Health and Social Care Bill

Baroness Wheeler Excerpts

Tuesday 11th October 2011 Lords Chamber

[Baroness Wheeler]

My Lords, in this marathon of debates, I want to focus my attention on two of the key issues that I will be leading for on behalf of the Front Bench. These arise from Part 5 of the Bill, and it is clear from the debate so far that they are matters which will absorb much of your Lordships’ attention in the coming weeks. First, I refer to the issue of how patients’ voice and involvement can be truly embedded into the Bill, and, secondly, how we might ensure that the Bill promotes integration across the NHS, public health and community and social care and gives impetus and encouragement to the progress that has been made over the past few years, despite the difficulties and obstacles that can be faced joining services up to the benefit of patients and carers.

In the 15 September debate in your Lordships’ House on the implementation of the Future Forum recommendations, which noble Lords variously described as an overture or limbering up for today, my noble friend Lady Pitkeathley described reflecting patients’ voice in health and social care as,

“enabling disadvantaged individuals—clients, carers and patients—to speak up for themselves and to contribute to policy formation”.—[Official Report, 15/9/11; col. 873.]

This sums up in a nutshell what must arguably be the major priority if the laudable aim of “no decision about me, without me” is to become a reality for the majority of patients and clients. The Future Forum underlined the importance for the voice of patients and the public to be embedded in our health services, including the voices of children, vulnerable adults, carers and those who are often excluded. In evidence to the House of Commons Select Committee on the reconvened Bill, the chief executive of the mental health charity Rethink, Paul Jenkins, supported the need to,

“put patients and carers on the same footing as specialist clinicians in terms of the requirement to seek advice, so the advice of expert patients is as important in some aspects of long-term conditions as that of clinicians”.

We support that aim, which, along with harnessing the collective patient view of such organisations as Rethink or the Stroke Association, will be essential if services that are high quality and sustainable in the future are to be designed. We will seek changes in the public involvement provision in the Bill to place greater emphasis on the proactive involvement of public and patients before decisions are made. I would also ask how lessons in future are to be learnt from the mid-Staffs experience, where we know that this collective patient voice was ignored.

It is clear from the contributions in the debate today that there needs to be much discussion and development to define what patient involvement and shared decision-making actually means at each level, and that the Bill as currently constructed does not deal with or address these issues and is in effect woefully inadequate in embedding the patients’ voice into the new structures. From these Benches we will table and support amendments to the Bill which strengthen the emphasis on patient and public involvement in the structures of all local bodies, including foundation trusts, clinical commissioning groups and health and well-being boards. We will aim to get the current loopholes and get-out provisions, for example in the requirement for these bodies to hold public meetings, well and truly plugged. Health commissioners and providers must operate under the same standards of good governance to which local authorities and other public bodies comply.

We will also support the proposals from key patient groups to define what the duty under Clauses 20 and 23 to promote the involvement of each patient means, and the specific aspects of involvement that commissioners should promote. We will seek specific proposals in the Bill to recognise expert patients, carers and patient organisations as people from whom commissioners should obtain advice. As the Patient Voice has said:

“It is about commissioning care and treatment services in such a way that those services engage patients as fully as possible in managing and controlling their health and care”.

How will the NHS Commissioning Board and CCGs be held to account for promoting patient involvement?

We also support the need for the establishment in the Bill of a duty of candour for any organisation providing NHS and social care, so patients and clients can be informed when things go wrong with their care and treatment, as soon as it is known, not after months of denial, legal obfuscation and cover-up. This is a new area of development, and I ask the Minister if the Government would support the provision of such a duty.

Finally HealthWatch England must have the teeth, strength and independence to be an effective patient champion. We strongly support the principle of a national body representing patients, with local outposts, but running alongside other measures which ensure patients and public are directly involved in decision-making. We do not support HealthWatch England being a sub-committee of the Care Quality Commission, and will seek amendments to the Bill that delete this provision. We agree with members of the current Local Improvement Networks, LINks, that HealthWatch’s role, work, independence and authority will be severely compromised if the proposed CQC relationship remains. Instead, HealthWatch's powers should be extended to enable it to make recommendations direct to the Secretary of State and to the various arm’s-length bodies to which it relates. We will also be seeking to ensure that these bodies are required to respond publicly to HealthWatch. We will also seek to ensure that local HealthWatch organisations are properly resourced to undertake the important and key work that they will have.

Let me turn to the issue of integration of NHS public health and social care. In his written response to questions raised by me during the 15 September debate on the Future Forum’s continuing role, and how its findings would be fed into the Bill, the Minister responded:

“The future work of the forum is focused on implementation of the Government’s modernisation plans, and is therefore unlikely to require further amendments to the Bill”.

So, no second pause, then. The forum has been asked to look at how to ensure that,

“the Government’s modernisation programme leads to better integration of services around people’s needs”.

Good question. The forum will be asking where services should be better integrated around patients, service users and carers—both within the NHS and between the NHS and local government. I am pleased to note that they are particularly interested in social care examples, for example better management of long-term conditions, better care of older people, more effective handover of a person’s care from one part of the system to another.

From these Benches we will be tabling and supporting amendments to provide for a definition of integration in the Bill so that it encompasses NHS, public health and social and community care. Given the Future Forum’s continuation into what is becoming to look like a pretty permanent role, what better way than to provide a clear legislative framework, context and direction for the forum to work to?

There is much confusion about what is meant by integration, which needs to be addressed. Even the Prime Minister himself is confused, since one of his famous five pledges is on integration but relates primarily to NHS integration, not integration across health, public health and community and social care.

In practice, integration models in the NHS and social care are varied and diverse. You have provider integration in the NHS; commissioning integration across health and social care; structural integration across health and social care organisations, such as healthcare trusts; integrated pathways, which are mostly NHS focused but with some excellent examples across both systems, such as stroke and reablement; and finally, integration around individual patient users, such as personal budgets and direct payments.

We strongly support defining integration in the Bill to ensure that national policy promotes the supporting context for integration. Currently, health and local government are only required to “act in an integrated way”. Both the excellent work undertaken, for example, by the Nuffield Trust in its Integration in action case studies, and by the Local Government Association report by Professor Gerald Wistow, Integration this time?, point to how such a strategic overview definition could be developed and framed. It would help rebalance the Bill into more of a health and social care Bill. Does the Minister intend to clarify and define integration in the Bill?

Finally, in closing, I want to stress our recognition of the importance of the future role that health and well-being boards need to have in ensuring integrated services and promoting patient and public involvement in the commissioning of services. We support health and well-being boards and the health and well-being strategy—in the context that the local authority has real powers over its implementation.

Moreover, if health and well-being boards own the well-being strategy then they must also own the plans to deliver it. CCG commissioning plans should be agreed by the health and well-being board, and we will be putting down amendments which seek to give the boards this important power of sign-off. Only in this way will we achieve genuine joint ownership between boards and CCGs of commissioning plans which match local needs and are firmly based on the health and well-being priorities of the local community.