Health and Social Care Bill

Baroness Wheeler Excerpts

Monday 28th November 2011 Lords Chamber

[Baroness Wheeler]

My Lords, I am pleased to support the spirit, intention and thrust of all the amendments in this very large and, I hope, uncontroversial group, which are intended to ensure that provisions in the Bill to involve the public, patients, carers and specialist professionals and patient groups in the development and decisions about services, care and treatment are reinforced and strengthened. We recognise that the duties proposed by the Government for the NHS Commissioning Board and clinical commissioning groups—to promote the involvement of each patient and to enable patients to make choices on the services provided to them and obtain advice from specialist professionals—are a significant step forward from the original provisions in the Bill. They build on the foundation work on this issue undertaken by my own Government. However, it is clear from this excellent debate that these general duties do not go far enough to mark the significant step change that we need in getting genuine shared decision-making and participation of patients, carers, and patient groups in decisions about care and treatment, and on how services are planned and developed.

We also now have the added complexity of the reorganisation itself. Senates, networks and health and well-being boards are acting as the system integrators, all alongside our newly enlarged CCGs with their giant private sector support organisations behind them, as we now know from the Government’s recently issued draft guidance on commissioning which was referred to in the previous debate by the noble Baroness, Lady Williams. This will be a highly complex raft of interactions and interconnections with no notable route to accountability. I would be grateful if the Minister could give me some insight into how he envisages the voice of patients being heard among all the clamour and shouting that will go on between these different spheres of interest.

We must try to achieve real involvement. For individuals, that means involvement in care planning and support for patients with their carers, relatives and support groups to manage their conditions and share in the choice of treatment. On collective involvement, this means that knowledgeable patients’ groups should be able to advise commissioners on how to design services, rather than to have token consultation after decisions have already been made, which is the case now in so many situations. We must make sure that we harness fully the collective experience and knowledge of patients and specialist care organisations.

We recognise that this will involve a major cultural change in the behaviours, approaches and attitudes of key professionals from across the specialisms, moving away from seeing patients as units of disease, not as people with rights to information and to participation in discussions and decisions about their care and treatment, as the Health Foundation puts it. We need to change the way that patients and clinicians, in particular, relate to each other, and change the way that the NHS relates to patients in terms of, for example, information provision and the organisation of clinics, and in the style of consultations that professionals have with patients.

In respect of the NHS Commissioning Board, we support Amendment 121, which calls for the board to have the duty to secure rather than promote the involvement of patients, carers and their representatives in decisions about the provision of health services. This is important, and Amendment 150C—which seeks to ensure that the board’s annual report includes accounting for how it has carried out its duties in involvement, choice and advice—complements and underlines the importance of this duty.

Amendments 125 and 126, tabled by my noble friends Lord Warner, Lady Thornton, and Lord Patel, turn the focus on clinical commissioning groups and call for a published guidance to CCGs to ensure that they are clear about what is required of them to meet the duty to promote the involvement of each patient. I also pay tribute to the work of National Voices on the principles of integrated care and on other patient and involvement issues relating to these matters.

We know that many commissioners, both nationally and in CCGs, are unaware of the increasing evidence that involving individual patients in their care and treatment is proven to be more clinically effective, provides better patient experience and makes much better use of healthcare resources. In other words, it is the vital underpinning for the Nicholson challenge and for commissioners’ other duties to improve quality. A far stronger signal is needed in the Bill and in statutory guidance to draw commissioners’ attention to the proven interventions that they require from their providers. I would be grateful to hear from the Minister how he intends to do this.

Clearly, many CCGs will not make the changes that we need without help and support. Amendment 125 is therefore crucial, as it calls on the NHS Commissioning Board to draw up guidance to CCGs which will enable patients, carers and their representatives to make informed decisions. This includes patients having the means to express their views on the quality of services provided, opportunities to consult with service providers, access to appropriate information about their care and treatment, opportunities to consider available treatment options and their risks and benefits, and to participate in decisions about their care and treatment and its managers. The information they receive about these areas must be simple and well presented—not league tables or comparison charts, but clear information about treatment options, how effective they are and what the consequences might be for the patient. As other amendments underline, these rights of patients must be accessible to all patients.

Amendment 126 stresses how important it is to have information on access and location and about the providers of health services and performance if informed decision-making is to become a reality for the majority of patients. We fully support Amendments 127A and 197A, which would give expert patients’ organisations equal status to professionals in providing advice to commissioners. This would help ensure a patient voice in the clinical senates and networks. It is an approach that was supported by the clinical work stream of the Future Forum but overlooked in the Government’s response. We also strongly support Amendments 175A and 175B from the noble Baroness, Lady Finlay, which calls for regulations providing for the governing bodies of CCGs to include individuals who are fully aware of the different aspects of specialist provision in the areas covered by CCGs.

Amendments 140 and 142, tabled by my noble friends Lady Thornton and Lord Hunt, require the Commissioning Board to ensure that patients are involved and consulted in the development and planning of commissioning and in the consideration of how proposals for change in health services are organised and delivered. Most importantly, Amendment 205 secures the involvement of the local healthwatch in these decisions, vital if HealthWatch is to be able to fulfil its key watchdog and patients role. The importance of this role was ably underlined by my noble friend Lord Harris, so I will not expand further on it.

On patient choice, we support Amendment 127, which proposes a definition of patient choice. Research shows that patients care most about being able to exercise choice about the care and treatment they receive, but currently the NHS performs poorly in involving patients in this way. A full definition of patient choice should be included in the Bill to ensure that commissioners provide opportunities for patients to exercise choices that go beyond the choice of provider. Does the Minister accept the need for this definition in the Bill, and if not, how will he seek to achieve the cultural change in systems and attitudes that we all want to see?

