Health and Social Care Bill

Baroness Northover Excerpts

Tuesday 22nd November 2011 Lords Chamber

[Baroness Jolly]

My Lords, they say that too many cooks spoil the broth, but I think this is an occasion where that probably has not happened. Many hands might make light work. I ask the Minister to take these amendments away because there is an awful lot of good to be found in each of them, but not in each together, as it were.

Amendment 318C, tabled by the noble Lord, Lord Whitty, inserts a new clause and subsection (2)(a) of the new clause is about complaints. It is a nice idea that complaints could be taken to HealthWatch England. Complaints are a big issue to which we will be returning on Amendment 108.

The noble Baroness, Lady Cumberlege, raised the relationship between local and national healthwatches. It is critical. We would support the election of local healthwatch representatives to the national body.

Finally, on independence and finance, I believe very strongly that it is very difficult to criticise and challenge an organisation if you sit within it. I understand the point about the benefits, but if you are local, and you sit within your local health authority or nationally you sit within the CQC, generally the feeling that you are monitoring the organisation that is your host is never a good place to start. Similarly, I, too, have had letters from people who were CHIPs and then LINks about budgets being not just cut a little bit but absolutely hacked away. I would be really uncomfortable if, for example, locally the healthwatch was going to be located within the principal local authority that held the budget. We have had it already today. Intentions will be good and then somebody will come along and say, “We really need a bit more just for this”. It will happen in a meeting where they are not present and, all of a sudden, there will be another slice taken. We have seen it before with lots of other things. You could look at it from a negative point of view and say these are like curate’s eggs and bad in parts or good in parts, but I think too many cooks will not spoil this broth. Many hands will make light work. I ask my noble friend to take this away and have a look at it.

[Baroness Northover]

My Lords, I sympathise with the noble Lord, Lord Patel. He is forgiven for being subject to the beatings of the noble Lord, Lord Harris. When I made my maiden speech, the noble Lord, Lord Harris, gave me a very interesting and less than usual tribute. Noble Lords will see that we have a slight history.

[Lord Harris of Haringey]

The noble Baroness stood against me.

[Baroness Northover]

As the noble Lord points out, I stood against him as a paper candidate—a non-serious candidate. When I went up to congratulate him on winning by about 2,000 votes to my 20 or whatever it was, I was given a blasting in relation to the successful campaign of one of my colleagues. That apart, I have great respect for the noble Lord, Lord Harris, and I am very happy to discuss these amendments wherever they come in the Bill. However, I would point out that these amendments are about HealthWatch England and we will return to local healthwatch organisations later on. I gather that the noble Lord, Lord Harris, will not be here at that point so has flagged up some issues which I hope to be able to address. But noble Lords may wish to be aware that we will be coming back to this in relation to the local aspects.

This has been yet another high-quality debate and a range of different perspectives have been expressed. One of the things that has come through is the concern about trying to make sure that the NHS is genuinely patient-centred. All too often, patients are expected to fit around services, rather than the other way around, and that is what we are seeking to tackle here. Years back, I was a very junior spokesperson on health for the Lib Dems and then I moved to international development. I remember the debates on this issue, in particular on the National Health Service Reform and Health Care Professions Bill in 2002. It is one of the things that I asked about when seeking a briefing. Various noble Lords have referred to what has happened over the years. I was interested in what the noble Lord, Lord Hunt, said in 2002 when he put forward proposals to involve patients. After they had gone back and forth and around and about and there had been much discussion, he described his position as being,

“as good as it gets”.—[Official Report, 13/6/02; col. 419.]

The noble Lord, Lord Harris, said that they now had a system,

“which will act robustly in the interests of the public and patients”.—[Official Report, 13/6/02; col. 430.]

I very much welcome the fact that the noble Lord, Lord Harris, recognises that we are trying to improve on things.

[Lord Harris of Haringey]

It went down before it went up.

[Baroness Northover]

Then there were the patient forums of 2004. The noble Lord, Lord Warner, said that these were,

“the cornerstone of the arrangements we have put in place to create opportunities for patients and the public to influence health services”.—[Official Report, 5/7/04; col. 516.]

In 2007, we moved on to LINks. We have abandoned the commission that was at the centre—the noble Baroness, Lady Cumberlege, referred to this—because it was centralising, bureaucratic and absorbed money that was supposed to be devolved. I have the Health Select Committee report criticising that commission.

