Local Government and Public Involvement in Health Bill

I rise to speak to the clause stand part Motions in relation to Clauses 229, 230 and 231. In so doing, I ask the Minister to consider whether she is sufficiently well prepared at this stage to justify abolishing patients’ forums, their functions and their parent body, the Commission for Patient and Public Involvement in Health. I also wish to speak to Amendment No. 252A, which would ensure that if LINks are introduced, nothing will be done to abolish PPI forums or the commission until host organisations have been appointed in every local authority area. The purpose of Amendment No. 252A is to ensure that there is not a hiatus between the demise of PPI forums and the creation of LINks, if this is what happens. I hope the Minister will accept that principle. I want to focus on the clause stand part Motions. In so doing, I fully accept that patients’ forums have been restricted to monitoring health service providers; they have not had a remit for commissioning bodies, as others have mentioned, social care providers or institutions in the criminal justice system, which provide a form of service for many of the most disadvantaged people. There is therefore a need to fill the gaps in the system. I am just not yet convinced that LINks are the best way to do that, and I am not sure how anyone else can be convinced with the present state of knowledge. My main concern is that the world has moved on while the preparatory work has been undertaken for the introduction of LINks. The Government in their paper on local government networks, creating a stronger voice in health and social care, claim that LINks differ from previous systems as they are based on broad networks rather than small specialist groups involving representatives from organisations as well as individuals. Indeed, the Minister indicated that LINks are some incredibly new and unique form of organisation, but I have to say that that statement is not really correct. The model already in place in foundation trusts is similarly based on broad networks and involves representatives from organisations as well as individuals. Indeed, the whole idea of these boards of governors and the membership is that they should cover every conceivable small group, BME community group and so on. The Government envisage that all health provider trusts will be foundation trusts by 2008 and that all foundation trusts will have boards of governors, sometimes called members councils, comprising patients, service users, carers, members of the public, representatives of voluntary organisations and, as I have mentioned, BME communities and so forth. The majority of board members are elected by the thousands of public and staff members who have been signed up to each foundation trust. The regulatory authority expects each foundation trust to have between 5,000 and 8,000 members. That is roughly what has been said in relation to LINks; that they should have thousands of members and all the little groups and voluntary organisations. My understanding is that primary care trusts will also become foundation trusts, with boards of governors and a broad membership, so we are all going to be hunting in the same pool, the same borough, if you like, for these thousands of members and for every conceivable group to sign up. These clauses in the Bill provide for the abolition of patients’ forums to make way for the proposed LINks. My suggestion is that in the health sector it may be more sensible to retain patients’ forums at this stage while the LINks pilots, to which I have already referred, are undertaken, while they are evaluated and while the boards of governors are evaluated. They have never been evaluated, so perhaps they are not the right way forward—I am simply saying that we do not know. The question concerning me is whether the introduction of LINks to the health service, as I referred to in relation to the previous debate, will duplicate the structure as well as the work of boards of governors. The House of Commons Health Committee report 2006-07 rightly pointed out that the foundation trust system is still in its infancy. I would be the first to say that foundation trust boards of governors will take several years to find their feet, to operate really effectively in representing the interests of patients, service users and carers and to ensure that services respond to those interests and needs. A Peer I was talking to over dinner said that similar organisations that he is aware of have taken 10 years to settle down and be really effective. This is the sort of issue that all of us need to be aware of; these things do not just happen overnight. My point here is that these PPI boards need to be evaluated before anything further is done. Indeed, the Government’s regulator, Monitor, warned of the same problem of duplication. The situation may not be helped if there are two sets of bodies struggling to find their feet. On the face of it there are possible advantages in either of these two systems. Maybe LINks will be better than boards of governors. Certainly on paper they appear to be more independent. But as I understand these two sets of systems, the boards of governors look to me to be very much stronger and more effective potentially for patients, service users, carers and everybody else. The crucial element here is that LINks do not appear to have any powers; what they have is activities. I will just go through some of the powers and responsibilities of these boards of governors—they are quite interesting. These boards, comprising more than 50 per cent of users and carers, elected quite interesting bodies. The boards of governors must be consulted on forward planning by the board of directors and the board of directors must have regard to their views. They have to explain if they do not put those views into effect. The board of governors must approve the appointment of the chief executive of the trust. The process of this incredibly important appointment must be made under the scrutiny of these boards of governors. The board of governors hires and fires the chairman of these trusts. Will a trust chairman allow the board of directors to disregard the governors in any respect? I do not think so. This is a masterstroke by the Government. It will ensure that every health trust board, whether a commissioner or provider, will in future take full account of their patient service user, carer and public representatives. The board of governors, we are told, will represent the interests of the trust’s thousands of members and partner organisations in the governance of the trust. The board of governors will hold the board of directors to account for the performance of the trust; that is, the quality of services delivered to patients and service users. The role of LINks appears rather weak by comparison. We are told that they will have a role in promoting and supporting the involvement of people in the commissioning, provision and scrutiny of services. They will be obtaining the views of people about their need for, and experiences of, services. There is no indication that those views will be taken seriously, although the Minister made a useful contribution on that issue. They will be enabling people to monitor and review the commissioning and provision of services. As I have said before, there is a terrible fear of duplication here. They will make their views known to the people responsible for commissioning, providing, managing and scrutinising those services. But they will be at arm’s length. The boards of governors are going to be right there; these trusts cannot ignore them. They are independent and they are right there, with these powers and they can report direct to the regulator if they are not happy with the way the trust board treats them. The foundation trust boards of governors will regard all the roles of the LINks as essential to the exercise of their powers. The roles under the two systems may look different on paper because the boards of governors have defined powers whereas LINks will have defined activities, but in reality the LINks may simply turn out to be a less powerful form of boards of governors. Certainly the questions relevant to LINks set out on page 18 of the Government’s consultation document are precisely the questions that boards of governors will be addressing. But my main point in speaking to these clause stand part motions is that none of us is yet in a position to know whether LINks will have any real value for the health service over and above what we have in the boards of governors. I shall mention briefly two further issues. In abolishing the Commission for Patient and Public Involvement in Health, the Government apparently have no plans to create a national body in its place to support the work of the LINks. Noble Lords have already had a bit of a discussion about that, but in my view a national body is essential, and it is of no little interest that the boards of governors have not had a national body. So the Foundation Trust Network, the national body supporting foundation trusts, is now going through the process of setting up a national body to support the boards of governors. If there is going to be a national body for the LINks, we shall then have two national bodies for patient, service user, carer and public user bodies apparently duplicating each other’s work. Again, and most important, I repeat that the crucial point is that we need pilots and evaluation. I am sure that we all agree that patient and public involvement is central to achieving the high quality services we want, but none should underestimate the difficulties of organising this work, particularly in the mental health field. In my experience, PPI forums have struggled desperately to operate effectively. Rushing into the establishment of LINks, albeit after a lot of discussion and consultation, is a very high-risk strategy. I hope that the noble Baroness will give consideration to the points I have raised.