Health and Social Care Bill

Debate between Baroness Cumberlege and Lord Whitty

Thursday 8th March 2012 Lords Chamber

[Baroness Cumberlege]

My Lords, I have several amendments in this group and the next one. There are synergies between the two groups, so I shall speak briefly introducing both groups and go on to those in this group.

I have tried hard throughout our debates to ensure that we have a more robust accountability framework. As I see it, the framework is in three parts. First, there is the local authority. Secondly, there is HealthWatch England. Thirdly, there is the local community. I will not go into the independence of HealthWatch England, because I debated it very fully in Committee, but I understand the passion that has been expressed on that issue. For me, those three elements balance each other, and it is important that they do, because that will improve transparency.

To give an example, if HealthWatch England makes recommendations to local authorities on how they commission local healthwatch, local healthwatch and the community can hold the local authority to account for how it commissions. That gives it a yardstick by a third party, HealthWatch England, against which to measure the local authority commissioning arrangements. The policy document produced by the Government on Friday, Local Healthwatch—The Policy Explained, states that the Government are considering how the constitution and governance of local healthwatch needs to ensure that it operates for the benefit of and is accountable principally to its local community.

The third element is local people. They are critical to the accountability framework. As the noble Baroness, Lady Masham, said, in many eyes, they are the most important.

The government amendments, including those laid on Friday, go some way to addressing that, but they also introduce fresh concerns, which I shall refer to later. The loss of statutory structure is a great threat to independence. The value for money and rationale still have to be adequately explained, but I am sure that my noble friends on the Front Bench will do that shortly.

My noble friend Lady Jolly and I tabled Amendment 224, which improves accountability nationally by linking the perspectives of HealthWatch England more closely to the grassroots by electing the members of local healthwatch to the HealthWatch England statutory committee. The noble Lord, Lord Harris, gave that a warmish welcome, although I say to him that that is not a sub-committee, it is a committee. It is not subservient to a committee, it is a committee.

The Government have sought broader opinion with their public consultation on that and other topics which closed on Friday. That elected membership would serve two functions: first, as a counterweight to the influence of the Care Quality Commission, making HealthWatch England more independent; and, secondly, as an agent for the accountability of HealthWatch England, keeping it in touch with the patient and user reality. If local healthwatch does not think that HealthWatch England is really speaking out for people, it can say so through its elected representatives. They would be elected against a skill specification to ensure that they were the right people to fulfil that important role. Without that, HealthWatch England is a free-floating organisation with no local connection, a mere national harvester of local data. I hope that the Minister can reassure me again that that accountability gap will be dealt with.

Government Amendment 226 is very much welcomed. I strongly support it, because it responds to my amendment in Committee. It provides for the majority of the members of HealthWatch England to be made up of non-CQC members, making it independent of the CQC, which therefore cannot dominate HealthWatch England. My Amendment 226A stitches the accountability framework together transparently, by providing for local healthwatch to have regard to the standards set by HealthWatch England. I hope that my noble friend can give me some assurances as to how that last element can be covered.

The introduction of the HealthWatch trademark under government Amendment 235C is a very interesting device and may well help. Amendment 228 was also tabled by my noble friend Lady Jolly and me. It enhances independence and transparency nationally by providing for the Secretary of State to issue conflicts guidance to which both the CQC and HealthWatch England must have regard. I hope that the Minister finds that sensible. Amendment 229 is another government amendment which I support. It includes a risk management strategy, so that what may have gone wrong in one place may stimulate vigilance in another. I strongly support that.

I am sure that my noble friend will wish to speak to her amendments, but I have introduced mine and hope that some of them find some favour with those on the Front Bench.

[Lord Whitty]

My Lords, I want to add a couple of brief points to the already powerful case made by the noble Lord, Lord Patel, and my noble friend Lord Harris. I do so from some experience of the consumer interest in other markets. First, I resort to what the clause says is the purpose of the HealthWatch England committee. It states that it is,

“to provide the commission or other persons with advice, information or other assistance”—

not to challenge, not to represent the user interest, not to deal with issues of general complaint but to provide assistance to the body of which it is a committee. That is not a sufficiently powerful role to fulfil the requirements for independence.