All these amendments seek to ensure that the NHS Commissioning Board and CCGs understand fully their responsibility, and that they commission for involvement. These changes would give a clear signal to the system that the Government mean business in wanting meaningful patient participation and involvement, and that real change can be achieved.

[Earl Howe]

My Lords, this large group of amendments all relate to the different ways in which patients, the public and others will be involved in decision-making, and although I shall be suggesting that noble Lords should not press them, I am very much in listening mode on the themes that they raise. The only thing that I cannot promise to take forward is the suggestion of the noble Baroness, Lady Masham, that I should introduce an amendment on the death penalty, but, no doubt, she can persuade me.

The issues that noble Lords have covered are central to our vision of informed and empowered patients, and responsive commissioning that is clinically led. These are also issues that were considered in great depth as part of the listening exercise, in response to which significant improvements were made. Those improvements created much stronger duties than currently apply to primary care trusts, so it is important to begin by recognising how this Bill takes us forward from the current position. Nevertheless, I recognise that some confusion remains about what we mean when we talk about involvement, and what the different duties in the Bill are intended to achieve. The noble Lord, Lord Warner, has tried to frame an all-embracing definition of involvement through Amendment 125, and I find little to criticise as regards the purpose and intent of that amendment. However, I would argue that much of what the noble Lord intends through this amendment is already provided for in the Bill. Indeed, it is because there can be different elements to involvement that would be appropriate in different situations that I would be cautious about trying to wrap them up in a single definition.

It will be helpful to begin by considering the duties on the board and clinical commissioning groups to involve patients in decisions about their own healthcare. The noble Lord, Lord Harris, made some useful distinctions on this point. These new duties reflect our vision of shared decision-making, referred to by the noble Baroness, Lady Finlay—“no decision about me without me”, and an NHS where patients are involved fully in decisions about their care in partnership with clinicians. This is primarily about the relationship between the individual patient and their clinician; it does not extend to commissioning decisions. Therefore, I do not think that it would be appropriate for HealthWatch or indeed any other body to have a role in what are meant to be sometimes very personal decisions.

There is clearly a role for CCGs as commissioners, as distinct from the role of general practitioners, in supporting and encouraging this personal involvement. However, it is not completely within their control, so I do not think that it can be for them to secure, as the amendment proposes. Nor do I think that there should be any sort of hierarchy, where the board is in the lead with a weaker duty on CCGs. That would run counter to what we are trying to achieve, which is after all a more personalised service. Therefore, I am afraid that I cannot agree with Amendments 121, 123, 124A, 191 and 192. However, such a service might include giving patients greater control over their medical records, as Amendment 124 suggests. The noble Lord, Lord Patel, may know that this was a key theme of our consultation on an information revolution. Responses to that consultation showed a clear desire to enable people to be more in control of their care, supported by greater access to the information held about them in their care records. We are committed to this and our forthcoming information strategy will set out how we propose to achieve it.

These duties are of course closely linked to those relating to enabling choice. As noble Lords will be aware, patient entitlements to choice are set out in the NHS constitution. These are underpinned by directions by the Secretary of State, which will in future be the standing rules and regulations under Clause 17 which we have already discussed.

I reassure noble Lords that, as now, the role for commissioning bodies in respect of enabling choice in the future will include acting with a view to making people aware of their rights and entitlements, giving them the information that they need to make informed decisions and working with providers to ensure that these are delivered. I did, however, listen with considerable care and sympathy to the noble Lord, Lord Neill, regarding patients who need advocates to speak on their behalf. This will be further reinforced by the new duty that the board and clinical commissioning groups will be under in relation to promoting the NHS constitution among both patients and staff. The board will set the choice offer, establishing the parameters for choice and competition, based on the choice mandate that the Secretary of State will set as part of the annual mandate to the board. I remind the Committee that we recently sought views on these issues through the consultation, Liberating the NHS: Greater Choice and Control. This is an important approach because it allows the Secretary of State and the board to manage the rollout of choice in a controlled way—something that I know many noble Lords are anxious to ensure. That is why we have deliberately used broad terms in describing the types of choice that patients can exercise. Indeed, I think that defining them in more detail, as some of the amendments attempt to do, could paradoxically limit their scope. They could also be unsuitable or indeed unfeasible in particular circumstances, and that is why, although I am in sympathy with the spirit behind them, I am unable to agree with Amendments 126, 127, 193, 196, 197 or 197ZA.

Greater choice means, among other things, patients being able to choose between a greater range of providers. Amendments 125A, 125B, 195A and 195B are particularly concerned with the impact that greater choice and provider plurality might have on the viability of existing services—a matter that we discussed at our last session in relation to amendments tabled by noble Lords opposite about the interdependency of services. That is an issue that I completely understand. In securing healthcare services to meet the needs of their patients and populations, commissioners must have regard to the stability and financial viability of those services, including taking account of the interlinkages between services, where relevant, on an ongoing basis. Commissioners will need to commission high-quality integrated care that will deliver value for money for local communities and promote opportunities for patients to exercise choices in relation to their care. In taking commissioning decisions, they will have to consider what the noble Baroness, Lady Pitkeathley, reminded us of—that is, what will be in the best interests of their patients. This would always be their primary concern, and we would expect the board to ensure sufficient competency over these issues in authorising CCGs to take on their new responsibilities and in holding them to account for doing the job.