Health and Social Care Bill

Baroness Morgan of Drefelin Excerpts

Wednesday 9th November 2011 Lords Chamber

[Lord Rea]

My Lords, I have a short question, on a subject mentioned by my noble friend Lord Turnberg and others. The National Institute for Health Research is now directly related to the Department of Health. Is it going to stay there, or is it going to be moved over, as was suggested, to the NHS Commissioning Board? Is the funding going to be assured? I do not think that we are quite sure about these things.

[Baroness Morgan of Drefelin]

My Lords, I was delighted to lend my name in support of these amendments. We have had a tremendous debate, which is a sign that the Committee stage of the Bill is starting to get down to business and focus on some of the nitty-gritty, now that we have moved on from some of the more extremely high-level principles about whether or not we should see Clauses 1 and 4 in the Bill.

I very much support the opening remarks of the noble Lord, Lord Willis. He is chair of the Association of Medical Research Charities. I declare an interest myself as chief executive of a medical research charity, Breast Cancer Campaign. We are members of the noble Lord’s association, and are very grateful to him for the leadership that he gives.

There are very few points I want to add to the debate, as it has already been very comprehensive. In thinking about this, I want to stress how incredibly important it is that we understand the role of research in the NHS as a driver for quality and improving outcomes for patients. Only today at the AMRC AGM, I heard someone describing research as one of the three pillars, alongside service delivery and education, and stressing the role that research plays in driving up quality and outcomes for patients.

We know that this is something that is not lost on the public. We have already heard what importance the public place on research delivery in the NHS—93 per cent of people asked by the AMRC in a MORI poll said that they wanted their local NHS to be encouraged or required to deliver research locally. That is an enormous vote of confidence in research in the NHS.

The public do not just say this in answer to surveys. They vote for research through their wallets, as we have already heard from a number of noble Lords. Medical research charities contribute £1 billion to research in this country. That is an enormous achievement.

The contribution that the NHS makes to medical research worldwide is very special indeed. It is quite simply a no-brainer that research has consistently delivered real progress for patients. I believe it is agreed that the NHS has a special and unique role to play, which is unparalleled in the world. We have already agreed around the House that in this country we punch above our weight, as the noble Lord, Lord Walton, said. As the noble Lord, Lord Turnberg, said very eloquently, we know that the UK generates over 10 per cent of the world’s clinical science and health research outputs and has created nearly a quarter of the world’s top 100 medicines. That is a great achievement. Now that the noble Lord, Lord Darzi, is back in his place, I can remind the House that in the earlier debate he commented on how life expectancy continues to rise, following on from the success of medical research.

As I said at Second Reading, there are many examples where the special nature of the NHS has contributed to progress. I mentioned particularly the million women study, supported by Cancer Research UK in partnership with the NHS, a collaboration that revealed the role of hormone replacement therapy in breast cancer risk—an enormous study, made possible by the NHS. I also talked about a project that my own charity is involved in. It is a real challenge. Noble Lords have already made many points about the difficulty in establishing informatics systems. We are working to establish a tissue bank, to look at breast cancer specifically, and to drive forward the vital role that genomics plays. This is also made possible by the NHS. There are many examples, as I have said.

I welcome this duty. It is the first time we have seen a duty of this nature on the Secretary of State, and it is a very important step forward, but if the duty is going to be meaningful we need to know—so I would like to hear from the Minister—what the Government will see as success in executing that duty. I want to understand what success will look like—what will be the benchmarks that the Secretary of State will use to know whether his duty has been executed successfully.

Will we continue to evaluate the contribution that NHS research makes to GDP? How will the NHS research duty play in to the research assessment exercise that is undertaken in higher education? Could that be used to show how effective partnerships work in the NHS, because it is often those partnerships between NHS trust and academic institutions which are so important? What could Monitor or the Care Quality Commission do to help us understand the contribution that research has made to improving outcomes in various settings? Will we have an impact rating for NHS foundation trusts relating to their promotion of R&D? Will we be considering the number of patients in clinical trials as a measure—that is something that many people are worried about at the moment? Should we be looking at the number of clinical fellows or clinical professors in surgery?

