Health and Care Bill

Debate between Baroness Tyler of Enfield and Lord Harris of Haringey

Lords Hansard - Part 2 & Committee stage
Tuesday 18th January 2022 Lords Chamber

[Baroness Tyler of Enfield (LD)]

My Lords, I support this group of amendments in the name of the noble Lord, Lord Hunt. My name is attached to Amendment 149, but I want to talk more generally about this group. Like the noble Lord, Lord Hunt, I am very supportive of the work of Healthwatch, at both national and local level. It provides very helpful and important insights about what it is like to be at the receiving end of our healthcare system. We sometimes do not hear quite enough about that. The national-local structure is helpful, ensuring that local bottom-up insights are then reflected in national-level reports.

Like the noble Lord, Lord Hunt, I have found some of the reports produced by Healthwatch recently, and during the pandemic, extremely helpful. I am thinking of its work on mental health—particularly, children’s mental health. It has also done a series of projects on social care that are very relevant to the current situation. One project particularly dear to my heart involved engaging with care home residents and their loved ones, and feeding insights into the development of national visiting guidance—very practical, important work. Another recent report, which I have already quoted in your Lordships’ House, looked at vaccine confidence and, particularly, what might need to be done to help support those communities with a higher degree of vaccine hesitancy; again, Healthwatch does some really important work.

I turn now to the amendments more specifically. In the recent survey of ICS leaders for Healthwatch England and NHS England, 80% of respondents said that they would support Healthwatch having a formal seat on the ICB if this was set out in legislation or guidance. We have already heard the question: what about the other 20%? Should noble Lords have the time, I recommend a quick look at the Healthwatch document and the survey, mapping the relationship between local Healthwatch and integrated care systems. There is a lot of important information in it. I particularly noted in the survey that 100% of ICS respondents said that they would support a mandated seat for Healthwatch on the integrated care partnership. That was one of the main reasons that I wanted to add my name to Amendment 149.

Fundamentally, why I think this so important is that I am not convinced that, in all our important deliberations so far, sufficient weight has been given to what we might call the service user voice or the individual patient voice more generally. These deliberations have, understandably, been very much about structures and how these new integrated care systems will work. I feel that there is scope for the Bill to set out some minimum requirements to ensure that the patient voice is heard at the decision-making table. It is fine to have lots of other sentiments about patient voices but, are they there, and are they heard at that table?

The principle is really quite simple. Patient choice at an individual level—that is, in relation to the patient’s own healthcare—has changed radically. We have moved from a situation where the doctor knows best and will tell you what is happening to the doctor setting out the options and you making a decision with the doctor—almost a co-produced decision. We need to think more about that approach, at the community level, the local level and then the integrated care system level. This will be particularly important in relation to tackling health inequalities because, frankly, if people are not involved in the decision-making or feel that their voice is not being heard, they often do not trust the outcome.

A recurrent theme in our discussions so far has been who should be on what body. We have had those big debates about whether there should be public health and mental health representatives and so on, which are very important, and those conversations still have some way to go, and we have just had this very interesting debate about place-based partnerships and “insiders” and “outsiders”. Again, that has quite a long way to go, but it would be ridiculous if the patient was seen as the outsider; patients need to be front and centre of all this and the reason we are undertaking a restructuring in the first place.

My main plea is that in all our discussions we consider the user voice and how it can be heard. I think that Healthwatch is an obvious way of doing it; it has the existing infrastructure. There may well be other ways of doing it, but that was the reason I was keen to support the noble Lord, Lord Hunt.

[Lord Harris of Haringey (Lab)]

My Lords, I refer to my health interests as declared in the register; in particular, I chair the General Dental Council, but I should make it clear that I am not speaking on its behalf in Committee.

