Health and Social Care Bill

My Lords, I apologise to my noble friend Lord Patel if he in any sense felt beaten up by me. I absolve my noble friend Lady Wheeler from any involvement in that process. I also apologise to the long-suffering officials in the Government Whips Office. If my robust style is mistaken, they should really see what I am like when I am angry. I added my name to a number of amendments in the various versions of this group. I also proposed Amendment 305. If the noble Baroness whom I believe is replying to this debate is planning to highlight any technical flaws in that amendment, I should point out that I drafted it myself. Therefore, it no doubt does contain a number of technical flaws. But the purpose of the amendment is to assess the feeling within the House and the strength of feeling in the department about the extent to which it is important that HealthWatch England and healthwatch organisations at local level should be independent. The principle underlying this group of amendments is straightforward—the centrality of the voices of patients and users in the NHS. That voice must be, and must be seen to be, independent of the various provider and regulatory interests. That is what underpins all of the different amendments. I find it difficult to understand how the Government will oppose the amendments. They keep telling us that the voice of the patient and the user will be central to all these arrangements. They say that that is their intention. But they must be aware, because everybody else is, of the cynicism and doubt that is being expressed around the country about this whole package of NHS changes. Therefore, they should be able to reassure patients and users that their voices will be heard at every level within this complicated restructuring that will take place. That is extremely important. What is more, it will be important for that voice to be seen to be independent. Members of the public will be concerned about what is happening. They will worry whether their doctors, who that they do not fully understand as being part of commissioning groups, will somehow be making judgments about their care, influenced by financial interests. They will want to be assured that they can go somewhere for proper advice and support, and that that place will genuinely be independent of all of those interests. A huge expectation is now being placed on local healthwatch organisations. They are expected to provide that independent advice and information, to be able to monitor the nature of the service at local level and to be able to comment on the various changes that are taking place and on the proposals that are coming from the plethora of commissioning groups, senates and goodness knows what else we are going to have. They are going to be there to make recommendations. So, there will be enormous expectations on behalf of the public as to what these groups are going to do. Similarly, the national body, HealthWatch England, will have enormous expectations upon it. That is why it is so important to get these arrangements right. The proposals for HealthWatch England and local healthwatch are an advance on what we have at present in terms of LINks. There is no question about that—they are a step forward. The record of successive Ministers and Governments in terms of patient representation in the NHS is not very good. This is a step forward from where we are at the moment. So, let us try to get it right. Why not deal with what are comparatively small issues in terms of how the system works? The trouble is that, at the moment, the arrangements that the Government are proposing are flawed in two key respects: first, on the issue of independence, as the noble Lord, Lord Patel, has already indicated; and secondly, in terms of the resources available. Let us consider for a moment the position of HealthWatch England as a sub-committee of the Care Quality Commission. That might be a very neat way of not increasing the number of quangos by one; it may be that was the sole motivating feature. However, the reality is that it dangerously compromises the independence that I talked about as being so important. Often, HealthWatch England will have to say, on behalf of local healthwatch organisations, that the regulator should be doing something, has failed to do something or has been inadequate in the way that it has done that. In the last few weeks, we have seen the Minister’s colleagues in the Department of Health making quite critical comments about the way in which the CQC has fulfilled its remit. If Ministers are saying that—and Ministers are, after all, the paymasters of the CQC—what is it going to be like for those people whose remit is to raise these issues but are themselves subordinate to that regulatory body? It is going to be a real conflict and a very difficult position for them. The nature of that relationship—the fact that they are a mere sub-committee and are subjected to all of the panoply of arrangements that go with that—is going to be seriously limiting. I am aware that the CQC is making enormous efforts to try and demonstrate their good faith in all of this. I am sure that the individuals involved have good faith as far as this is concerned. However, we are here considering legislation that will set those arrangements. Once those arrangements are set, the good will of the individuals who may be trying to make it work at the moment may not persist—not because those individuals will change their minds, but because, over time, those individuals will move on and others will take their place. Budgetary and other pressures on the CQC will rise. The feeling that they do not like being criticised by a body that is technically subordinate to them will increase. That is why that arrangement does not work. There is an even stronger argument as to why local healthwatch organisations should not be subordinate to principal local authorities in their area. The Government’s flaws here are flaws twice over. Not only are they imperilling the independence of local healthwatch organisations