What will success look like for the Secretary of State? I have heard talk that a research tariff is being developed; that has been referred to in correspondence. I would be grateful if the noble Earl could explain whether it is and what the consultation process might be. There has been a suggestion that a diagram or an organigram might help us here when looking at how the funding streams might work. We had a meeting with Dame Sally Davies when that was on the agenda. We have been reassured that funding will work in the same way as in the past. I am not sure whether it can, so I should be grateful if the Minister could reassure us on how that would work and perhaps produce a diagram for us.

[Baroness Emerton]

My Lords, I have appreciated all the contributions on the amendments on research. There is just one thing that I take issue with: the contribution of the noble Lord, Lord Ribeiro, who said that his profession was the Cinderella of research. Other professions would describe themselves as being Cinderellas in terms of research funding. Obviously, I speak for nursing and midwifery, but also for the other healthcare professions, which are all graduate professions and which are concerned to give evidence-based practice wherever they are in the NHS. Perhaps the noble Earl could re-emphasise that it will be multiprofessional research. All the contributions this evening have been on medicine and scientific research, but the other professions can contribute an enormous amount. Nursing is very reliant on charitable, voluntary funds for its research and has done some tremendous research exercises in clinical procedures, as have the other professions—midwives and physiotherapists. Will the noble Earl consider this being a multiprofessional research board?

Health and Social Care Bill

Baroness Morgan of Drefelin Excerpts

Monday 7th November 2011 Lords Chamber

[Baroness Morgan of Drefelin]

My Lords, I agree with the noble Lord, Lord Mawhinney, who has given the Minister some very positive and practical advice. When the Minister responds to this debate he will probably say something similar to what he said at Second Reading, where he was very clear that the Government agree that there should be a duty of candour. The question is about how best to deliver that. As I understand it, the Government have launched a consultation about how to deliver a duty of candour through the contractual means that noble Lords have already alluded to. There seems to be agreement around the House; the noble Lord, Lord Winston, suggests that he is unpopular, but he too accepts that there is an issue we need to address.

I believe that the consultation on the contractual route finishes on 2 January. I do not know how that fits in with our Committee timetable, but it would be helpful for the Committee to see how my noble friend’s amendment could be worked through in a more practical way. My noble friend Lady Masham has spoken very eloquently about issues of deep concern to patient organisations in this country, and we have to do better than a contractual route. Patients have a right to know when something goes wrong, and in this country’s NHS we need a system, a process, that allows health professionals to admit when something goes wrong in an environment that can learn from those mistakes. Where there are errors and where professional misconduct takes place then of course action must be taken, but it is important that there is openness so that the system can learn and these errors can be stopped from happening again. The noble Lord, Lord Harris, made the point about patients and others not always seeking legal redress but in many cases looking for an apology and an assurance that the mistake will not happen to anyone else.

I am sure that the Minister will be persuaded by this debate that we need a more practical and constructive way forward. I appreciate his comment in his response at Second Reading where he said that it would be inappropriate to pre-empt the consultation that finishes on 2 January and to amend the Bill before the Government have a chance to respond to the consultation. That may coincide very well with Report stage—I do not know what the timetable is like—but I hope that the two can dovetail and help my noble friend Lady Masham with her cause in this amendment.

[Lord Marks of Henley-on-Thames]

My Lords, I welcome the amendment introduced by the noble Baroness, Lady Masham, and others, and applaud the powerful and eloquent way in which she opened the debate and in which others have spoken.

I wish to make a brief contribution regarding the litigation consequences of a lack of transparency. Over a number of years, though not in the immediate past, I conducted clinical negligence cases, many of which concerned allegations of negligence against practitioners and organisations within the health service. I am not one of those who regard such litigation as frequently the result of an unwelcome development of a compensation culture within this country, approaching the situation in the United States. Without generalising, in most of the cases in which I have been involved— certainly those that came to trial—there has been a real basis for concern on the claimant’s part, whether or not the claimant has ultimately been successful.

With respect to the points made by the noble Lord, Lord Winston, I remember cases where the process of litigation itself demonstrated not only that that particular claimant had been poorly served but that there had been systemic failings within aspects of the health service that required changes to be made. When those changes were then made, they brought substantial benefit to subsequent patients.

A feature of much of the early litigation in which I was involved, though, was that it was frequently very difficult to obtain full records and a full account of the history from the point of view of the defendants within the NHS providers, and of course they alone were in possession of the relevant information. That is against the background that for many years there has been a procedure for obtaining the disclosure of relevant documents from potential defendants to these actions, even before the actions are commenced.

