Health and Social Care

Baroness Walmsley Excerpts

Thursday 15th December 2016 Lords Chamber

[Baroness Walmsley (LD)]

My Lords, I congratulate the noble Lord, Lord Harris of Haringey, on introducing this debate and I add my condolences to those expressed to the noble Lord, Lord Prior, on the loss of his father. I congratulate the noble Baroness, Lady Chisholm of Owlpen, on the way she has stepped into the breach this week. There has been a lot of health business, so she has been kept very busy.

This has been an interesting debate. The main issues to come out of it have been the independence and funding of Healthwatch England and local Healthwatch; what the Government really want out of PPI; and the difficulty of defining what a good system of service user representation should look like.

Like the noble Baroness, Lady Watkins of Tavistock, I was interested in the King’s Fund’s analysis. I shall not repeat them, but it asked three very interesting questions that need to be answered to look at what would make a good service user system. That was a very useful analysis.

Although highly desirable, user representation has a chequered history. Phoebe Dunn, a policy researcher at the King’s Fund, has observed:

“Local Healthwatch organisations represent the latest in a long line of attempts to give patients and wider communities an effective collective voice”.

Since the 1970s, successive Governments have implemented a series of structures, beginning with the community health councils, followed by the patient and public involvement forums in 1973, with the LINks replacing those in 2008. Interestingly, along with health services, they also covered state-funded social care and were,

“designed to reflect a more integrated approach to social care”.

We are still trying to do that eight years later. Dr Pam Carter and Professor Graham Martin, from the University of Leicester’s Department of Health Sciences, have suggested:

“Successive reforms arguably demonstrate political commitment to, and sustained high-level interest in, PPI in its various organisational forms”.

I am sure we can agree about that, but we do not appear to have achieved it just yet.

Healthwatch’s establishment was part of the coalition Government’s desire to increase public involvement in how the health and social care system worked. The 2010 White Paper, Equity and Excellence: Liberating the NHS, which set out the coalition’s vision for the future of the NHS, stated:

“We will put patients at the heart of the NHS, through an information revolution and greater choice and control”.

I want to comment on what the noble Lord, Lord Lansley, said about that and clarify the situation. The Liberal Democrats indeed wanted local authorities to be involved, but we warned against the funding coming directly from local authorities because, of course, they are commissioners and providers of the services. My noble friend Lady Jolly emphasised that to me a little earlier, because I was not working on health at the time.

Over the years, ways to consult patients and the public have been set up, but they quickly either become subsumed by NHS organisations or are effectively ignored, although their suggestions are always politely listened to. Healthwatch was meant to be far stronger and more influential than those bodies that went before. Part of this intention came in response to the Mid Staffs scandal. The Francis report commented on the shortcomings of the various PPI policies of the past. In the case of Stafford’s main hospital, the report argued that,

“patients and relatives felt excluded from effective participation in the patients’ care”.

It also suggested that the policies that followed the community health councils did not succeed in giving patients a voice. It stated:

“It is now quite clear that what replaced them, two attempts at reorganisation in 10 years, failed to produce an improved voice for patients and the public, but achieved the opposite”.

In the current climate, it is unfortunate that local Healthwatch funding is provided by local authorities because of the drastic funding cuts for local government. It is not surprising, I suppose, that some of the funding provided has not reached local Healthwatch. There is also the cumbersome bureaucracy mentioned by the noble Lord, Lord Harris, which causes some of the money to seep away. Healthwatch is saying all the right things but, without proper funding, even the best policy and the best structure will fail to fulfil its brief.

One good example of the contribution of service users and their carers used to be the Experts by Experience programme, which the CQC uses to augment its independent inspections. These are skilled workers who have personal experience of using health and social care services. They provide the patient perspective to inspectors. Sadly, since three-quarters of this programme was taken over by Remploy, the number of experts used by inspectors has fallen considerably because of serious shortcomings in the way the programme is now run. I know the CQC is looking carefully at that.

A group of Experts by Experience and former experts—some have now given up in disgust—gave evidence to the House of Commons Health Select Committee and this has been published. It makes very sad reading. The contracts in different parts of the country were awarded to two different companies, with the majority going to Remploy. Problems with the Remploy contract have been well documented and I do not have time to go into all of it, but the real victims in this sad saga have been the most vulnerable people in society, whose views are not sought in as expert a way as they should be during inspections, at least in three of the four regions of the country. I am looking forward to the comments of the Commons Health Select Committee on that evidence.

The hot topic in health at the moment is the STPs, the sustainability and transformation plans. There was recently an article in the Consultation Institute magazine which gave the views of Paul Parsons, who is actively working with institute clients, considering how best to implement STPs. He believes that some common themes are emerging from conversations with commissioning leaders since the first STPs started to seep into the public domain. First, commissioners are not yet won over to the principle of an open public dialogue about the principles and objectives contained in the plans they have published; secondly, each appears to be concerned with the extent to which they have met their legal responsibilities on public involvement in developing the plans; and, thirdly, there is a range of acceptance of, or resistance to, the concept of formally giving the public a chance to comment on the plans at this stage.

Each of the 44 commissioning partnerships are at different stages in their change process and have different challenges in their area. NHS England recognises that and is keen that the plans involve a range of stakeholders and are all led locally. So it is understandable that guidance does not provide a paint-by-numbers approach to the public engagement requirements of these exercises. But Parsons feels that a lack of specific guidance can create some inertia in the system that prevents organisations wanting to be one of the first to commit to a course of action, including consultation on the plan itself. He outlines the advantages to commissioners of formally engaging on the plans at an early stage with patients and the public. He says that it would, first, give STP partnerships the chance to fine-tune the content and understand the priorities that key stakeholders would apply; secondly, help identify people and groups who want a say in the plans; and, thirdly, give the partnerships an opportunity to reduce the risks of challenge later in the process by documenting that they have met the requirement for public involvement at an early stage.

The noble Lord, Lord Harris, mentioned the NHS Five Year Forward View, which sets out a vision for the future of the NHS. As we know, it was developed by the partner organisations that deliver and oversee health and care services, including NHS England, NHS Improvement, Health Education England, the National Institute for Health and Care Excellence, Public Health England and the Care Quality Commission. I note that that list does not include any patient-centred organisations. I want to ask the Minister why the Government did not insist that it should do so.

Some experts, such as David Gilbert, co-director of the Centre for Patient Leadership, believe that the basic premise is that in the NHS all patient consultations end up with the professionals saying, “Thanks, but now we will go back and decide what to do”. That is very unfortunate, even if it is only the impression of one person. He explained in a recent lecture why he feels we must move forward to a model of patient-influenced change and away from the current model of “them and us” that exists between professionals and patients. The simple fact is that patient involvement results in better services. Does the Minister agree?