by saying that—even though they are supposed to be independent—they are creatures of the local authority, the funds will be provided by the local authority and many of the facilities may well be provided by local authority but, because the funds will not be ring-fenced, it will be far too easy for local authorities to start to apply the screws if they do not like the criticisms that come from it. A major conflict of interest is being created. HealthWatch cannot be accountable to, and at the same time funded by, local authorities because the bodies which commission and provide the services are the local authorities in many instances. However, the Government are saying that HealthWatch can advise members of the public about those services. How can HealthWatch organisations be funded by the same bodies that are commissioning and providing those services? This is precisely the area where the confidence of members of the public and of individual patients is so important. They have to go for advice to a body which is funded by the people about whom they wish to take advice. That hardly looks independent or satisfactory. If HealthWatch is made accountable to local authorities as the Bill proposes, the public will, frankly, have no confidence in that and all the efforts that the Department of Health and the Government have made to try to create a better structure will be wasted. That resource will be wasted because the public will not have confidence in these arrangements. There is also a failure to protect the funding. I do not know how many hot coals Ministers in the Department of Health had to crawl over to get £60 million out of the Treasury for HealthWatch. I am not suggesting that the Department for Communities and Local Government is any more evil than any other government department, but if you hand the funding to that department, which then hands it on to individual local authorities without a label saying, ““Not only is this money to be used for HealthWatch but it cannot be used for anything else””, my experience as a former council leader tells me that you cannot guarantee that the money will be used for the purpose that you wish. I spoke earlier about localism and said how wonderful it was that the Government should devolve responsibility for this issue. However, it is not a wonderful example of localism if you expect something to happen, you pass the money on and then you are shocked if the money is not used for that purpose. If you want the money to be used for a particular purpose, you have to label it and ring-fence it. However, the Government will not do that. They say that they cannot do that as it would be inappropriate in the spirit of localism. I have received numerous e-mails and messages from LINks on this very subject. Their experience of not having ring-fenced budgets this year is salutary. One message states: "““As a LINk our funding was reduced by the local authority by 65 per cent this year””." Another states: "““I have spent 30 years as a senior business professional and business consultant and it is ludicrous to set an organisation targets to be funded by set criteria and then reduce those funds by 65 per cent. This makes a mockery of the organisation’s ability to carry out its public remit””." That is what is happening at the moment. What guarantees can the Government give that it will not happen in the future? There is a technical point here. The Department of Health has presumably secured these funds through the comprehensive spending review. Who will own those funds the next time that the comprehensive spending review is negotiated? Will it be the Department of Health or the Department for Communities and Local Government? If it is the Department for Communities and Local Government, how will it rank given its other priorities which have nothing to do with HealthWatch? If it is the Department of Health, how will it answer the question from the Treasury, ““How do you know that this money is being spent in the way that you intend?””. It will not be able to answer that question, as I suspect that the correct answer is that the money will disappear. LINks already have huge concerns about the resources question. The other element of this concerns what sort of patient representative mechanism we want. Do we want something which is top-down or something which comes from local organisations? The amendment that stands in my name seeks to establish an arrangement whereby local healthwatch organisations have ownership of the national body which speaks in their name. I believe that that is essential. Even if you created HealthWatch England as an independent structure without the problems of it being a tool of the regulator, you will still not get the necessary buy-in at local level unless local organisations feel that they are part of it and have a say in its organisation. I speak as someone who was director of the Association of Community Health Councils for England and Wales for 12 years, and I know how important it was for the member organisations to feel that what we were saying as the national body reflected—not to the letter, but reflected—what they felt was important as local organisations. If you do not have that mechanism, if you do not have that process built into the legislation, I am afraid that you will create a gulf between the national body and the local bodies. That is surely unsatisfactory. The Government’s proposals could make an enormous difference to patient representation in the new NHS, and patient representation is going to be enormously important in the new structure, because I think that many patients will feel disempowered and worried by what is happening. However, those arrangements are flawed unless the Government accept the spirit of the amendments in this group—and unless they accept that HealthWatch, both nationally and locally, should be independent, and that resources should be clearly ring-fenced and clearly identified and cannot be used by bodies that have no interest, necessarily, in patient representation used for other purposes.