This has been tried in other sectors. Until 2006, when I brought legislation through this House, there was a panel to represent consumers within Ofwat. Since that has been removed, and in contrast to the first 20 years of the privatised water industry, the Consumer Council for Water has represented the consumer interest effectively in terms of price review and influence on the individual water companies, region by region. That has been an improvement.

There are two other examples where regulations have required panels within existing regulators. One is in communications, where Ofcom had a consumer panel. Frankly, that has withered on the vine because Ofcom has not supported it or given it adequate resources. The other is in financial services, where the Financial Services Consumer Panel has done some sterling work, but no one could claim that the interests of consumers has been fully protected through the past five years of financial service provision. Noble Lords may remember that when our colleague, the noble Lord, Lord Lipsey, was briefly chair of that panel and attempted to extend the interests of consumers more independently from the regulator, he found it necessary to resign. That is not a good model for independence either. Although that panel does good work, it has to follow the rhythm and priorities of the regulator, not the priorities, concerns and interests of consumers. If you are part of an organisation, a committee or sub-committee of an organisation, that inevitably follows.

The other point that I wish to raise concerns powers, my views on which are set out in subsections (7) to (12) of the proposed new clause. Unless the consumer organisation has separate powers from those of the regulator to require information and advice, then, again, it cannot be truly independent. The powers are very similar to those of the other independent, statutorily based consumer organisations, and it will require information from the regulators, the commissioners and the providers within the complex new structure of the health service that we are setting up here.

On both those counts, there is no experience elsewhere of consumers’ interests having been effectively represented by a committee, a panel or a sub-committee within one of the three overlapping regulators, all of which impact on the users of the health service under the Bill.

Unless the Government rethink this, they will be doing a great disservice to all the hundreds and thousands of people out there who depend on care services and on the National Health Service. The reality is that all the Minister needs to do is to tell us today that he is going to reject the idea of a committee and genuinely come forward with a proposition that gives independence to consumer representation within the new structure. If we get anything short of that, I think we will have let down the users of the National Health Service.

Health and Social Care Bill

Debate between Baroness Cumberlege and Lord Whitty

Thursday 15th December 2011 Lords Chamber

[Baroness Cumberlege]

My Lords, perhaps the noble Lord, Lord Whitty, ought to speak next, because I suspect that his amendments relate to what the noble Lord, Lord Low, was saying, and it may be that the synergy would be better that way.

[Lord Whitty]

My Lords, I thank the noble Baroness very much. In this case, logic trumps chivalry.

I have four amendments in this group, all of which relate to the independence of the local healthwatch—some of them in some slightly indirect ways. We spent some time at an earlier stage, and again today, talking about the independence of Healthwatch England from the regulator. I did not intervene today, but it is evident that the Government are not persuaded that we need to unravel them. I am afraid we are going to have to return to that at a later stage, because I am certainly not convinced by the Government’s arguments. However, I think that even the Government must recognise that a body representing patients, users and consumers of health and social care services has to be independent from the provider.

The problem with some of these clauses is that the local healthwatch organisation, as the noble Lord, Lord Low, has said, is not clearly independent from the local authority in all respects. We are not yet clear how independent of the local authority it will be in its membership and how that membership is appointed. Schedule 15, which comes in with Clause 179, is pretty general as to who the members would be. As the noble Lord, Lord Low, said, we have to await regulations before we see that. Meanwhile, there are other reasons why one is a bit suspicious that the local healthwatch organisations would come too much under the sway of the local authority, which is going to be the provider of many of the services to which they relate.

