Care Quality Commission (Healthwatch England Committee) Regulations 2012

Lord Collins of Highbury Excerpts

Wednesday 21st November 2012 Lords Chamber

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[Lord Collins of Highbury]

That this House regrets that the Care Quality Commission (Healthwatch England Committee) Regulations 2012 (SI 2012/1640) fail to provide sufficient safeguards to ensure the independence of Healthwatch England from the Care Quality Commission, despite Government assurances given to the House at report stage of the Health and Social Care Bill on 8 March 2012, and that the regulations fail to provide for effective national patient representation in the health service.

[Lord Collins of Highbury]

My Lords, my purpose in tabling this Motion is to highlight how these regulations, in their present form, may undermine the one thing Healthwatch England needs to succeed: public trust and confidence.

As my noble friend Lord Harris of Haringey argued so brilliantly on Report, an effective organisation for patients must be measured against three basic criteria: first, independence from the providers, commissioners and regulators of health services, because a patient complaint may involve the need to challenge any or all of these interests; secondly, genuine grass-roots representation from groups and individuals—no top-down organisation; thirdly, that its work and comments be derived from sound local information.

Over the past 40 years, we have seen community health councils, then patient participation forums and, most recently, LINks. They may not have always fully met these criteria, but each built on the progress of its predecessor in delivering greater patient involvement. No matter how often the Government assert to the contrary, the arrangements proposed in these regulations do not pass the test of independence. They say that Healthwatch England will have genuine operational independence by ensuring that the majority of its members are not also members of the Care Quality Commission. However, under the regulations the Healthwatch England chair must consult the CQC chair before the first appointments are made. That does not exactly reinforce the notion in my mind of independence. However, even with this measure and some of the others in place, it remains difficult to see how Healthwatch England can build public trust when its governance is controlled by the CQC, a body whose own organisation and resource problems have been so publicly aired.

The fear for many is that that the Healthwatch England committee will be rapidly absorbed into, and moulded and overwhelmed by, the dominant culture and infrastructure of the CQC. The Government have told us how important the duty of collaboration is within their reformed NHS. If that is the case, why not use this duty rather than leave Healthwatch England within the governance structure of the CQC?

The skill and ability of the new Healthwatch England chair will no doubt be a significant factor in whether it succeeds. I congratulate Anna Bradley on her appointment. Having worked at Which? for many years and been a former chief executive of the National Consumer Council, she is extremely well qualified to meet the challenge. From her public statements, it is clear that she fully appreciates that for Healthwatch England to succeed it must meet the challenge of independence and effective patient representation.

A key to this will be the strength of the local Healthwatch network. As local Healthwatch develops during the next six months, it must show that it listens to patients and service users and captures their feedback, a role that LINks have performed with distinction in many areas.

However, with no clear rules in law, we are potentially left with a range of different local social enterprises determining national representation. By not providing statutory status to local Healthwatch, the Government missed the opportunity for them to be organisations that were fully trusted and supported by patients and public alike. At the launch of Healthwatch England, Anna Bradley also acknowledged that, with stretched health and social care budgets, an ageing population and significant systems reform, it was essential that HWE be focused on real people, their experiences and their needs. She said that Healthwatch England would actively seek out evidence from all sections of the community and collate it to find out what needed to change. I fully understand her desire to ensure that such evidence is not dependent on those who shout the loudest. She said that Healthwatch England would go out of its way to hear from those who sometimes struggle to be heard. However, I fear that, with these regulations, we will have a body that is perceived to be appointed from high—a top-down organisation which is not representative. The 10 members recently appointed to Healthwatch England have highly relevant knowledge and experience, and I have no doubt that their specific skills and expertise will be a tremendous asset to its work—three have been appointed because of their specific local involvement. However, to be genuinely representative, there is a case for more, if not a majority, to be drawn from local Healthwatch.