In recent years, procedures have been greatly improved by the impact of the clinical negligence protocol, introduced in 1999 as part of the Woolf reforms. However, the protocol is not binding, although it introduces a code of good practice and provides a partial answer to the points made by the noble Lord, Lord Mawhinney. The code requires a comprehensive system of what it calls adverse outcome reporting. It requires clear and comprehensible information to be given to patients, and for advice to be provided to patients on any serious adverse outcome and the options available to them. In such cases, access to records is to be given to patients within 40 days of a request. The protocol has done a great deal when it is fully observed. However, the fact that it is not always observed is clear from many of the speeches that we have heard this evening.

A further point is that the protocol applies only in cases where there is a serious adverse outcome for patients. Furthermore, it is only a code and does not impose statutory requirements. Even in serious cases, and where the code is followed, requests for documents and pursuit of the procedures generally involve lawyers, and this process can be lengthy, time-consuming and expensive. If not well handled, the process can tend to harden and entrench positions, making conflict and, therefore, contested proceedings more likely. Furthermore —this is another point I make to the noble Lord, Lord Mawhinney—the process is not effective in less serious cases but this amendment would apply in such cases, although there is a limit to it. It refers only to cases that,

“may have caused harm, or may in the future cause harm”.

The cost of negligence cases to the NHS is simply staggering. According to a Written Answer given in the other place on 8 June this year, the total in damages paid to successful claimants in 2010-11, including in periodical payments cases—which are treated in the figures as lump sums—exceeded £1 billion. The total of claimants’ costs paid out was around £214 million, and the total of defendants’ costs was £72 million. If improvements in transparency could be made to reduce these vast amounts, particularly the costs, they would be very welcome. As my noble friend Lord Mawhinney pointed out, all the money spent on costs is money that might have been made available for healthcare.

In a large number of cases, as the protocol recognises and as the noble Lord, Lord Harris of Haringey, and others have pointed out, what claimants and potential claimants want is to know at a very early stage what has happened to them—to have someone explain frankly exactly what has gone wrong and then, where appropriate, to have someone apologise for any errors. Anything that helps to bring about a more effective way of ensuring that that happens will avoid many cases that currently end in litigation. As a result, many patients will be far better served. Therefore, there is much to be said, across a range of cases, for establishing far better procedures than there are now to ensure that full explanations are provided in a timely fashion.

Health and Social Care Bill

Baroness Morgan of Drefelin Excerpts

Tuesday 25th October 2011 Lords Chamber

[Lord Rea]

My Lords, I have spent most of my professional life working in the National Health Service. I have also worked in and observed other healthcare systems and have come to value the NHS all the more not only for its universality but for the high quality of its coverage. I admire it also for its economy of working. We spend considerably less on health per head of population than most other countries at a similar stage of economic development.

By and large, the NHS has conformed to the principles laid down in the amendment. Of course, it is far from perfect. Its bureaucracy, as the noble Baroness, Lady Williams, said, is sometimes inflexible. For example, the treatment of whistleblowers is often inappropriate. Internal criticism should be heard and acted upon and not suppressed, but this Bill is not necessary in order to correct that. The amendment is an important reminder to government at both national and local level of what the NHS stands for. Any action by government or individual staff should be taken with these principles firmly in mind.

[Baroness Morgan of Drefelin]

My Lords, there is nothing like suggesting to a House of Lords Committee that we move on to encourage one to stand up and contribute.

The noble Baroness, Lady Thornton, mentioned the debate that took place at the start of the Committee stage of the Apprenticeships, Skills, Children and Learning Bill, now an Act, in 2009. I remember sitting behind the Dispatch Box next to my then noble friend Lord Young listening to the noble Lord, Lord Hunt of Wirral, make a very convincing case for the Opposition on the need to set out a clear definition of apprenticeships and the importance of a well thought through, principled preamble. I remember listening to my noble friend take the Committee through a detailed and well argued explanation of how all those issues were carefully covered throughout the very long Bill. However, both Her Majesty's Opposition and the Liberal Democrats were united in saying that they needed to be stated clearly at the start of the Bill. They won the day and there that statement is in the apprenticeships Act.

When I saw the amendment of the noble Baroness, Lady Thornton, it made me think about all the important legislation of the past, and it led me to the Children Act 1989, which I am sure the Government are still very proud of. An important aspect of that Act is the principle of paramountcy, whereby the interests of the child are paramount in any decisions taken about their health and welfare.