As others have said, there is a history of trying to move this forward and trying to ensure that there is better patient and public involvement. I welcome what various noble Lords have said about the improvements in the Bill. We are trying to learn from that history and move it on, although I hear what people say that we possibly have not got it as far as they people wish.

The Government are seeking a fundamental shift. The aim of HealthWatch England is to help orientate the NHS first and foremost around the patient. Healthwatch, at both local and national levels, aims to strengthen the ability of service users and other members of the public to shape and improve health and social care. The role that Healthwatch England will play is crucial. Its aim is to provide leadership, support and advice to local healthwatch organisations and to make them more effective. I looked at the LINks reports and although they are welcome, anyone can see that there is much more that can be done. They do not reflect the whole range of patient voices and the kind of responsiveness you might wish to see in the health service, which is why it is such a challenge.

HealthWatch England will also provide information and advice about the views of patients, the public and local healthwatch to the key players in the NHS and social care—the Secretary for State, the NHS Commissioning Board, Monitor, English local authorities and the Care Quality Commission. At present there is no statutory body with either of these roles. Therefore, I am sure we can all agree that this represents a step forward. As noble Lords have said, the HealthWatch England committee will be a committee of the CQC, with a chair who we intend will be a non-executive director of the CQC. Part of this debate has focused on whether this is the appropriate organisational form for HealthWatch England: whether, in this form, it can sufficiently and independently serve the interests of patients and the public and whether it will have the status it needs to achieve this. I have listened to these concerns and I fully agree that this area is too important to get wrong. We are interested in change that works and this Government believe that setting up HealthWatch England within the CQC is the best way to achieve this aim.

I shall explain the reasoning behind this. First, there are key synergies to exploit here. To be effective, HealthWatch England is going to need extensive capabilities which the commission that existed before clearly did not have. It will need clout, which clearly that commission did not have. Being part of the CQC will enable it to have both of these. HealthWatch England will be able to draw on the infrastructure and support from the CQC to deliver its work to a high standard. It will have easy access to the CQC’s information sources, which have been referred to, enabling it to develop a deeper understanding of how health and social care organisations are functioning or where there are problems where the views of people may have made a difference. Being part of one of the big national bodies will, we hope, give HealthWatch England a real profile, and one we feel would be hard to generate if it was a new, separate body—and there is the history that we know about. Operating from within the CQC should enable HealthWatch England to punch considerably above its weight.

Secondly, it will enable the voice of patients to have a real influence on the regulatory work of the CQC. Close working and communication between HealthWatch England and the CQC opens up the possibility of having the patient voice hardwired into the work of the commission. It is not just a matter of looking at HealthWatch England but seeking to ensure that it really has a positive effect.

[Lord Warner]

Can the Minister give the House any information that the department has on the name recognition of the Care Quality Commission which would deliver the kind of profile for HealthWatch that she is claiming for it?

[Baroness Northover]

The noble Lord, Lord Warner, is very concerned that HealthWatch itself is a name that is going to be far too easily recognised and obliterate his charity. This is HealthWatch. The fact that it is in that relationship with the CQC does not obviate that. I would turn it back to the noble Lord and ask him who might recognise any of those predecessor organisations over the past 10 years and whether there was ever wide recognition of those.

[Lord Warner]

That was not my question. The noble Baroness is arguing that HealthWatch would actually benefit from being hosted by or being part of the Care Quality Commission because it would be a powerful national body. I was asking the noble Baroness what the name recognition of that powerful national body was that would produce benefits for HealthWatch.

[Baroness Northover]

At the moment the CQC is relatively well known because its reports are in the press fairly frequently. The reports of the investigations that it has been undertaking have caused considerable concern. I cannot give the noble Lord a scientific response based upon polling as to the recognition of the CQC, but I would guess that it is somewhat higher than some of the organisations representing the patient voice that have been there before. When patients went into hospital and had concerns about various things, did those organisations spring to the forefront of their minds? Possibly not.

[Baroness Morgan of Drefelin]

I too have listened to this extremely important debate with a great deal of interest. I am slightly losing the thread of the Minister’s argument. When the Minister started, she was saying that the debate was about how we put patients at the centre of the NHS. However, I think that the debate has been about whether or not HealthWatch England should be independent. What the Minister is saying is very interesting, and I do not want to interrupt her for too long. I want to understand what the benefits to HealthWatch England are of being enclosed within or subordinate to another organisation. If we want to have a HealthWatch England that is out there punching above its weight and really taking patient interests to the Secretary of State and the Commissioning Board, it would seem to have a much better opportunity to be heard, recognised and understood as an independent organisation that is not subordinate. Why do the Government think it is better to wrap it up inside another organisation which is very different in character, and make it dependent and subordinate to that organisation? How will that help it to fulfil its objective?