Healthwatch England will be looked to by 152 local Healthwatches as an organisation that understands and has experience of both national and local problems and issues, including the special needs of deprived communities, people suffering as a result of health inequalities and people living in rural areas. The connection between local Healthwatch and Healthwatch England must be more than a brand, a name and a conversation.

The decision to restrict local Healthwatch membership of Healthwatch England to only four members, one from each of the four NHS regions, Greater London, North, Midlands and South, appears totally inadequate. In addition, the decision to restrict from 2013 local Healthwatch membership of Healthwatch England to people described as “directors” of local Healthwatch organisations is limiting and confusing.

Not only is there a risk of reduced funding with local authorities commissioning local Healthwatch, some of which we have already seen in the tendering process that has commenced, but there is also huge potential for conflicts of interest. Can we really ask a patient or carer to have confidence in a complaint being properly pursued when it involves a regulatory failure in a local authority social service? I am sure that patients will see the potential conflict of interest even if the Government cannot.

We are facing the prospect of fragmented services being delivered by multiple providers even within a single local authority. One issue of particular concern for me, which I have raised previously in the House, is the patient advocacy service, used by adults, young people and children wishing to make a complaint about NHS healthcare. There are currently three providers of the Independent Complaints Advocacy Service in England, commissioned by the Department of Health centrally. In future, this will be commissioned instead by 152 local authorities. It has been estimated that this will add £2.2 million to the cost of the service—which currently costs £11.7 million—massively reducing what is available for other patient services provided by the Local Involvement Networks.

Further, while there will be only one local Healthwatch contracted in a single local authority, this body will be permitted to subcontract most, if not all, of its activities. This will result in some areas in multiple contracts, solicitors’ fees and all the other on-cost of commissioning. The waste of public money on contracting is absolutely appalling.

In the end, it will come back to how the structure proposed in these regulations will play out in practice and how conflicts of interest between Healthwatch England and the CQC, or indeed Healthwatch organisations in local authorities, will be dealt with. The issues that the Minister must therefore address and questions that he must answer tonight are: how will public trust be maintained when a complainant about a CQC investigation into a care home discovers that the body investigating the complaint or championing improved quality of care on behalf of patients is a committee of the CQC itself? How will the culture clash between Healthwatch and the CQC be addressed and managed? How will the Minister, to quote the word used by many in this House, stop CQC “suffocating” Healthwatch England? How will he ensure that potentially serious conflicts of interest are dealt with?

I conclude with the issue I started with: public perception and understanding of, and confidence in, the independence of Healthwatch. It is important that Healthwatch is seen to be credible and truly independent, able to challenge and to scrutinise the work and decisions of the regulators, both CQC and Monitor. We need an independent Healthwatch England and we need local Healthwatch bodies that everyone can rely on to be genuine patient representatives. I am afraid that these regulations give us neither.

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I ask the noble Lord, Lord Collins, and noble Lords opposite in particular, to support Healthwatch England, with Anna Bradley at the helm, to achieve our common goal, which is to build confidence among the public that they will be heard—that confidence is important—and to do that in the interests of health and social care services, and the outcomes that those services deliver.

[Lord Collins of Highbury]

My Lords, I thank the Minister for his response, and all noble Lords for their contribution. The noble Baroness, Lady Jolly, said that this was a missed opportunity and I am glad that she recognises that on this occasion. I wish that, on Report, we could have pushed through some of those concerns in a much more positive way. I am afraid that it is still a missed opportunity in view of the contribution from the noble Earl. As my noble friend Lord Whitty says, there was an opportunity today to state publicly not only a genuine commitment, but how we can translate that commitment into the assurances that the public will want. I hope that the Government will keep this matter under review. It is a sad fact that we have an organisation whose formal governance is under the Care Quality Commission. The chief accounting officer of Healthwatch England will not be Anna Bradley; it will be the Care Quality Commission. That poses some fundamental issues for the public.

Nevertheless, we have had a good debate. Everyone on this side of the House wishes Healthwatch England every success. We certainly wish its new chair every success. In the light of the debate, I beg leave to withdraw the Motion.

Motion withdrawn.