monitor services. There is a big difference. When LINks have comments and recommendations to make, they should be able to make them to any appropriate body, not simply those listed in Clause 222. If they are not seen locally to have teeth and real influence, not only will they lose credibility but they will find it hard to drum up people to lead them. Part 14 of the Bill does not pass the key test that was set by both the Bristol inquiry and by Derek Wanless in 2001, who saw patient and public involvement in healthcare as essential for the delivery of what he termed the ““fully engaged scenario””. That scenario, let us remind ourselves, was viewed as essential to the long-term sustainability of the NHS. We see in the Bill the Department of Health divesting itself of responsibility for delivering patient and public involvement and health and social care, and indeed getting as far away from it as it possibly can. I shall not speculate on the real reasons for that; noble Lords can perhaps do so for themselves. Whatever the reasons, we should be sorry that this is a path that the Government have chosen to take.