[Baroness Northover]

I am sorry that I am not putting this clearly. One of the major points about this is for HealthWatch England to be in a place where it can have a direct effect upon organisations like the CQC. We know from history that even when you have a national organisation, it does not necessarily mean that it has the effect that one would wish; the noble Baroness will know that all too well. Various parts of this organisation have various obligations built in to listen to HealthWatch, which we hope will help, but because it is there as part of CQC there is an obvious relationship, because CQC is the organisation that goes in and regulates the institutions that deliver care. The CQC regulates; the various institutions and other bodies provide the care. HealthWatch England is trying to draw out the patient’s voice in this, and make sure that it is heard loud and clear.

Fancy this; I have just been given a quote from the chief executive of National Voices, Jeremy Taylor, who says that he is,

“not sure that it matters where HealthWatch England sits. What matters is whether it has clout, credibility, independence and sufficient resources. One could have a big debate about whether it should sit as a separate body or as part of the CQC. Colleagues may have different views. My view and the view expressed in the forum is that HealthWatch England will be an important part of the architecture for the patient voice, so we should welcome it.”––[Official Report, Commons, Health and Social Care Bill Committee, 28/6/11; col. 67.]

[Baroness Emerton]

My Lords, we have referred to “patients” all the time, and I understood that HealthWatch was going to be public and patients. The Care Quality Commission looks at complaints. There is a culture issue here. The independence of HealthWatch is vital, because we are talking about the future as well as the present. My experience over the years, when we have been looking at new services, is to have the public and patient representation coming forward with ideas—it should not be governed by a health authority or anyone else, but be independent—and reporting back to the body that asks the question. We are going a little off-beam in terms of the Care Quality Commission, which would be culturally oppressive to any organisation that is set up to look to the future.

[Baroness Northover]

The noble Baroness is quite right that this is patients and public. One of our concerns about some of these amendments which refer only to patients is because the whole of the public are potentially patients, or related to or caring for patients and so on. It therefore does have to be defined widely, and she is right that we are looking to the future. I am not sure that I would share her view as to the CQC, which indeed needs to help play its part in driving up quality, which underpins much in the Bill.

Maybe I can carry on and address some of the specific points raised by noble Lords. The Bill preserves a clear distinction between the CQC and HealthWatch England. Although HealthWatch England will be established as a statutory committee of the CQC, it will be solely responsible for setting the direction of its own work and exercising particular functions. This will ensure that HealthWatch England targets issues and gathers evidence from the public to base its national advice on service standards and improvements. HealthWatch England will maintain its independent role by presenting the collective patient and public voice to the Secretary of State and to the relevant bodies.

--- Later in debate ---

[Lord Patel]

I did not have in mind the scientific meaning of “research”. This is research of what is going on in individual hospitals. I use the example of Mid Staffordshire, where it was the research following initial incidents that made everybody aware of the extent to which bad practices were going on. That is the kind of research that local healthwatch should be involved in.

[Baroness Northover]

I take on board what the noble Lord says, and indeed he is absolutely right. There are various ways in which such problems should be picked up, but it is exceedingly important that that happens, and we certainly hope that local healthwatch will be part of that.

The noble Baroness, Lady Wheeler, talked about engagement with stakeholders. I can assure her that there is ongoing engagement with stakeholders through a HealthWatch advisory group. The National Association of LINks Members and others are members of this group, and there are others. The noble Baroness also asked about the funding for transition. The Government continue to make funding available to LINks— £27 million during the transition—and as part of the HealthWatch development programme we will make £3.2 million available for start-up costs for local healthwatch organisations.

The noble Lord, Lord Harris, asked about conflicts between the CQC and HealthWatch England. We disagree that the Bill does not already provide sufficient safeguards to ensure the independence of HealthWatch England within the CQC. Obviously, in extreme cases, the Secretary of State has the ability to intervene if HealthWatch England is significantly failing. However, both the CQC and HealthWatch England have responsibilities that they must deliver.