Almost exactly 35 years ago, I became director of the Association of Community Health Councils for England and Wales, which was then the national statutory body representing the interests of the patients and the public in the NHS. Since then, both local and national representation of patients has gone through a series of iterations—indeed, the number of occasions on which I have been sitting on the opposite side of the Chamber from the noble Earl, Lord Howe, talking about patient representation seems too many to recount. After community health councils, we went through a series of iterations of which local Healthwatch is the latest version. I admit that when we had the debate which my noble friend Lord Hunt began by referring to, I was extremely dubious about whether local Healthwatch would be able to flourish and the national body be effective. I have to say that my worst fears have not been founded, but it has to be recognised that the way in which it was structured, in particular the late changes introduced by the Government during that legislation, made it much more difficult for Healthwatch, both at local and at national level, to be as effective as it might be.

The context of this debate is the centrality of patients and service users in delivery. Every time the NHS is reorganised, whether it was the reorganisation of the noble Lord, Lord Lansley, or the reorganisations we have every three years or so, there is always a grand White Paper which says, “Patients will be at the centre of this new structure”, but it is never quite like that. In the new arrangements being brought forward, the Government need to make sure that the local patient voice is represented and articulated and that, at national level, those voices can be aggregated and put forward. That is why this group of amendments is so important.

We have just had a debate which ended up revolving around how many separate interests should be represented on the various bodies that we are creating. I can see the problems if we add and add, and how difficult that is going to be. However, what I hope the Government will take away from the consideration of this amendment and look at before Report is how they can make the patient representative structure within the future arrangements better and more effective. I think that a number of things could be done.

The first is about the budgets. The budgets for local Healthwatch go through a complicated, notional process. It is very difficult to define why the allocations are what they are. It would be far better if it was clear what the expectations were to run a local Healthwatch and to deliver what is needed.

The second thing that can be done concerns the degrees of independence: from the local authority, health providers and health commissioners, at the local level, and from the CQC at the national level. The noble Lord, Lord Patel, talked about the problems of Healthwatch England being a sub-committee of the CQC. I understand that the relationship has actually worked quite well, but that is probably because of the good will of all concerned. It might be that, in the future, Healthwatch England has serious criticisms of the regulator. How can it do that, as a sub-committee of that body? Whether formally or informally, you can see the difficulties.

Health and Social Care Bill

Debate between Baroness Tyler of Enfield and Lord Harris of Haringey

Monday 13th February 2012 Lords Chamber

[Lord Harris of Haringey]

I am grateful to my noble friend for that reinforcement. I regret that, within some NHS trusts and some provider organisations, there is not the same approach. There is a concern that it is better to keep a patient, or the family of a patient, in ignorance and hope that the whole matter goes away. The purpose of the amendment is not to penalise the individual clinician—we all recognise that accidents happen—but to foster the culture of openness that the department wants to see; it wants to ensure that that duty is reflected, not only as far as the individual professionals are concerned, but also as far as the organisations are concerned. Otherwise, too often the lawyers and managers will say, “In the interests of the trust, let us try to keep this quiet”. I am glad to hear that it does not happen in every instance, as I am sure it does not, but the purpose of the amendment is to provide a statutory framework that will make it quite clear to all those who might otherwise be tempted to cover up these incidents that they must say, “This is important and we have to be open”.

[Baroness Tyler of Enfield]

My Lords, I have a few remarks to make in support of the amendment, to which my name is attached. I shall be as brief as possible, because much of what I wanted to say has already been said. I pay tribute to the noble Baroness, Lady Masham, for arguing so eloquently for a statutorily enforceable duty of candour.

Having listened to the debate, I remain of the view that a provision in the Bill requiring provider contracts to include a duty of candour clause would be the best way forward and would send the clearest possible signal to the whole healthcare system about the need for openness. We have already heard that, as presently constructed, not all parts of the healthcare system would be covered by the contractual route. It would certainly send a much stronger message than merely relying on the contractual route. I do not see the two being mutually exclusive nor do I think that the principle of contractual freedom would be compromised by having a statutory duty of this sort. I believe that the duty of candour issue is of a different order from much of what else will appear in provisions in provider contracts. I also believe that it resonates very well with the public and would make a reality of what I think should be the most important underlying philosophy of the Bill, putting the patient first and the whole “No decision about me, without me” mantra.