Listening to debates on this Bill, I have felt genuine concern about how we resolve issues around conflict of interest. The relationship between a health professional —a doctor, nurse or physiotherapist, but principally a doctor—and their patient is based on an extremely high level of trust and is one of the cornerstones of our NHS, and I was wondering how the importance of that trust and that relationship could be incorporated in some principles. Have the Minister or the noble Baroness, Lady Thornton, thought about whether it would be appropriate to have a principle under which the needs and interests of the patient should be paramount when decisions are made about them? Obviously, there are a lot of ways of thinking about that from a legal perspective, but it is something that we need to be very concerned about. How is the conflict of interest to be carefully managed where a GP refers a patient to a service that they own and profit from? How can patients—whether as individuals or a population—be absolutely sure of the decisions being made about them, at every level throughout the system, including commissioning? It is very important that we think about the principles underpinning the health service. This is a very important debate.

[The Earl of Listowel]

My Lords, I am most grateful to the noble Baroness for this debate on the primacy of patient care. It is very important. All noble Lords may well agree that this is fundamental, so I hope they will forgive me if I raise one concern with the Minister, which has been raised by people who practise in the NHS. The constant changes to the National Health Service over many years, particularly in England, have undermined, to some degree, our efforts to deliver the best to our patients. It is something I am familiar with from speaking to child mental health professionals in the past. They have complained that constant change undermines their ability to make relationships with other professionals work effectively around the child. Also, they get to know a commissioner who then changes. It is a different area, but social workers have also raised with me the issue of local authority changes. I remember speaking to a local authority social worker on a Friday evening who was despairing at yet another structural change to social service provision within the local authority.

In its briefing to Members of your Lordships’ House on the Bill, the Nuffield Foundation also expressed concern at the constant changes to the NHS and the short horizons. One Secretary of State may make changes but then a new Government arrive and there is another upheaval. I recognise what the noble Baroness, Lady Williams, says: flexibility and changes are needed, but my sense from speaking to the professionals and expert think tanks is that there has been too much change over a continual period. This was reinforced in the briefing that the presidents of the royal colleges gave to Members of your Lordships’ House this week, in which the president of the Royal College of General Practitioners finished with a very powerful plea: “Please, give us some stability; please stop changing the NHS”. She particularly alluded to the experience in Scotland. If I remember correctly, she said that for about the same investment Scotland has better productivity. She lays this at the door of the fact that over several years there has been some stability within the health service there. I take this opportunity to ask the Minister whether, in future, he will keep in mind the need to allow important changes to bed down. Perhaps we could build a bit more of a consensus on what needs to be done, recruit and retain the best professionals on the ground and allow them to evolve the best practices. Then we will see better outcomes for our patients, with a similar input.

Health: Breast Cancer

Baroness Morgan of Drefelin Excerpts

Monday 3rd October 2011 Lords Chamber

Asked By

[Baroness Morgan of Drefelin]

To ask Her Majesty’s Government what assessment they have made of the impact Improving Outcomes: A Strategy for Cancer, issued by the Department of Health, has had on women with breast cancer.

[The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)]

My Lords, our cancer outcome strategy sets out our ambition to improve outcomes for all cancer patients and save an additional 5,000 lives every year by 2014-15. Specifically on breast cancer, the strategy outlined commitments on local awareness campaigns, expanding breast cancer screening, measuring the prevalence of metastatic breast cancer, and one-day stays for breast surgery. Good progress is being made in all these areas and the strategy’s first annual report will be published in the winter.

[Baroness Morgan of Drefelin]

My Lords, may I remind the House of my interest as chief executive of the research charity Breast Cancer Campaign? I thank the Minister for his response. I have two brief questions. We know that radiotherapy is a very cost-effective treatment, improving outcomes for people with cancer at 5 per cent of the NHS cancer spend. Can the Minister explain to the House what progress is being made to ensure that the additional investment set out in the outcomes strategy is actually being converted into improved outcomes rather than lost in the bottom line? Can the Minister say what steps are being taken to improve access for women to IMRT radiotherapy, which is, of course, the modern version of this treatment and which can be so beneficial for appropriate referrals?