The noble Lord also spoke about the relationship between LINks and local authorities, and expressed some concern about that. LINks have been funded by the local authorities and it is right that so too will the local healthwatch. The relationship of local health authorities and LINks overall has been a successful one—although I take the point that he makes—that has encouraged collaborative working between LINk and the local authority. The Government believe that if local healthwatch organisations are to play a full part in their local communities, it is appropriate for them to be accountable to directly elected local bodies that are better able to assess the needs of the local population. It would not be appropriate for them to be funded nationally, but I hear what the noble Lord said.

My noble friend Lady Cumberlege spoke strongly in support of many of these developments from her knowledge of the history of the past few years. She showed how we are trying to build on the experience of previous Governments to take this forward. However, she will not be surprised to know that I have some concerns about some of her amendments. Her Amendments 307A and 308A would prescribe certain aspects of the membership of the HealthWatch England committee. For example, Amendment 307A proposes that:

“The majority of the members of the Healthwatch England committee shall not be members of the Commission”.

The debate that we have just had illustrates why this is important. Certainly, we have sympathy with that point of view. However, we do not think that it should be in the Bill. It is best to put these in regulations, which would enable flexibility. Clearly, rules about the membership and procedure need to be consulted on and that will be taken forward when we engage over those regulations.

I told myself that we would write to the noble Lord, Lord Walton, about his organisation. However, it turns out that I am aware of a number of other organisations that use the name HealthWatch. The Government’s proposals mean that the HealthWatch we envisage will be unique as the champion of the patient and the public voice. I am not sure whether that totally answers the concern of the noble Lord, Lord Walton. Perhaps I had better write to him after all.

My noble friend Lady Jolly flagged up concerns about complaints. Perhaps I may reiterate that HealthWatch England’s role is that of a national champion of the consumer voice. Its purpose will be to bring that voice to the attention of regulators and others. Giving HealthWatch England powers of investigation of complaints could compromise its primary role in that regard. One of the developments introduced by the previous Government was to bring in a statutory framework for an investigation of NHS and adult social care complaints. It remains the Government’s view that complaints are best dealt with in the existing framework and initially at the local level. This provides a better opportunity for local organisations to learn from their mistakes and to improve services as a result. Where resolution is not possible locally a complainant is able to complain further to the Health Service Commissioner, the ombudsman or the local government ombudsman, as appropriate. The ombudsman’s functions of investigation are statutory. Therefore, we see no reason to duplicate. The structure set in place by the previous Government will stay in place and acts in that way.

As ever in this House there is a wide range of experience, particularly perhaps in this instance on what has not worked in the past. It is a great challenge to enlist patients and the public in making sure that standards are driven up. We believe that devolving to the local level with clinicians and patients more in the driving seat should help. I welcome the support of noble Lords who feel that these changes are a move forward, but I hear them when they say that there are areas that still need to be addressed. For that reason, we would certainly like to continue discussions with those who wish to feed in on this issue in order to make it as good as we can: namely, a system that more effectively brings to bear the voice of patients and the public, which has so far proved to be a difficult challenge not only to the previous Government but to Governments before that.

[Lord Patel]

My Lords, I was hoping that at the end the noble Baroness would be able to say more strongly how the Government intend to take forward today’s debate, but I am afraid that she did not do that, which is a pity. There was strong support for HealthWatch England and local healthwatch to have more independence. Her argument about a synergy between the CQC and HealthWatch England is not absolutely correct. Yes, there is a degree of synergy, but not in all areas, including: commissioning, as mentioned by the Minister; community care, where the CQC is not involved; advice to the Secretary of State on the mandate; and social care as it develops to more home-based care where the CQC will not be involved. HealthWatch England has a much wider remit than the CQC.

I have a rule in life never to oppose anything that the noble Baroness, Lady Cumberlege, says or does and I will not break that rule now. She is always well researched and communicates her research well, but I have to say that her well researched argument supports the Government more and I am surprised that the noble Baroness, Lady Northover, did not feel able to accept some of her amendments. None the less, it is a halfway house that would give more independence to HealthWatch England within the CQC. If we are serious about giving HealthWatch England independence, it should be truly independent. It should have its own powerful voice for the public and patients. It should not be answerable to another body that will control it, fund it and employ its members. That is the great weakness.

The outside voice of the people involved in this work is strong. They would like to test their work in an independent way. Previously, they have failed because they have not been given that independence. Let us be serious about giving a strong voice to the public and patients. Let us give them independence and see whether they can stand up to the challenge.

There was a lot of support today but I am willing to continue talking, particularly with the outside organisations, if that commitment can be made by the Government. We will always have an opportunity to come back. I beg leave to withdraw the amendment.