There may be other ways of doing this, but these amendments are attempting to make clear the independence of the local healthwatch body by establishing that it sets its own priorities and manner of operating, subject only to any guidance given by Healthwatch England; that is, it would not be subject to any guidance, restriction or direction from the local authority. There are then a number of clauses which are pretty complicated in themselves, but appear to treat the local healthwatch as if it were an excrescence of the local authority.

For example, I want to delete the bulk, or the purport, of Clause 181, which appears to treat local healthwatch organisations as if they came through the local authority rather than being independent bodies. Some of the requirements may well apply to healthwatch locally, but they should not be implemented and enforced via the local authority in any sense. The noble Lord, Lord Low, has already referred to some of the problems about freedom of information, but some of the other provisions could well raise difficulties if the local authority was the one ensuring that the local healthwatch met those provisions.

Independence of consumer organisations across the economy is important, and I will return to that on Report. Local bodies, in particular, need to be independent. They are the bodies to which individual patients and users will relate, and if they believe that the local healthwatch is in any way associated with, dominated by, or accountable to the actual providers of the bodies that provide the services, its credibility will be diminished. I would therefore hope that the Government took note of these concerns and made it more explicit in the final version of this Bill that local healthwatch organisations were independent of the local authority and made their own decisions, with their own priorities and manner of operation. I do not think that we can leave all that to regulation; it has to be more explicit in the Bill. This is one way of doing it, although the Government may well come up with better ways of doing it, but I think that we need to ensure that we reach that stage before we finish with this Bill.

[Baroness Cumberlege]

My Lords, I have a number of amendments in this grouping concerning local healthwatch. As has already been said this afternoon, local healthwatch is the source of intelligence from the people who are actually using the services. This intelligence is gathered through their enter and view monitoring visits to both health and social care services—we should not forget that it is social care as well—and through their local involvement work.

However, neither commissioners nor overview and scrutiny committees have the same binding arrangements to enter and view health and social care facilities. Local healthwatch has the opportunity to interview people at the time they are actually using the service. The local healthwatch has the independent messenger status with local people that neither commissioners nor overview and scrutiny committees have. Local healthwatch has the right to enter and view, to talk and listen, to the most vulnerable of all people, those with dementia or other mental illness, those lying on trolleys in A&E, or on mental health in-patient wards. “No decision about me without me” can be tried and tested when most fresh in the minds of patients and users. It is only here that the reality of the services that results from the theory of commissioning is to be found. To fail to take due account of this perspective in commissioning services is commissioning wearing a blindfold. The purpose of Amendment 318E is to ensure that commissioning is evidence based.

New Sections 14Z and 14Z11(2) require clinical commissioning groups to involve and consult on their commissioning plans. We know that this is a somewhat bureaucratic exercise, and it is often simply for the cognoscenti. Although these clauses are to be welcomed, they do not go far enough—hence the insertion of my new clause. Frail elderly patients lying in hospital wards who are not being fed will not be responding to consultations any more than will patients who have been sectioned under the Mental Health Act. The local healthwatch must talk to those patients and its findings must be an indispensable component of the evidence on which commissioning is based.

New subsection (3A), inserted by Clause 180(6), also requires commissioners and others to have regard to reports and recommendations from local healthwatch. This replicates the current arrangements for reports and recommendations from LINks, which has failed to bring the patient experience into the heart of commissioning. Compared to the status given to the views of health and well-being boards on commissioning plans—the strategic beginnings of commissioning—this is weak. What is needed is equal attention to the evidence on the outcomes of that commissioning, which local healthwatch is uniquely well placed to provide.

My new clause requires local healthwatch to hold the clinical commissioning group to account for incorporating the evidence that the local healthwatch has produced at the very start of the commissioning period. It should then heavily influence the commissioning plan for that period in taking the reality and applying it to commissioning theory. Binding the patient experience into commissioning is a much more specific requirement than merely “having regard to” local healthwatch reports and recommendations. The conjoint benefit of this new clause is that it increases the accountability of local healthwatch for producing robust evidence of the patients’ experience. Providers must also satisfy the local healthwatch if they are to secure further contracts.