Tobacco Advertising and Promotion (Display and Specialist Tobacconists) (England) (Amendment) Regulations 2011

Baroness Morgan of Drefelin Excerpts

Monday 11th July 2011 Lords Chamber

[Lord Judd]

My Lords, I strongly support my noble friend and applaud the fact that she has brought this Motion before the House. People have spoken with great emotion about the rights of individuals. There is no proposal before us to ban people from smoking—perhaps there should be. It concerns me that we always dance round the brutal, central point about smoking: that it is known beyond doubt to be a killer. We are condoning a delay in discouraging young people and others from indulging in a habit that kills.

It is not just the smokers themselves but their families, the grief, the cost to future production as people fall ill and the heavy cost on the health service when we already know that the health service is stretched almost beyond all reason. In the arguments of those who are against my noble friend, I find it difficult that they seem to suggest that this is a private matter for the individual. It is not: it has social implications and the cost falls upon society as a whole. It is not just a cost upon the individual who decides to smoke. What evaluations have been made of the cost of this delay? What will be the cost to the health service? How many people will die prematurely who would not otherwise have died? What will the cost be of supporting families where people have died prematurely because of indulging the habit? This is an absolutely inexcusable delay.

In the last 24 hours, we again heard the Prime Minister make great speeches about how he will not brook delay in his decision to decentralise and make sure that people share in responsibility and participate in the kind of society of which he dreams. If he will not brook delay in that circumstance, why does he do so in allowing a practice to go on of encouraging people to take up a habit that is dangerous and results in death? We must face these central facts. If we condone what the Government propose, we condone more death, suffering, cost to the general public and burdens upon the health service. How on earth can that be justified?

[Baroness Morgan of Drefelin]

My Lords, I thank my noble friend Lady Thornton for tabling this Motion of regret. Like many around this House, I am particularly concerned about the issue of tobacco control and I value this opportunity to seek assurances from the Minister on a number of key questions. For the record, I declare my interest as chief executive of the research charity Breast Cancer Campaign and also trustee of Lung Cancer Campaign Carmarthenshire. I have a particular perspective—it is not necessarily an interest—as my father was diagnosed with lung cancer when he was 40 and I was a child. My noble friend Lord Judd talked about the impact on the family. We have not got time to talk about that but I appreciate that comment.

I look forward to hearing from the Minister a full explanation of the rationale for the delay in the implementation of the tobacco advertising and promotion regulations. My noble friend Lord Judd asked what the cost will be. I would particularly like to know who will benefit from this delay. In the Government’s analysis, who are the real beneficiaries?

The House has already heard very passionate words about the campaign by the National Federation of Retail Newsagents to delay implementation, about how it was funded by British American Tobacco and that this was not made clear and transparent. I personally feel very concerned about that—if we do not address it now, where will that lead? I very much hope that the Minister can give us the assurance that the noble Baroness, Lady Thornton, is seeking that the Government are still committed to the framework convention on tobacco control, which aims to protect a range of public health policies, and this policy as an example, from vested interests.

We should not think for a moment that our understanding of the impact of smoking on our health is fully understood. We are for ever learning more about the impact of smoking on health and, as our understanding of that impact deepens, so does the case for control. We already know that smoking is the single largest preventable cause of cancer, with smoking causing 28 per cent of all deaths from cancer. Worryingly, an estimated two-thirds of smokers started smoking before they were 18 and almost two-fifths started smoking regularly before the age of 16.

Until recently the link between smoking and breast cancer, a particular interest of mine, was poorly understood, but only a few months ago new evidence emerged demonstrating a clear link between smoking and breast cancer for the first time. While previous reviews had not demonstrated an association between active smoking and breast cancer risk, a cohort study published in the BMJ on 1 March has made a very clear association between active and passive smoking and an increased risk of breast cancer in post-menopausal women, the group of women most likely to develop breast cancer. Significantly higher breast cancer risk was observed in post-menopausal women who are active smokers, with links between the intensity and the duration of smoking—what some might describe as a dose response—as well as a link with the starting age of smoking.

Compared with women who had never smoked, breast cancer risk was increased by 16 per cent among current smokers. This is yet more evidence in favour of the need to control tobacco. Among former smokers, the time since quitting smoking was significantly inversely associated with breast cancer risk. It took 20 years for a former smoker’s risk to fully reduce. On the point made by the noble Lord, Lord Judd, about whether or not this is a private matter, passive smoking was also looked at in this research very effectively. The same study suggests an association between passive smoking and breast cancer and this is a really important new piece of understanding. Among women who have never smoked, those with the most extensive exposure to passive smoking had a significantly increased risk of breast cancer compared with those who had never been exposed to passive smoking. This is a very important development in our understanding.