Many noble Lords on these Benches feel very strongly on this issue. The key principle at stake is the right of patients, their families and their carers to know what has gone wrong with their care and treatment when, unfortunately, mistakes, including negligence, have been made. The statutory route would help to ensure consistency. We have already heard an interesting debate about the current lack of consistency. I very much agree with the noble Lord, Lord Harris, about the extent to which it would help to change the culture under which, currently, we know cover-ups have occurred, and make them much less likely to happen in the future. I recognise that a statutory duty alone will not achieve this; it will be a necessary but not a sufficient condition. The culture change that we have heard about will need role models among both clinicians and managers walking the walk, as well as training and support for staff, so that mistakes are acknowledged and, critically, lessons are learnt from the mistakes.

Health and Social Care Bill

Debate between Baroness Tyler of Enfield and Lord Harris of Haringey

Wednesday 8th February 2012 Lords Chamber

[Baroness Tyler of Enfield]

My Lords, I also support the amendment on prostate cancer, which is a very important area. However, I wish to support the government amendments in this group—Amendments 68, 112 and 144, to which my name is also attached. These amendments all relate to reducing health inequalities and, in a nutshell, create a new duty on the Secretary of State, the NHS Commissioning Board and the clinical commissioning groups to report annually on their progress in tackling health inequalities.

As this is Report stage I will not rehearse the stark statistics on life expectancy that we heard during earlier stages of the Bill. We also heard compelling accounts of what needs to happen to improve health outcomes for those particularly vulnerable and disadvantaged groups whose patterns of usage of the health service often take a different form from those of other sections of the population. These groups include the homeless, those with mental health problems and others whom we heard about earlier.

As I recognised in Committee, the explicit duties on health inequalities which the original version of the Bill placed for the first time on the Secretary of State, Commissioning Board and CCGs were landmark duties. They certainly represented a major shift from the current position. However, as a number of noble Lords, me included, argued in Committee, those duties did not go far enough, and we called for their strengthening, particularly so that CCGs and other parts of the structure would be required not simply to “have regard” to the need to reduce health inequalities but to act to secure real improvements in terms of access to health services as well as outcomes. It is also critical that those bodies should account publicly for their progress in so doing.

I thank very much my noble friend the Minister for listening and acting. The nub of these amendments is that they shine a clear spotlight on health inequalities by introducing real transparency and accountability at national and local levels. I very much hope that the amendments will be instrumental in changing the culture so that things such as sharing good practice in tackling health inequalities become a key part of workforce training and very much part of the currency of everyday language in the NHS.

These amendments have the potential to make a reality of the words in the public health White Paper that spoke of,

“improving the health of the poorest, fastest”.

It is for those reasons that I support these amendments, and I thank the Minister for tabling them.

[Lord Harris of Haringey]

My Lords, I support the amendments in this group because I believe that it is important that we look at the mechanisms that will be embedded in the Bill, assuming that it eventually receives Royal Assent in some form, and that will in practice drive change in the direction that we all want. That includes improving the quality of the care offered, and it means addressing the issues of health inequality to which the noble Baroness, Lady Tyler, referred.

One of the omissions from the Bill is that, apart from placing some general duties on the various bits of the NHS, there is very little about demonstrating how those duties will then be exercised or creating a mechanism for assessing that. The amendment, which talks about reporting annually to Parliament on the progress made, seems an essential first step in making sure that that happens.

The reports on inequalities will be increasingly important in this area. However, Amendment 112, dealing with CCGs’ annual reports on how they have discharged their duty to reduce inequalities, raises another question, and this comes back to the issue of what will be the catchment areas of individual CCGs. Unless there is far more central direction than I have understood—and perhaps the Minister can reassure us on that—it seems likely that there will be, to use an unpleasant term, ghettoisation in some CCGs.