While there is still much more to be done to understand the precise link between smoking, both active and passive, and breast cancer, one thing that is crystal clear to me is that women will not benefit from a delay in this measure. The noble Lord, Lord Borrie, makes a very good point about the need for balance in public health policy, but it is important that we recognise that, in that balance, the desire of smokers to quit, the need to prevent young people starting and the fact that our understanding of smoking and the impact on public health continues to unfold need to be factored in.

The case for the tobacco display regulations has already been made. I do not believe that the case for delaying these regulations has been made to the satisfaction of this House and I very much welcome this debate.

Southern Cross

Baroness Morgan of Drefelin Excerpts

Thursday 16th June 2011 Lords Chamber

[Earl Howe]

My Lords, the Department of Health is being very clear with the company that we expect it to maintain service continuity and quality of care while the restructuring process is going on. As I have said, our principal concern is for the safety and well-being of the residents of the care homes that might be affected. The CQC will pay particular attention to any care homes where there is a concern that quality may be at risk or inadequate. We are continuing to talk to ADASS, the LGA and the CQC to ensure that contingency plans are in place which will allow for the continuation of care under any eventuality. If the noble Lord will forgive me, I would rather not be drawn into hypotheses as to what might happen if the restructuring does not take place. We must encourage the company to believe that that is the prime and sole option before it. If there is ever a question of a change in the arrangements for providing residential care to any resident of a Southern Cross care home, or indeed any other, the rights of those residents remain absolutely clear in law. The duties of local authorities are absolutely clear in law. I believe that all residents in Southern Cross’s homes can rest assured that local authorities are well seized of those duties and processes.

[Baroness Morgan of Drefelin]

My Lords, the Minister has reassured the House that he does not see Southern Cross as the first of many providers to go into crisis. Can he share with the House the advice that he has had to enable him to give us those assurances that Southern Cross is not just the first of a number of providers to go into crisis?

NHS: White Paper

Baroness Morgan of Drefelin Excerpts

Monday 12th July 2010 Lords Chamber

[Baroness Northover]

My Lords, perhaps I may remind the House, as invited, that this is a brief Statement. We have 20 minutes all together and we are already five minutes in. Many people want to intervene on this extremely important Statement, so if people can be brief we will be able to cover as much as possible.

[Baroness Morgan of Drefelin]

My Lords, the Minister talked about an NHS that was stifled by top-down bureaucracy. Given the impressive outcomes that we have seen with improvements in cancer treatment, I do not think that many people would recognise that story. Does the Minister accept that medicine is a fast-changing field where innovation needs to be translated into practice on the front line as quickly as possible? Does he further accept that there needs to be leadership in a complex system like this if patients are to have access to the improvements in innovation and care? How does he see that leadership working?

How will patients be represented throughout the system? For example, how will they be represented at the NHS board? How will GPs ensure that they can access fairly and without bias the views of all their patients, not just those they see regularly? How will GPs translate those patient perspectives into commissioning in line with this new strategy that the local authorities will be responsible for developing? I want to hear the Minister answer that important question in some detail.

[Earl Howe]

My Lords, the noble Baroness makes an important point about innovation. We are clear, as is the White Paper, that driving innovation through the system will remain an extremely important part of what we mean by quality. The QIPP agenda is alive and kicking. For those noble Lords who are not familiar with the acronym, QIPP stands for quality, innovation, productivity and prevention. The innovation part of that will be driven in several ways, not least by the NHS commissioning board, which will have access to sources of advice from NICE, the NHS quality board and many other sources. But we also plan to put in place incentives in the tariff, which will drive innovation and high-quality care. Our proposals for those will be forthcoming.

The noble Baroness asked about patient representation. She was absolutely right about clinical leadership, but she was also correct to say that we need to ensure that the patient’s voice is heard at every level of the health service. At the local authority level, there is no doubt that Health Watch will have a presence as the voice of local patients. We are also creating a national Health Watch, which will act as the national voice for patients, feeding directly into the Care Quality Commission so that assessments of quality can be informed by patient experience on the ground. We are not planning in any way to dilute the duty under Section 242 of the 2006 Act to involve patients in the configuration of services. It is important that local people feel that they have a say in the way that services are developed. Our proposals for this will be laid out in an engagement document that is to be published in a short while.